Patient Safety Tip of the Week
March 13, 2012
Medical Emergency Team Calls to Radiology
We’ve done multiple columns (see list at end of this column) on the patient safety issues that occur in the radiology suite, most of which have little to do with radiology per se. In our October 16, 2007 Patient Safety Tip of the Week “Radiology as a Site at High-Risk for Medication Errors” we noted at least 14 factors that make adverse events more likely in the radiology suite. Undoubtedly there are many more contributing factors and conditions.
Recently, a series of articles by Lora K. Ott and colleagues (Ott 2012, Ott 2011a, Ott 2011b) has looked at medical emergency team/rapid response team calls to the radiology suite and analyzed patient factors related to those calls. The percentages in the papers differ, presumably because the time frames for each were different, but the most recent paper appears to account for all the cases over a two-year time period so we’ll use those statistics. The majority of the calls (60%) were for patients not from the ICU’s and for almost half they occurred on the patient’s first day in the hospital. The authors speculate that this could be due to several reasons: (1) ICU patients are recognized to be more at risk and are more likely to be accompanied to radiology by nursing staff (2) the subtler evolving signs of clinical deterioration may not have been appreciated in the patients from the general units who are not as closely monitored.
The majority had a Charlson comorbidity index equal to or greater than 4 and about a third each had nasal cannula oxygen, dyspnea, or tachycardia.
The nature of the events in the radiology suite were primarily cardiac in 41%, respiratory in 29%, and neurological in 25% and most required a higher level of care after the event.
44% of the calls involved patients undergoing CT scan and 22% MRI scanning. That should not be surprising, given our many prior articles on safety issues in the radiology suite. During either procedure the patient is relatively isolated from monitoring staff for periods of time. In addition, sedation may be used to facilitate completion of some of those studies. Dislodging of catheters, tubes and lines during transfer to the CT/MRI platforms could also play a role. Also, the nature of the underlying condition necessitating the CT or MRI scan may also predispose these patients to the types of deterioration seen. In one of the earlier papers (Ott 2011b) neurological causes of deterioration were more frequent so it’s not surprising that many of these would have occurred during CT or MRI.
In one of the articles (Ott 2011b) peak time for such events was between 10 AM and noon. The authors ascribe this interesting temporal trend as most likely reflecting detection on morning rounds of symptoms and signs necessitating the diagnostic studies.
Although few of the patients died in the radiology suite, the overall prognosis in patients needing medical emergency team interventions in radiology was not good. A quarter of the patients died during the hospitalization and two-thirds had poor outcomes.
Transport of ICU patients to the radiology suite has for a long time been known to be hazardous. In our September 16, 2008 Patient Safety Tip of the Week “More on Radiology as a High Risk Area” we noted a paper by Smith et al (Smith 1990) which reported adverse events during 34% of all ICU transports. Specifically, transport of ICU patients to the CT suite was associated with a 71% incidence of adverse events. Adverse events included disconnection of monitoring equipment, interruption of vasoactive medication drips, unintentional extubations, etc. A program at the University of Missouri (Stearley 1998) showed that use of a specifically trained ICU transport team had an overall complication rate of only 15.5%, most of the complications being minor.
But we were somewhat surprised by the frequency of events in non-ICU patients in the studies by Ott and colleagues. We suspect that may reflect that ICU patients are most often accompanied by ICU staff on transports to radiology whereas those from the non-ICU areas are more likely to be transported by nonclinical personnel.
So that brings us back to another of our favorite topics – the handoff. In our February 14, 2012 Patient Safety Tip of the Week “Handoffs – More Than Battle of the Mnemonics” we discussed how the structure and format of handoffs needs to be tailored to the specific situation. The “Ticket to Ride” concept (see our Patient Safety Tips of the Week for April 8, 2008 “Oxygen as a Medication” and November 18, 2008 “Ticket to Ride: Checklist, Form, or Decision Scorecard?”) is a tool ideally suited for the radiology suite. It was originally developed for patients on oxygen therapy needing transport to radiology since studies had shown over 50% of such transports resulted in patients running out of oxygen. However, this concept addressing handoffs has been expanded to include attention to medication management, suicide risk, wandering risk, etc. in patients transported to radiology or other sites within the hospital.
The Pennsylvania Patient Safety Authority “Patient Safety Advisory” discussed development of a standardized handoff communication tool for intrahospital transports (PPSA 2009). It has an excellent discussion on the development of questions you’ll want to use in your own transport communication tool.
The Maryland Patient Safety Organization’s Handoffs & Transitions Learning Network, in their version of the Ticket to Ride, recommends inclusion of the following information on the form:
- Patient’s medical record number, weight, blood pressure, IV specifications, and use of O2
- Fall risk, isolation precautions, and mental status
- Precautions that need to be taken if the patient is diabetic (NPO, etc.)
- Rapid Response Team calls within the within the last 24 hours
- Time and dose of last pain medicine dose
- If the patient is able to stand, transfer and ambulate
- Synopsis of the patient’s status to avoid flipping through the chart
The Ticket to Ride format we recommend also includes details about the oxygen (flow rate, estimated time of oxygen remaining in tank, etc.). We also recommend including timing of other key medications, such as insulin, and time of last meal. Some patients remain in the radiology suite for long periods so you don’t want a diabetic to get hypoglycemic because he got insulin but not food. And don’t forget to include things like code status. Having a checkbox regarding the patient’s mental status and level of arousal is important. We’ve seen patients become obtunded or confused in transit to radiology and its often incorrectly assumed that was their baseline status. The tool should also include checkboxes to indicate if the patient is at risk for suicide or wandering. It’s also valuable to include on the Ticket to Ride a reminder to make sure you bring the patient’s reading glasses or hearing aid since these may be needed if informed consent for a procedure is to be obtained in the radiology suite.
But don’t forget that research indicates that the best handoffs include both a written and a verbal component. So if nursing staff are not accompanying the patient from a floor to the radiology suite, there is no substitute for the floor nurse speaking directly to the radiology nurse.
Physicians and nurses often have an underappreciation of the risks that are present when they send their patients to the radiology suite. Increased awareness of the dangers and vulnerabilities is helpful and tools such as the Ticket to Ride help increase that awareness.
Some of our prior columns on patient safety issues in the radiology suite:
· October 16, 2007 “Radiology as a Site at High-Risk for Medication Errors”
· September 16, 2008 “More on Radiology as a High Risk Area”
·
October 7, 2008 “Lessons
from Falls....from Rehab Medicine”
·
January 2010 “Falls
in the Radiology Suite”
·
August 2010 “Sedation
Costs for Pediatric MRI”
·
January 25,
2011 “Procedural
Sedation in Children”
·
February 19, 2008 “MRI
Safety”
- March 17, 2009 “More on MRI Safety”
- October 2008 “Preventing Infection in MRI”
- March 2009 “Risk of Burns during MRI Scans from Transdermal Drug Patches”
- February 1, 2011 “MRI Safety Audit”
- October 25, 2011 “Renewed
Focus on MRI Safety”
Some of our prior columns on the “Ticket to Ride” concept:
- April 8, 2008 “Oxygen as a Medication”
- November 18, 2008 “Ticket to Ride: Checklist, Form, or Decision Scorecard?”
References:
Ott LK, Pinsky MR, Hoffman LA, et al. Medical emergency team calls in the radiology department: patient characteristics and outcomes. BMJ Qual Saf 2012; published online ahead of print March 2, 2012
http://qualitysafety.bmj.com/content/early/2012/03/01/bmjqs-2011-000423.short?g=w_qshc_ahead_tab
Ott LK, Hoffman LA, Hravnak M. Intrahospital Transport to the Radiology Department: Risk for Adverse Events, Nursing Surveillance, Utilization of a MET, and Practice Implications. Journal of Radiology Nursing 2011; 30(2): 49-54
http://www.radiologynursing.org/article/S1546-0843%2811%2900038-1/abstract
Ott LK, Hravnak M, Clark S, Amesur NB. Patients’ Instability, Emergency Response, and Outcomes in the Radiology Department.
Am J Crit Care November 2011; 20(6): 461-469
http://ajcc.aacnjournals.org/content/20/6/461
Smith I, Fleming S, Cernaianu A. Mishaps during transport from the intensive care unit. Critical Care Medicine. 1990; 18(3): 278-281
Stearley HE. Patients' outcomes: intrahospital transportation and monitoring of critically ill patients by a specially trained ICU nursing staff. American Journal of Critical Care. 1998; 7(4): 282-7
PPSA (Pennsylvania Patient Safety Authority). Patient Safety
Advisory. Safe Intrahospital Transport of the non-ICU Patient Using
Standardized Handoff Communication.
Pa Patient Saf Advis 2009; Mar;6(1): 16-9.
http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2009/Mar6%281%29/Pages/16.aspx
Maryland Patient Safety Organization. Handoffs & Transitions Learning Network. 2008
http://www.patientsafetysolutions.com/