Pennsylvania Patient Safety Advisory Safe Intrahospital Transport of the non-ICU Patient Using Standardized Handoff Communication ABSTRACT with communication, intravenous lines, monitoring, The intrahospital transport of the non-intensive care and other issues in 280 reports. More than 40% of unit (ICU) patient is often performed by unlicensed these issues indicated the need for improved com- hospital personnel who frequently encounter patient munication between healthcare providers (see Table). condition changes requiring immediate intervention. Healthcare organizations have increasingly recognized Healthcare organizations have increasingly recog- the benefits of standardized handoff communication nized the benefits of using a standardized handoff processes when patients are transported from one process particularly when patients are transported care area to another. from one care area to another. Of the 2,390 patient transport reports submitted to the Pennsylvania Patient Evidence from the Clinical Literature Safety Authority from May 2004 through September Current research and guidelines focus primarily on 2008, facilities identified patient transport Incidents the outcomes or equipment-related factors in the and Serious Events having problems with communica- intra- and interhospital transport for critically ill and tion, intravenous lines, monitoring and other issues pediatric populations.1-3,6,9 The clinical literature yields in 280 reports. This article will examine risk reduction few peer-reviewed articles, guidelines, or standards for strategies to ensure the safe intrahospital transport of intrahospital transport of non-ICU patients.6 In the the non-ICU patient, including but not limited to the absence of specific guidelines for the intrahospital development of an intrahospital transport team for the transport of the non-ICU patient, contributing fac- non-ICU patient, standardization of patient handoff tors to Serious Events relating to transport of critically communication tools used during transport, and a ill patients may be applied to non-ICU patient trans- robust educational program for unlicensed hospital port events. These factors should be considered when transport personnel as ways to ensure the accurate facilities develop or revise policies for the intrahospi- exchange of patient information, to decrease the num- tal transport of the non-ICU patient and competency ber of adverse events, and to promote optimal care. requirements for unlicensed hospital personnel (Pa Patient Saf Advis 2009 Mar;6[1]:16-9.) involved in patient transport. A six-month prospective observational study with a concurrent retrospective chart audit revealed Intra- or interhospital transports expose patients to 66 adverse events among 290 intrahospital transports periods of potential instability and increased risk for of critically ill patients from the emergency depart- complications, morbidity, and mortality.1-5 The Society ment (ED) to the ICU, including some admissions via of Critical Care Medicine (SCCM) and the American the operating room or after a computed tomography College of Critical Care Medicine (ACCCM) devel- (CT) scan.10 Equipment problems, hypothermia, car- oped formal transport guidelines for the intra- and diovascular events, and delays in transport were the interhospital transport of critically ill patients.1,2,4,6 adverse events identified.10 One adverse event that These guidelines suggest that critically ill patients be also occurred was the discovery of an incorrect patient transported typically by a minimum of two highly qual- identification band during a preoperative check.10 ified and specialized critical care team members who A cross-sectional analysis of 176 intrahospital transport focus on monitoring and ventilatory support.1,4,6,7 reports of critically ill patients, submitted to the No formal guidelines exist for the intrahospital trans- Australian Incident Monitoring Study in Intensive port for the non-intensive care unit (ICU) patient.6 Care database between 1993 and 1999, identified These patients are typically transported by unlicensed 55 serious adverse outcomes that included four patient personnel who lack the clinical qualifications or expe- deaths.1,9 These adverse events identified system- rience to safely monitor these patients.6,8 Facilities based problems and human factors as the underlying have had to develop their own intrahospital transport policies for the non-ICU patient.6 Without practice Table. Patient Transport Issues Submitted guidelines, essential elements necessary to complete to the Authority, May 2004 through the safe intrahospital transport of the non-ICU September 2008 patient may be inadvertently absent from policies, TRANSPORT ISSUES NUMBER OF REPORTS potentially compromising patient safety. Communication issues 115 (41%) There were 2,390 patient transport-related reports Intravenous lines/tubes 93 (33%) submitted to the Pennsylvania Patient Safety Monitoring/techniques 47 (17%) Authority from May 2004 through September 2008. Other 25 (9%) Facilities identified patient transport Incidents (or Total 280 (100%) near misses) and Serious Events having problems Page 16 REPRINTED ARTICLE - ©2009 Pennsylvania Patient Safety Authority Vol. 6, No. 1—March 2009 Pennsylvania Patient Safety Advisory contributing factors.1,9 The data taken from this anony- Scope of Practice mous, voluntary incident monitoring system identified [A] patient sent to [magnetic-resonance-imaging (MRI)] important causes of poor outcomes and contributing on 3 liters of oxygen and returned on 6 liters with no factors, while other studies focused on outcomes or call to nurse as to why it was changed. [The] trans- equipment-related mishaps.1 According to Beckmann porter told nurse that patient was [short of breath] in et al., system-based problems involved battery/power MRI so [the transporter] increased [the oxygen rate]. supply, ventilatory equipment and monitors, and Patient has chronic obstructive pulmonary disease medication-delivery systems.1 The contributing and and was unable to tolerate 6 liters. underlying human factors problems included issues Patient arrived to unit with blood transfusing, with- with communication, airway management, vascular out RN [registered nurse] accompaniment, only with lines, patient monitoring, and positioning.1 the [transporter]. The transporter personnel [was] unaware they could not transport patient with blood Handoff Communication with Transports transfusing. Handoff communication occurs whenever patient Patient in ED with [complaints of] chest pain. information and responsibility is transferred from Patient on monitor and EKG [electrocardiogram] one care provider to another. Many facilities have done. Patient sent to x-ray department [for a com- developed and implemented handoff procedures, puted tomography (CT) scan] unmonitored [and] but the Joint Commission requires that each patient accompanied by transport escort. Patient became handoff communication include a standardized and unresponsive in x-ray waiting area. X-ray staff called interactive approach for the safe transfer of a patient emergency room RN. Upon arrival in x-ray waiting from one care area to another.11 Significant barriers to area, emergency room RN called [a code] and initi- handoff communication include the lack of national ated CPR [cardiopulmonary resuscitation]. . . .upon standards for building a handoff communication arrival to CT, [the patient] collapsed, [went into car- system.12 Healthcare providers often perceive handoff diac arrest and died]. communication as a burden, and poor or failed hand- Supportive service called floor and stated that the off communication is not always apparent to those [patient’s] chest tube was stuck on the [stretcher] who perform the handoff.12 Communication break- wheels and asked that someone come and help; then downs can occur between healthcare providers along reported that they fixed the problem. Patient returned the continuum of care particularly when recent or to floor with a large hole noted in the chest [tube anticipated patient condition changes are not commu- drainage system] tubing. nicated. Handoff communication that occurs between licensed providers considers issues related to patient Monitoring monitoring, assessment, and interventions and differs Patient was transported from one telemetry unit from communication between—or may not be consid- to another without a monitoring device or appropri- ered by—unlicensed personnel because they may not ate staff. understand or be able to act upon the information or Patient transferred to ICU from [patient care unit]. monitoring data. [The patient’s] lips [were] blue and legs [were] mot- tled. [Patient was] unresponsive to any stimuli [and Safety Risks Related to Patient Transport had] inadequate respiratory effort. Patient [was] not The following reports were submitted to the on a monitor [and had] no pulse oximetry monitor- Authority from May 2004 through September 2008 ing. No IV access [because] the IV site in left forearm and illustrate Incidents and Serious Events associated initiated [was] puffy, unable to flush. with the intrahospital transport of non-ICU patients. Transport Team Development Several issues identified include patient misidenti- fication, intravenous (IV) lines/disconnection, and The development of a specialized transport team has personnel who lack the clinical qualifications or expe- been explored by many facilities after having identi- rience to safely monitor these patients. fied risk-prone situations in which unstable patients had been transported by inadequately trained person- Patient Identification nel. These interdisciplinary transport teams help to Central patient transport took [the] wrong patient reduce patient risk during transport by using stan- for chest x-ray. Radiology did not check [the patient’s dardized protocols and policies, some of which are identification] and completed the chest x-ray on the adapted from the aviation industry.7,12-14 wrong patient. The transport team protocols include the devel- opment or use of communication standards, Disconnect coordinated teamwork, defined roles and responsibili- A patient with elevated creatine phosphokinase ties of the team members, and appropriate equipment and blood pressure on a nitroglycerine [IV] drip was for a safe and effective transport. It is essential that sent to x-ray. The transport technician shut off the this process includes an intrahospital transport cur- [IV] pump, stating it was beeping. The pump was riculum consisting of step-wise, competency-based restarted with no problem for the patient. education for professional and unlicensed personnel Vol. 6, No. 1—March 2009 REPRINTED ARTICLE - ©2009 Pennsylvania Patient Safety Authority Page 17 Pennsylvania Patient Safety Advisory Questions in Assessing Transport Policies and Procedures Which patients are being transported? ■ Are they required to have Basic Life Support ■ Focus initial efforts on the most frequent source (e.g., CPR [cardiopulmonary resuscitation]) cer- units and patient types (ages, clinical diagnoses). tification (in the case of an arrest, could they initiate the ABCs of CPR)? To which locations are most patients transported? ■ What is the content of their training (does it ■ Are these destinations in the main hospital, cover how to get help during transport or how to adjacent buildings, across the street? receive and provide handoff communications)? ■ Are there special safety hazards in any of the units (e.g., MRI [magnetic resonance imaging] Handoff communication magnets)? ■ How are the patient’s condition, potential safety risks, and needs communicated? Pre-transport patient assessments ■ Is a checklist used? Is patient identification ■ What criteria are used to determine patient sta- included? bility, patient risk, and level of monitoring during transport? ■ What is the responsibility of the sending and receiving providers and/or transporters? ■ Who is responsible for this assessment? ■ What is the recommended timing for this Necessary supplies and equipment for transport assessment? ■ What equipment is required to accompany the ■ Do the assessment criteria include risk factor acute care patient during transport (eg, mask assessment based on the type of procedure/ with Ambu bag, ECG [electrocardiogram] diagnostic, patient positioning during transport, monitor)? and duration of transport time? ■ Who ensures that therapies (e.g., oxygen, infu- ■ Does the assessment take into account the pos- sions, etc.) are maintained during transport? sibility of decline in clinical condition and the need for escalating support (e.g., increase in ■ Would the transport personnel know how to use oxygen flow rate and change to NRM [non- or troubleshoot any accompanying equipment/ rebreather (oxygen mask)] with same oxygen supplies, if needed? saturations)? ■ How is this assessment communicated to the Transport monitoring care team, the transport personnel, and the des- ■ What basic level of monitoring is expected during tination personnel? transport (e.g., change in level of consciousness, ■ Finally, how is compliance monitored? color, respiratory effort, IV [intravenous] pump alarm, etc.)? And are the transporters qualified Transport personnel or adequately trained for this? ■ Who transports patients (unlicensed and ■ What is the expected level of intervention (e.g., licensed personnel)? replace an oxygen mask if it falls off, silence an ■ What are their specific responsibilities before IV pump)? and during transport? Reprinted from: Schell H, Wachter RM. Moving pains. ■ What level of training and competency assess- Web M&M [online]. 2006 Jul [cited 2008 Oct 27]. ment is done related to patient safety during Available from Internet: http://webmm.ahrq.gov/case. transport? aspx?caseID=128&searchStr=Hildy+Schell#table1. that includes but is not limited to intravenous lines, patient to the pretransported status.7 While evidence Foley catheters, and oxygen use.8,15 Many facilities suggests that dedicated transfer teams for critically ill use handoff communication checklists (e.g., SBAR patients may reduce patient mortality and morbidity, [situation-background-assessment-recommendation], little research studied specialized transport teams for read-back, ticket to ride) to standardize the approach the intrahospital transport of non-ICU patients.15 to safe intrahospital patient transport from one care Applying these same transport team protocols for area to another.12-14 Two facilities have developed the intrahospital transport of non-ICU patients can separate handoff communication checklists to differ- provide the professional and unlicensed personnel entiate between inter- and intrahospital transports.12,14 specific guidelines that promote overall patient safety before, during, and immediately following a transport. The benefits of implementing a transport team include an increase in patient safety, a decrease in the number of adverse events and in the resource burden, Risk Reduction Strategies and fewer delays in treatment, which limit interrup- The following risk reduction strategies are based on tion of patient care. Still other studies indicate a the SCCM and ACCCM practice standards for the time-saving benefit, as less time is required to prepare intrahospital transport for critically ill patients, on patients for the actual transport and to return the expert opinion, and on case series in which published Page 18 REPRINTED ARTICLE - ©2009 Pennsylvania Patient Safety Authority Vol. 6, No. 1—March 2009 Pennsylvania Patient Safety Advisory supporting data are unavailable for the intrahospital decrease the number of adverse events, and promote transport of non-ICU patients.1,2,4,6,7 overall patient safety during intrahospital transports. ■ Develop a transport team model of care with a Notes clear outline of the specific responsibilities for each 1. Beckmann U, Gillies DM, Berenholtz SM, et al. Inci- team member.2,4,6-8,15 dents relating to the intra-hospital transfer of critically ■ Coordinate pretransport communication between ill patients. An analysis of the reports submitted to the the transporter, nurse, and destination areas.2,4,13,16 Australian Incident Monitoring Study in Intensive Care. Although patient assessment is completed by the Intensive Care Med 2004 Feb;30(8):1579-85. nurse, a time lapse of the assessment greater than 2. Warren J, Fromm RE Jr, Orr RA, et al. Guidelines for two hours involves reassessment.5 All findings are the inter- and intrahospital transport of critically ill verbally communicated to the transporter and patients. Crit Care Med 2004 Jan;32(1):256-62. reviewed in the handoff communication. 3. Martins SB, Shojania KG. Safety during transport of ■ Implement a robust educational and competency critically ill patients. Chapter 47. In: Agency for Health- program for unlicensed hospital transport person- care Research and Quality. Making health care safer: a nel to ensure that facilities have staff with optimal critical analysis of patient safety practices [online]. [cited qualifications to perform non-ICU patient trans- 2008 Oct 21]. Available from Internet: http://www. ports safely.1,2,4,7,8,13,16 There are no requirements for ahrq.gov/clinic/ptsafety/chap47.htm. training or certification of unlicensed personnel 4. Pope BB. Provide safe passage for patients. Nursing Man- who transport non-ICU patients without a nurse or age 2003 Sep;34(9):41-6. physician.6 Educational competencies for unlicensed transport personnel should include but not be lim- 5. Esmail R, Banack D, Cummings C, et al. Is your patient ited to CPR certification, knowledge of the National ready for transport? Developing an ICU patient transport Patient Safety Goals, handoff communication, decision scorecard. Healthc Q 2006 Oct;9 Spec No:80-6. and expected level of intervention for unexpected 6. Schell H, Wachter RM. Moving pains. Web M&M patient decompensation during transport.2,8,14,15 It [online]. 2006 Jul [cited 2008 Oct 27]. Available is important for transport personnel to know how from Internet: http://www.webmm.ahrq.gov/case. to activate the rapid response team or code blue aspx?caseID=128. and how to contact the nurse who is caring for the 7. McLenon M. Use of a specialized transport team for patient should his or her condition change. intrahospital transport of critically ill patients. Dimens ■ Ensure that essential patient equipment for safe Crit Care Nurs 2004 Sep-Oct;23(5):225-9. intrahospital transport is functional (e.g., fully 8. Thrall JH. Education and cultural development of the charged, filled, in good repair).2,4,13 health care workforce. Part II. Opportunities for nonpro- ■ Provide cardiac monitoring, if warranted, by quali- fessional workers. Radiology 2006 Aug;240(2):311-4. fied clinical personnel.1,2,4,13 9. Shirley PJ, Bion JF. Intra-hospital transport of critically ■ Provide clear documentation to ensure that all ill patients: minimising risk. Intensive Care Med 2004 applicable patient information is available and Aug;30(8):1508-10. communicated to the next level of care and that 10. Gillman L, Leslie G, Williams T, et al. Adverse events an opportunity to ask questions is included in the experienced while transferring the critically ill patient handoff procedure (see “Questions in Assessing from the emergency department to the intensive care Transport Policies and Procedures”).1,2,13 unit. Emerg Med J 2006 Nov;23(11):858-61. ■ Monitor any Incidents or Serious Events that occur 11. Joint Commission. FAQs for the 2008 National Patient during intrahospital transport of non-ICU patients Safety Goals [online]. 2008 Mar [cited 2008 Nov 5]. because this will contribute to the overall improve- Available from Internet: http://www.jointcommission. ment in patient safety within your organization.1,15 org/NR/rdonlyres/13234515-DD9A-4635-A718- D5E84A98AF13/0/2008_FAQs_NPSG_02.pdf. Conclusion The intrahospital transport of the non-ICU patient 12. Hinkel JM. Report on the NCCN Third Annual is often performed by unlicensed hospital personnel Patient Safety Summit. J Natl Compr Canc Netw 2008 who frequently encounter patient condition changes Jul;6(6):528-35. that require immediate intervention. Risk reduction 13. Pesanka DA, Greenhouse PK, Rack LL, et al. Ticket to strategies include the development of an intrahospital ride: reducing handoff risk during hospital patient trans- transport team for the non-ICU patient. Handoff port. J Nurs Care Qual 2008 Aug26:1-7. communication using a specific tool, which includes 14. Leonard M, Graham S, Bonacum D. The human factor: written information facilitating clear communication the critical importance of effective teamwork and com- before, during, and immediately following transport munication in providing safe care. Qual Safe Health Care from the patient care unit to the destination point 2004 Oct;13(Suppl 1):i85-90. and back, is suggested. A robust educational and com- petency program for unlicensed hospital transport 15. Andrews S, Catlin S, Lamb N, et al. A dedicated personnel is essential to ensure that facilities have retrieval and transfer service: the QUARTS Project. Nurs Crit Care 2008 May-Jun;13(3):162-8. staff with optimal qualifications to perform non-ICU patient transports safely. These strategies benefit 16. Siegel N, Bird E. Opinion: letters to the editors. Health patients, ensure accurate information exchange, Environ Res Des J 2008 Summer;1(4):133-6. Vol. 6, No. 1—March 2009 REPRINTED ARTICLE - ©2009 Pennsylvania Patient Safety Authority Page 19 PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 6, No. 1—March 2009. 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THE PENNSYLVANIA PATIENT SAFETY AUTHORITY AND ITS CONTRACTORS The Pennsylvania Patient Safety Authority is an independent state agency created by Act 13 of 2002, the Medical Care Availability and Reduction of Error (“Mcare”) Act. Consistent with Act 13, ECRI Institute, as contractor for the Authority, is issuing this publication to advise medical facilities of immediate changes that can be instituted to reduce Serious Events and Incidents. For more information about the Pennsylvania Patient Safety Authority, see the Authority’s Web An Independent Agency of the Commonwealth of Pennsylvania site at http://www.patientsafetyauthority.org. ECRI Institute, a nonprofit organization, dedicates itself to bringing the discipline of applied scientific research in healthcare to uncover the best approaches to improving patient care. As pioneers in this science for nearly 40 years, ECRI Institute marries experience and independence with the objectivity of evidence-based research. 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