Weve identified the radiology suite as a high-risk area for untoward incidents in many of our columns, noting that most such incidents have little to do with the radiologic procedure being done. It simply reflects that many vulnerable patients with complex medical problems need to go to radiology, where many of the safety features we use elsewhere may slip through the cracks.
A recent report from the California Department of Public Health (CDPH 2018) illustrates the problem. A patient had been admitted after being found on the floor and noted to be in atrial fibrillation. He was placed on telemetry and had orders for serial EKGs and cardiac enzymes. It is not clear from the report whether the atrial fibrillation was persistent but subsequent EKGs apparently showed PVCs with trigeminy. A nurse notified his physician about the trigeminy and he was begun on oxygen 2 L/min.
He was scheduled for an MRI scan of the head (reason not provided in report). The nurse apparently contacted the physician, who okd sending the patient for the MRI, though it did not appear the physician realized the patient would be transported without telemetry monitoring.
No RN accompanied the patient to the MRI suite and he was not monitored in transit nor connected to telemetry on arrival at the MRI suite. The MRI technician did call the telemetry unit and asked a nurse whether the patient needed monitoring and the answer was no.
The patient was initially advanced into the MRI machine but was pulled out when he complained of shortness of breath. He sat up and was placed on high flow oxygen again but agreed to attempt the MRI again. He then asked to be pulled from the MRI again. As the MRI tech moved the patient back to the hallway and assisted him getting back in bed, the patient had a cardiac arrest. A code was called but attempts at resuscitation were unsuccessful.
The hospitals policy on intrahospital transports had been revised about two years earlier to enable registered nurses to utilize clinical criteria to discontinue telemetry for select patients for transport to and during a test.
The hospital, in its POC (plan of correction), again revised its policy and protocol for transport of monitored patients. It would require a physicians order stating that the patient could be transported without monitoring. If telemetry or other form of monitoring is to be continued, an RN must accompany the patient to the receiving area. The POC also included appropriate dissemination of the revised policy, inservice training, and an audit of subsequent transports of telemetry patients.
Though the hospital POC mentions the hospital uses patient safety tools like the Lean Daily Management Huddle on each nursing unit and multidisciplinary hospital Safety Huddles, there is no mention whether the hospital utilizes checklists like the Ticket to Ride. We have highlighted Ticket to Ride in multiple columns (see list below). It was originally started to ensure that patients being transported had adequate oxygen supplies, since some studies showed that over half of patients transported to sites like the radiology suite ran out of oxygen.
Its worth reiterating many of the points in our August 25, 2015 Patient Safety Tip of the Week Checklist for Intrahospital Transport. Most of the literature on the risks associated with intrahospital transport have dealt with critically-ill patients. While incidents do occur during intrahospital transport of non-ICU patients, those from ICUs are the most vulnerable. The percentage of ICU patients needing such intrahospital transfer probably depends on a host of factors, such as nature of the patient population, imaging capabilities, etc. One study ((Van Velsen 2011) noted that about a third of ICU patients required intrahospital transports. The literature also suggests that the risk of incidents and adverse events during transports is also related to the time duration of the transport. Hence, events such as CT scanning tend to be associated with more incidents because they require more time (PPSA 2005). Well also bet that the percentage of incidents related to transports to the MRI suite has been increasing as MRI scanning has superseded CT scanning for so many conditions.
The overall rate of incidents during intrahospital transports is difficult to glean from the literature. In our September 16, 2008 Patient Safety Tip of the Week More on Radiology as a High Risk Area we noted studies from the 1980s and 1990s that showed rates of transport incidents as high as 70%. A paper by Smith et al ( ) noted adverse events during 34% of all ICU transports but transport of ICU patients to the CT suite was associated with a 71% incidence of adverse events. Those high rates of transport incidents have probably diminished somewhat. Some authors had previously noted an incidence of 3.7% (Van Velsen 2011) but when they prospectively monitored transports (Brunsveld-Reinders 2015) they found that in 26% of 503 transports to Radiology one or more incidents occurred.
Probably the most comprehensive review of incidents related to intrahospital transport came from the Australian Incident Monitoring Study in Critical Care, reported by researchers from Australia and Johns Hopkins (Beckmann 2004). They found 191 incidents related to intrahospital transport from 37 Australian ICUs between 1993 and 1999. Roughly a third (31%) of the incidents had serious adverse outcomes, with major physiological derangement in 15%, physical/psychological injury in 4%, death in 2%, and prolonged hospital stay in 4%. In addition, patient/family dissatisfaction occurred in 7%. The site to which the transport occurred was evenly split between the Radiology suite and the OR, with some transports to the ward, ER, or other sites. And, of course, we refer you back to our October 22, 2013 Patient Safety Tip of the Week How Safe Is Your Radiology Suite? for a comprehensive discussion of all the things that can go wrong when a patient is sent to the radiology suite.
We also refer you back to our August 25, 2015 Patient Safety Tip of the Week Checklist for Intrahospital Transport for discussion about the many factors contributing to incidents related to intrahospital transports. These include equipment failures, oxygenation issues, battery/power issues, and things like attention to patient hydration. And dont forget the problems that arise when sending diabetic patients off for substantial periods of time (what to do with their insulin, planning for meals, etc.). We refer you to the Netherlands study itself (Brunsveld-Reinders 2015) to actually see the checklist they created for intrahospital transports. The article also addresses transport team composition (which may vary depending upon whether the patient is ventilated or on pressors or inotropes) and education/training needs for members of the transport team.
A good Ticket to Ride type checklist for intrahospital transport should cover all three phases of transport: pre-transport, during-transport, and post-transport (Jarden 2010, Brunsveld-Reinders 2015)
Of course, when doing an RCA (root cause analysis) of such cases, there are always two other questions you should ask:
Though we cannot answer these two questions based on the limited amount of information in the CDPH report, the questions are still important. The first question is important since one key component of most hospital alarm management programs now is reducing the use of unnecessary telemetry (see our Patient Safety Tips of the Week for October 2014 Alarm Fatigue: Reducing Unnecessary Telemetry Monitoring, August 16, 2016 How Is Your Alarm Management Initiative Going?, and October 17, 2017 ).
The second question is important because we often see transports from ICUs for imaging or other testing that are really of marginal value in patient management. In our August 25, 2015 Patient Safety Tip of the Week Checklist for Intrahospital Transport we noted a commentary by Shirley and Bion (Shirley 2004) which noted the importance of making the decision about whether to transport a patient. They note that such decision should be made by a senior, experienced and appropriately skilled clinician who remains responsible for the conduct of the transfer. The potential benefits of a transport must be critically weighed against the potential risks. Beckmann et al. (Beckmann 2004) cite studies suggesting that care plans were changed for patients after such transports in only 24-39% of cases. So one really needs to consider how likely the imaging study (or other procedure the patient may be going for) is really going to change patient management.
In our August 25, 2015 Patient Safety Tip of the Week Checklist for Intrahospital Transport we discussed the 5 Ws of intrahospital transport (Day 2010). The first W is Why or Why does the patient need to leave the ICU for the procedure?. Important questions to ask here are Are there bedside alternatives for the procedure? And Is the patients condition stable?. If the patient is considered unstable, the next questions are Is the transport for a lifesaving intervention? and Is the transport to a diagnostic test pivotal to decision for emergent plan?. Days second W is Who. This included both who is the patient and who will be caring for the patient and, importantly, will a handoff be required? The third W is What and refers to equipment, airway, ventilator support, circulatory support, and special considerations (eg. spine stability, intracranial pressure monitors, etc.). Under the fourth W for When Day discusses considerations about coordinating with the timing of the test or procedure (eg. fasting or withholding anticoagulants for procedures), renal protective protocols for contrast-using procedures, and collaborating with other healthcare providers. The last W is for Where which includes details about the route to be taken, issues regarding MRI safety if going for MRI, etc.
Intrahospital transports, whether involving critical care patients or others, need to be undertaken with considerable planning. You need to ensure that you have systems in place to ensure the safety of the patients and tools like the Ticket to Ride checklists may facilitate safe transports.
Some of our prior columns on the Ticket to Ride concept:
Some of our prior columns on patient safety issues in the radiology suite:
Some of our prior columns on patient safety issues related to MRI:
CDPH (California Department of Public Health). 2018. Intake Number CA00462998. Accessed April 21, 2018
Van Velzen C, Brunsveld-Reinders AH, Arbous MS. Incidents related to intrahospital transport of patients in the ICU. Critical Care 2011; 15(Suppl 1): P535
Pennsylvania Patient Safety Authority. Patient Safety Advisory. Is CT a High-Risk Area for Patient Transport? PA PSRS Patient Saf Advis 2005; 2(3): 11-12
Smith I, Fleming S, Cernaianu A. Mishaps during transport from the intensive care unit. Critical Care Medicine. 1990; 18(3):278-281
Brunsveld-Reinders AH, Arbous M, Kuiper SG, de Jonge E. A comprehensive method to develop a checklist to increase safety of intra-hospital transport of critically ill patients. Critical Care 2015; 19: 214 (7 May 2015)
Beckmann U, Gillies DM, Berenholtz
SM, Wu AW, Pronovost P. Incidents relating to the
intra-hospital transfer of critically ill patients: An analysis of the reports
submitted to the Australian Incident Monitoring Study in Intensive Care.
Intensive Care Medicine 2004; 30(8): 1579-1585
Jarden RJ, Quirke S. Improving safety and documentation in intrahospital transport: development of an intrahospital transport tool for critically ill patients. Intensive Crit Care Nurs 2010; 26: 101-107
Shirley PJ, Bion JF.
Intra-hospital transport of critically ill patients: minimising
risk. Intensive Care Medicine 2004; 30(8): 1508-1510
Day D. Keeping Patients Safe During Intrahospital Transport. Crit Care Nurse 2010; 30: 18-32