Impact of a preventive programme on the occurrence of incidents during the transport of critically ill patients

Intrahospital Transport of Critically Ill Patients: Safety First

How to cite this article: Juneja D, Nasa P. Intrahospital Transport of Critically Ill Patients: Safety First. Indian J Crit Care Med 2023;27(9):613-615.

Interfacility Transport of Critically Ill Patients

OBJECTIVES

To assess recent advances in interfacility critical care transport.

DATA SOURCES

PubMed English language publications plus chapters and professional organization publications.

STUDY SELECTION

Manuscripts including practice manuals and standard (1990-2021) focused on interfacility transport of critically ill patients.

DATA EXTRACTION

Review of society guidelines, legislative requirements, objective measures of outcomes, and transport practice standards occurred in work groups assessing definitions and foundations of interfacility transport, transport team composition, and transport specific considerations. Qualitative analysis was performed to characterize current science regarding interfacility transport.

DATA SYNTHESIS

The Task Force conducted an integrative review of 496 manuscripts combined with 120 from the authors' collections including nonpeer reviewed publications. After title and abstract screening, 40 underwent full-text review, of which 21 remained for qualitative synthesis.

CONCLUSIONS

Since 2004, there have been numerous advances in critical care interfacility transport. Clinical deterioration may be mitigated by appropriate patient selection, pretransport optimization, and transport by a well-resourced team and vehicle. There remains a dearth of high-quality controlled studies, but notable advances in monitoring, en route management, transport modality (air vs ground), as well as team composition and training serve as foundations for future inquiry. Guidance from professional organizations remains uncoupled from enforceable regulations, impeding standardization of transport program quality assessment and verification.

Intervenções da equipe multiprofissional no transporte de pacientes em estado crítico: revisão sistemática de métodos mistos

RESUMO Objetivo Analisar como intervenções da equipe multiprofissional promovem a segurança no transporte de pacientes em estado crítico. Método Revisão sistemática de métodos mistos elaborada com as recomendações do Joanna Briggs Institute, seguindo uma abordagem integrada convergente. A pesquisa foi realizada nas bases de dados MEDLINE, CINAHL, Cochrane Database of Systematic Reviews e Cochrane Central Register of Controlled Trials, resultando em 107 estudos. Após a remoção de estudos duplicados e a aplicação de critérios de inclusão e exclusão, 17 estudos foram avaliados quanto à sua qualidade metodológica, havendo 15 estudos na amostra final. A extração dos dados foi realizada por um instrumento em forma de tabela e sintetizada por meio de análise temática. Resultados A decisão ponderada, o planejamento, a atuação na resolução de problemas e a ação para a melhoria são intervenções que a equipe multiprofissional promove na segurança do transporte de pacientes em estado crítico. Conclusão e implicações para a prática A padronização do transporte (criação de protocolos institucionais, check-list e adequação de equipamentos), a educação permanente e o treinamento de competências na capacitação das equipes fomentam uma cultura de segurança que evita o dano ao paciente. Sugerem-se pesquisas sobre a dimensão subjetiva e a inclusão da família no transporte.

Multiprofessional team interventions in transporting critically ill patients: a systematic mixed-methods review

ABSTRACT Aim To analyze how interventions of a multidisciplinary team promote the safe transportation of critically ill patients. Method A systematic mixed-methods review was developed using an integrated convergent approach according to the Joanna Briggs Institute. This study was conducted using MEDLINE, CINAHL, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials electronic databases, which generated 107 references. After removing duplicates and applying inclusion and exclusion criteria, 17 articles were evaluated for methodological quality, resulting in 15 articles as the final sample. Data extraction was performed using a tool in the form of a table and synthesized through thematic analysis. Results Thoughtful decision, planning, problem-solving action and action for improvement are interventions that the multiprofessional team promotes the safe transportation of critically ill patients. Conclusion and implications for practice The standardization of transport (institutional protocols, a checklist, and equipment adequacy), continuing education, and skills training in the capacitation of teams foster a culture of safety that prevents harm to the patient. Further research is suggested on the subjective dimension and with the family in transportation.

Risk events during intrahospital transport of patients from the emergency department: a prospective observational study

BACKGROUND

We aimed to determine the incidence, nature of and predisposing factors for risk events (REs) that occur during the intrahospital transport of patients from the ED.

METHODS

We undertook a prospective, observational study of intrahospital patient transports from a single ED between 30 January and 20 March 2020. An investigator attended each transport and recorded any RE on a specifically designed data collection document. An RE was any mishap, even if not foreseen, that had the potential to cause the patient harm. A patient equipment number was assigned based on the number of pieces of equipment required during the transport. Poisson regression generated incidence rate ratios (IRRs) and determined risk factors for REs.

RESULTS

Of 738 transports, 289 (39.1%, 95% CI 35.6% to 42.8%) had at least one RE. The total of 521 REs comprised 125 patient-related, 279 device-related and 117 line/catheter-related REs. The most common included trolley collisions (n=142), intravenous fluid line catching/tangling (n=93), agitation/aggression events (n=31) and cardiac monitoring issues (n=31). Thirty-four (6.5%) REs resulted in an undesirable patient outcome, most commonly distress and pain. Predisposing factors for REs included an equipment number ≥3 (IRR 5.68, 95% CI 3.95 to 8.17), transport to a general ward (IRR 2.68, 95% CI 2.12 to 3.39), hypertension (IRR 1.93, 95% CI 1.07 to 3.50), an abnormal temperature and a GCS<14.

CONCLUSIONS

REs are common in transport of patients from the ED and can result in undesirable patient outcomes. Adequate pre-transfer preparation, especially securing equipment and lines, would result in a reduced risk.

Implementation of an Intrahospital Transport Checklist for Emergency Department Admissions to Intensive Care

Introduction

Intrahospital transports (IHTs) are high-risk activities with the potential for adverse outcomes. Suboptimal care of a patient in our emergency department (ED) needing IHT to the pediatric intensive care unit (ICU) identified improvement opportunities. We describe implementing a novel checklist (Briefing ED-to-ICU Transport To Exit Ready: BETTER) for improving the IHT safety of pediatric ED patients admitted to the pediatric ICU.

Methods

A multidisciplinary team used the Model for Improvement to create a key driver diagram and process map. An evidence-based IHT checklist was implemented on July 23, 2019 after multiple plan-do-study-act checklist revisions. The specific aim was a ≥80% checklist completion rate for 6 months and maintaining that rate for 6 months. An anonymous, voluntary survey of ED nurses and physicians, 9 months postimplementation, evaluated perceived improvements in IHT safety. The outcome measure was the proportion of IHT-related incident reports, per ED-to-pediatric ICU admission, comparing baseline (2-year preimplementation) and intervention (1-year postimplementation) periods. Balancing measures included a quantitative assessment for any throughput measure delays and a survey question on perceived delays.

Results

From July 23, 2019 to July 22, 2020, 335 (84%) of 400 ED-to-ICU admissions had completed IHT checklists. Ninety percent of survey respondents (84% response rate) agreed that the checklist improved IHT safety. The incident report rate was lower in the intervention period (0.5% versus 2.3%; P = 0.03), with special cause improvement on T-chart analysis. Balancing measures did not indicate any delays secondary to checklist implementation.

Conclusions

This IHT checklist was feasible and associated with improvements in perceived safety and incident event reporting. Further studies are needed to assess generalizability.

Soft Factors, Smooth Transport? The role of safety climate and team processes in reducing adverse events during intrahospital transport in intensive care

BACKGROUND

Intrahospital patient transports (IHTs) in intensive care involve an appreciable risk of adverse events (AEs). Research on determinants of AE occurrence during IHT has hitherto focused on patient, transport, and intensive care unit (ICU) characteristics. By contrast, the role of "soft" factors, although arguably relevant for IHTs and a topic of interest in general health care settings, has not yet been explored.

PURPOSE

The study aims at examining the effect of safety climate and team processes on the occurrence of AE during IHT and whether team processes mediate the effect of safety climate.

METHODOLOGY/APPROACH

Data stem from a noninterventional, observational multicenter study in 33 ICUs (from 12 European countries), with 858 transports overall recorded during 28 days. AEs include medication errors, dislodgments, equipment failures, and delays. Safety climate scales were taken from the "Patient Safety Climate in Healthcare Organizations" (short version), team processes scales from the "Leiden Operating Theatre and Intensive Care Safety" questionnaire. Patient condition was assessed with NEMS (Nine Equivalents of Nursing Manpower Use Score). All other variables could be directly observed. Hypothesis testing and assessment of effects rely on bivariate correlations and binomial logistic multilevel models (with ICU as random effect).

FINDINGS

Both safety climate and team processes are comparatively important determinants of AE occurrence, also when controlling for transport-, staff-, and ICU-related variables. Team processes partially mediate the effect of safety climate. Patient condition and transport duration are consistently related with AE occurrence, too.

PRACTICE IMPLICATIONS

Unlike most patient, transport, and ICU characteristics, safety climate and team processes are basically amenable to managerial interventions. Coupled with their considerable effect on AE occurrence, this makes pertinent endeavors a potentially promising approach for improving patient safety during IHT. Although literature suggests that safety climate is slow and hard to change (also compared to team processes), efforts to improve safety climate should not be forgone.

Improving patient safety during intrahospital transportation of mechanically ventilated patients with critical illness

Aim

Intrahospital transportation (IHT) of patients under mechanical ventilation (MV) significantly increases the risk of patient harm. A structured process performed by a well-prepared team with adequate communication among team members plays a vital role in enhancing patient safety during transportation.

Design and implementation

We conducted this quality improvement programme at the intensive care units of a university-affiliated medical centre, focusing on the care of patients under MV who received IHT for CT or MRI examinations. With the interventions based on the analysis finding of the IHT process by healthcare failure mode and effects analysis, we developed and implemented strategies to improve this process, including standardisation of the transportation process, enhancing equipment maintenance and strengthening the teamwork among the transportation teammates. In a subsequent cycle, we developed and implemented a new process with the practice of reminder-assisted briefing. The reminders were printed on cards with mnemonics including ‘VITAL’ (Vital signs, Infusions, Tubes, Alarms and Leave) attached to the transportation monitors for the intensive care unit nurses, ‘STOP’ (Secretions, Tubes, Oxygen and Power) attached to the transportation ventilators for the respiratory therapists and ‘STOP’ (Speak-out, Tubes, Others and Position) attached to the examination equipment for the radiology technicians. We compared the incidence of adverse events and completeness and correctness of the tasks deemed to be essential for effective teamwork before and after implementing the programme.

Results

The implementation of the programme significantly reduced the number and incidence of adverse events (1.08% vs 0.23%, p=0.01). Audits also showed improved teamwork during transportation as the team members showed increased completeness and correctness of the essential IHT tasks (80.8% vs 96.5%, p<0.001).

Conclusion

The implementation of reminder-assisted briefings significantly enhanced patient safety and teamwork behaviours during the IHT of mechanically ventilated patients with critical illness.

Pediatric Transport Triage: Development and Assessment of an Objective Tool to Guide Transport Planning

OBJECTIVES

We developed a Pediatric Transport Triage Tool (PT3) to objectively guide selection of team composition and transport mode, thereby standardizing transport planning. Previously, modified Pediatric Early Warning Score for transport has been used to assess illness severity but not to guide transport decision making.

METHODS

The PT3 was created for pediatric transport by combining objective evaluations of neurologic, cardiovascular, and respiratory systems with a systems-based medical condition list to identify diagnoses requiring expedited transport and/or advanced team composition not captured by neurologic, cardiovascular, and respiratory systems alone. A scoring algorithm was developed to guide transport planning. Transport data (mode, team composition, time to dispatch, patient disposition, and complications) were collected before and after PT3 implementation at a single tertiary care center over an 18-month period.

RESULTS

We reviewed 2237 inbound pediatric transports. Transport mode, patient disposition, and dispatch time were unchanged over the study period. Fewer calls using a transport nurse were noted after PT3 implementation (33.9% vs 30%, P = 0.05), with a trend toward fewer rotor-wing transports and transports requiring physicians. The majority of users, regardless of experience level, reported improved transport standardization with the tool. Need to upgrade team composition or mode during transport was not different during the study period. No adverse patient safety events occurred with PT3 use.

CONCLUSIONS

The PT3 represents an objective triage tool to reduce variability in transport planning. The PT3 decreased resource utilization and was not associated with adverse outcomes. Teams with dynamic staffing models, various experience levels, and multiple transport modes may benefit from this standardized assessment tool.

Using the Delphi method to establish nursing-sensitive quality indicators for ICU nursing in China

In this study, the Delphi method was used to develop evidence-based indicators of intensive care unit (ICU) nursing quality of care in China. Nursing quality indicators reflect elements of patient care that are directly affected by nursing practice. A comprehensive literature search identified 2,857 potentially relevant articles. From the 50 articles that were included in this study, researchers identified 38 commonly used nursing quality indicators. A panel of experts reduced these to 20, which were then subjected to two rounds of Delphi discussion by a different panel, and a final consensus was achieved. The 20 indicators were grouped into three dimensions: structure, process, and outcome (including adverse consequences). The agreement among the experts for the 20 indicators was high. These evidence-based nursing quality indicators provide for ease in data collection and a basis for clinical application and improvement in the quality of ICU nursing throughout China.

Incidence of patient safety events and process-related human failures during intra-hospital transportation of patients: retrospective exploration from the institutional incident reporting system

BACKGROUND

Intra-hospital transportation (IHT) might compromise patient safety because of different care settings and higher demand on the human operation. Reports regarding the incidence of IHT-related patient safety events and human failures remain limited.

OBJECTIVE

To perform a retrospective analysis of IHT-related events, human failures and unsafe acts.

SETTING

A hospital-wide process for the IHT and database from the incident reporting system in a medical centre in Taiwan.

PARTICIPANTS

All eligible IHT-related patient safety events between January 2010 to December 2015 were included.

MAIN OUTCOME MEASURES

Incidence rate of IHT-related patient safety events, human failure modes, and types of unsafe acts.

RESULTS

There were 206 patient safety events in 2 009 013 IHT sessions (102.5 per 1 000 000 sessions). Most events (n=148, 71.8%) did not involve patient harm, and process events (n=146, 70.9%) were most common. Events at the location of arrival (n=101, 49.0%) were most frequent; this location accounted for 61.0% and 44.2% of events with patient harm and those without harm, respectively (p<0.001). Of the events with human failures (n=186), the most common related process step was the preparation of the transportation team (n=91, 48.9%). Contributing unsafe acts included perceptual errors (n=14, 7.5%), decision errors (n=56, 30.1%), skill-based errors (n=48, 25.8%), and non-compliance (n=68, 36.6%). Multivariate analysis showed that human failure found in the arrival and hand-off sub-process (OR 4.84, p<0.001) was associated with increased patient harm, whereas the presence of omission (OR 0.12, p<0.001) was associated with less patient harm.

CONCLUSIONS

This study shows a need to reduce human failures to prevent patient harm during intra-hospital transportation. We suggest that the transportation team pay specific attention to the sub-process at the location of arrival and prevent errors other than omissions. Long-term monitoring of IHT-related events is also warranted.

Risks of Routinely Clamping External Ventricular Drains for Intrahospital Transport in Neurocritically Ill Cerebrovascular Patients

BACKGROUND

Current guidelines recommend routine clamping of external ventricular drains (EVD) for intrahospital transport (IHT). The aim of this project was to describe intracranial hemodynamic complications associated with routine EVD clamping for IHT in neurocritically ill cerebrovascular patients.

METHODS

We conducted a retrospective review of cerebrovascular adult patients with indwelling EVD admitted to the neurocritical care unit (NICU) during the months of September to December 2015 at a tertiary care center. All IHTs from the NICU of the included patients were examined. Main outcomes were incidence and risk factors for an alteration in intracranial pressure (ICP) and cerebral perfusion pressure after IHT.

RESULTS

Nineteen cerebrovascular patients underwent 178 IHTs (79.8 % diagnostic and 20.2 % therapeutic) with clamped EVD. Twenty-one IHTs (11.8 %) were associated with post-IHT ICP ≥ 20 mmHg, and 33 IHTs (18.5 %) were associated with escalation of ICP category. Forty IHTs (26.7 %) in patients with open EVD status in the NICU prior to IHT were associated with IHT complications, whereas no IHT complications occurred in IHTs with clamped EVD status in the NICU. Risk factors for post-IHT ICP ≥ 20 mmHg were IHT for therapeutic procedures (adjusted relative risk [aRR] 5.82; 95 % CI, 1.76-19.19), pre-IHT ICP 15-19 mmHg (aRR 3.40; 95 % CI, 1.08-10.76), pre-IHT ICP ≥ 20 mmHg (aRR 12.94; 95 % CI, 4.08-41.01), and each 1 mL of hourly cerebrospinal fluid (CSF) drained prior to IHT (aRR 1.11; 95 % CI, 1.01-1.23).

CONCLUSIONS

Routine clamping of EVD for IHT in cerebrovascular patients is associated with post-IHT ICP complications. Pre-IHT ICP ≥ 15 mmHg, increasing hourly CSF output, and IHT for therapeutic procedures are risk factors.

Safety First! Using a Checklist for Intrafacility Transport of Adult Intensive Care Patients

BACKGROUND

Adult critical care patients in an academic medical center experienced adverse events during intrafacility transport resulting from lack of preparation. An intervention was needed to help keep patients safe during intrafacility transport.

OBJECTIVE

To develop a checklist for transport that is easy to use and effective in preparing patients for transport.

METHOD

A checklist was developed and implemented. Elements of the checklist include preparation of the patient before transport, screening of patients for criteria that may place them at higher risk during transport, and a checklist for the procedural site.

RESULTS

From May 2011 through July 2014, 2506 transports were conducted. Of these, 97.6% (n = 2445) involved no reported complications.

CONCLUSION

This tool is suitable for bedside clinicians to use when preparing patients for transport.

How to Avoid Nontherapeutic Laparotomy in Patients With Multiple Organ Failure of Unknown Origin. The Role of CT Scan Revisited

Diagnosis of intra-abdominal diseases in critically ill patients remains a clinical challenge. Physical examination is unreliable whereas exploratory laparotomy may aggravate patient's condition and delay further evaluation. Only a few studies have investigated the place of computed tomography (CT) on this hazardous situation. We aimed to evaluate the ability of CT to prevent unnecessary laparotomy during the management of critically ill patients. Charts of all consecutive patients who had undergone an emergency nontherapeutic laparotomy from 1996 to 2013 were retrospectively studied and patient's demographic, clinical characteristics, and surgical findings were collected. During this period 59 patients had an unnecessary laparotomy. Fifty-one patients had at least one preoperative imaging and 36 had a CT scan. CT scans were interpreted to be normal (n = 12), with minor anomalies (n = 10), or major anomalies (pneumoperitoneum, portal venous gas/pneumatosis intestinalis, thickened gallbladder wall, and small bowel obstruction signs). Surgical exploration was performed through laparotomy (n = 55) or laparoscopy. Overall mortality was 37% with a median survival after surgery of 7 days. In univariate analysis, hospitalization in ICU before surgical exploration was the only factor related to death. In our series CT scans, objectively interpreted, helped avoid unnecessary surgical exploration in 61% of our patients.

A Workflow-Driven Formal Methods Approach to the Generation of Structured Checklists for Intrahospital Patient Transfers

Intrahospital transfers are a common but hazardous aspect of hospital care, with a large number of incidents posing a threat to patient safety. A growing body of work advocates the use of checklists for minimizing intrahospital transfer risk, but the majority of existing checklists are not guaranteed to be error-free and are difficult to adapt to different clinical settings or changing hospital policies. This paper details an approach that addresses these challenges through the employment of workflow technologies and formal methods for generating structured checklists. A three-phased methodology is proposed, where intrahospital transfer processes are first conceptualized, then rigorously composed into workflows that are mechanically verified, and finally, translated into a set of checklists that support hospital staff while maintaining the dependencies between different transfer tasks. A case study is presented, highlighting the feasibility of this approach, and the correctness and maintainability benefits brought by the logical underpinning of this methodology. A checklist evaluation is discussed, with promising results regarding their usefulness.

Complications during intrahospital transport of critically ill patients: Focus on risk identification and prevention

Intrahospital transportation of critically ill patients is associated with significant complications. In order to reduce overall risk to the patient, such transports should well organized, efficient, and accompanied by the proper monitoring, equipment, and personnel. Protocols and guidelines for patient transfers should be utilized universally across all healthcare facilities. Care delivered during transport and at the site of diagnostic testing or procedure should be equivalent to the level of care provided in the originating environment. Here we review the most common problems encountered during transport in the hospital setting, including various associated adverse outcomes. Our objective is to make medical practitioners, nurses, and ancillary health care personnel more aware of the potential for various complications that may occur during patient movement from the intensive care unit to other locations within a healthcare facility, focusing on risk reduction and preventive strategies.

Intrahospital transports of critically ill patients: critical care nurses' perceptions

BACKGROUND

Between 30% and 70% of intrahospital transports is associated with some form of adverse event, compromising patient safety.

AIMS

(1) To describe critical care nurses' perceptions of intrahospital transport problems, including the stress associated with transport and their perceived ability to respond appropriately to these problems; (2) to determine if there were associations between problems and responses.

DESIGN AND METHODS

This survey was conducted in three intensive care units. Descriptive data and correlations between perceived problems and responses and correlations between perceptions of the problems and ability to respond appropriately were calculated. Results from the open-ended item were categorised.

RESULTS

Eighty-six nurses completed the web survey, a response rate of 57%. Two-thirds said their intensive care Units had written transport guidelines, and two-thirds of the transports were performed by nurses without physicians. Circulatory failure was the most frequently perceived problem (4·2 ± 2·8) followed by decreased levels of consciousness (3·5 ± 2·9). Positive correlations between two perceived patient problems, circulatory failure and neurological deterioration and nurses' perceptions of how to respond appropriately to them, were identified. Failure in pulse oximetry and equipment-related problems were positively correlated to nurses' responses. Nurses described the transports as an unsafe and stressful task: 'It's like a marathon race'.

CONCLUSION

Nurses report that undertaking transports were a stressful activity, but they perceived transport problems to be an infrequent occurrence. They stated that they respond appropriately to the problem.

RELEVANCE TO CLINICAL PRACTICE

Nurses reported they were alert to the potential risks patients face during transport. Because fewer staff remained in the intensive care units, these remaining patients are also at risk during intrahospital transport.

Caracterização do transporte de pacientes críticos na modalidade intra-hospitalar

Objetivo: Caracterizar o transporte de pacientes críticos em unidade de terapia intensiva adulto. Métodos: Estudo transversal onde foram incluídos 459 transportes de pacientes críticos na modalidade intrahospitalar. Os dados foram coletados nos prontuários clínicos dos pacientes e em um formulário com a descrição dos materiais e equipamentos necessários ao procedimento, descrição de ocorrências adversas e da equipe que realizou. Resultados: Foram realizados 459 transportes de 262 pacientes críticos com média de 51 transportes por mês. Eram pacientes em suporte ventilatório (41,3%) e 34,5% em uso de drogas vasoativas. Em 9,4% dos transportes ocorreram eventos adversos sendo 77,3% das equipes compostas por médico, enfermeiro e técnico de enfermagem. Conclusão: Os transportes de pacientes críticos ocorreram no período da manhã, para realização de tomografia computadorizada, com pacientes dependentes de suporte ventilatório e drogas vasoativas. Os equipamentos durante o transporte estavam funcionando e, os eventos adversos ocorridos foram atribuídos a alterações clínicas dos pacientes.