Adverse events experienced while transferring the critically ill patient from the emergency department to the intensive care unit

Pro/con debate: do the benefits of regionalized critical care delivery outweigh the risks of interfacility patient transport?

You are providing input in planning for critical care services to a large regional health authority. You are considering concentrating some critical care services into high-volume regional centres of excellence, as has been done in other fields of medicine. In your region, this would require several centres with differing levels of expertise that are geographically separated. Given there are inherent risks and time delays associated with interfacility patient transport, you debate whether these potential risks outweigh the benefits of regional centres of excellence.

Epidemiology of adverse events in air medical transport

OBJECTIVES

This observational study determined frequency and describes all-cause adverse event epidemiology in a large air medical transport system.

METHODS

Records of a mandatory reporting system were reviewed and a data set containing all of the patient care records was searched to identify aviation- and non-aviation-related adverse events. Two reviewers independently identified adverse events and categorized them using an established taxonomy. Descriptive statistics were used to report adverse events, with frequency calculated per 1,000 flights and 1,000 hours flown.

RESULTS

Between January 1, 2002, and June 30, 2005, there were 1,447 reports, of which 598 included an adverse event. Case-finding identified an additional 125. A complete report was available in 680 of 723 (94.1%) events. There were 58,956 flights and 103,632 hours flown during the study period, for a rate of 11.53 adverse events per 1,000 flights (95% CI = 10.7 to 12.4 adverse events) or 6.56 per 1,000 hours flown (95% CI = 6.1 to 7.1 adverse events). The frequencies of events by category were as follows: communication (229; 33.7%), transport vehicle (143; 21.0%), medical equipment (88; 12.9%), patient management (77; 11.4%), clinical performance (68; 10.0%), weather (30; 4.4%), unclassified (24; 3.5%), and patient factors causing death (21; 3.1%). There was possible patient harm in 117 events.

CONCLUSIONS

Air medical transport is associated with a low incidence of adverse events and possible patient harm. Communication problems were the most common cause of an event. Determining event epidemiology is necessary to identify modifiable factors, propose solutions to decrease the adverse events, and direct future efforts to improve safety.

Are Trainees Equipped to Transfer Critically Ill Patients?

Transferring critically ill patients, whether intra- or inter-hospital, is an integral part of the daily working life of intensive care unit staff. It requires a multitude of skills, including thorough patient assessment, rigorous pre-transfer preparation, and constant vigilance throughout the transfer to ensure the safety of the patient. The development of these skills is a fundamental necessity for trainees in critical care. We investigated current critical care trainees' experience of patient transfer in one region in the UK, and assessed their views of their training in patient transfer. The results of our survey demonstrate some worrying conclusions about deficiencies in specific transfer training. We hope to encourage a discussion about the standards in transfer training which are needed and the best way to deliver such training.

Unexpected events during the intrahospital transport of critically ill patients

OBJECTIVES

To examine unexpected events (UEs) that occur during the intrahospital transport of critically ill emergency department patients.

METHODS

This was a prospective observational study of consecutive intrahospital transports between March 2003 and June 2004. The escorting emergency physician completed the data collection document either during or immediately after the transport. This document detailed equipment-related UEs, patient instability and invasive line-related UEs, whether the UEs required intervention, and whether the UEs were potentially life threatening (serious UEs).

RESULTS

Of 339 transports observed, 230 (67.9%; 95% confidence interval [CI] = 62.6% to 72.7%) were associated with 604 UEs. Overall, there was a median of 1.0 UE per transport (range, 0-16). There were 277 (45.9%; 95% CI = 41.8% to 49.9%) UEs related to equipment, 158 (26.2%; 95% CI = 22.7% to 29.9%) related to patient instability, 156 (25.8%; 95% CI = 22.4% to 29.6%) related to equipment lines, and 13 (2.2%, 95% CI = 1.2% to 3.8%) miscellaneous UEs. The most common UEs were oxygen saturation probe failures, lead and line tangles, hypotension, and the wearing off of sedation and/or paralysis. Most UEs (478 [79.1%]; 95% CI = 75.6% to 82.3%) required an intervention. Emergency physicians had a significantly lower UE rate than residents. Thirty serious UEs occurred; 5.0% (95% CI = 3.4% to 7.1%) of UEs and 8.9% (95% CI = 6.2% to 12.5%) of transports were associated with a serious UE. The most common were severe hypotension, decreasing consciousness requiring intubation, and increased intracranial pressure.

CONCLUSIONS

Unexpected events during the intrahospital transport of critically ill patients from the emergency department are common and can be potentially life threatening. Transporting physician experience is associated with UE rate. Strict adherence to and review of existing transport guidelines is recommended.