Adverse events during intrahospital transport of critically ill patients: A systematic review and meta-analysis

A new classification for emergency critically ill patients and analysis of their adverse events during intrahospital transport: A cluster analysis

BACKGROUND

Critical patients may experience various adverse events during transportation within hospitals. Therefore, quickly evaluating and classifying patients before transporting them from the emergency department and focusing on managing high-risk patients are critical. At present, no unified classification method exists; all the current approaches are subjective.

AIMS

To ensure transportation safety, we conducted a cluster analysis of critically ill patients transferred from the emergency department to the intensive care unit.

STUDY DESIGN

Single-centre cohort study. This study was conducted at a comprehensive first-class teaching hospital in Beijing. Convenience sampling and continuous enrolment were employed. We collected data from 1 January 2019, to 31 December 2021. All patients were transferred from the emergency department to the intensive care unit, and cluster analysis was conducted using five variables.

RESULTS

A total of 584 patients were grouped into three clusters. Cluster 1 (high systolic blood pressure group) included 208 (35.6%) patients. Cluster 2 (high heart rate and low blood oxygen group) included 55 (9.4%) patients. Cluster 3 (normal group) included the remaining 321 (55%) patients. The oxygen saturation levels of all the patients were lower after transport, and the proportion of adverse events (61.8%) was the highest in Cluster 2 (p < .05).

CONCLUSIONS

This study utilized data on five important vital signs from a cluster analysis to explore possible patient classifications and provide a reference for ensuring transportation safety.

RELEVANCE TO CLINICAL PRACTICE

Before transferring patients, we should classify them and implement targeted care. Changes in blood oxygen levels in all patients should be considered, with a focus on the occurrence of adverse events during transportation among patients with high heart rates and low blood oxygen levels.

Status of knowledge, attitude and practice of clinical nurses towards the intrahospital transport of critically ill patients: A cross-sectional study

AIMS

To explore the knowledge, attitudes and practice status of the intrahospital transport (IHT) of critically ill patients among clinical nurses and their influencing factors.

DESIGN

Cross-sectional study.

METHODS

A questionnaire determined the nurses' knowledge, attitudes and practice scores. The questionnaire was used for data collection in a tertiary hospital from 10 January to 17 January 2023. Multivariate regression analysis was also used to evaluate the related factors of IHT of critically ill patients in different dimensions.

RESULTS

Out of 670 distributed questionnaires, 612 nurses returned the completed questionnaire. The scores of KAP were (9.72 ± 1.61), (42.91 ± 4.58) and (82.84 ± 1.61), respectively. Pearson's correlation analysis showed that knowledge, attitude and behaviour scores were positively correlated. Variables that were associated with the scores of transfer knowledge were the scores of transfer practice, different departments and the scores of transfer attitude. The score of practice, number of IHT and received hospital-level training had statistical significance on the nurses' attitude scores. Furthermore, the score of the attitude and transport knowledge had statistical significance on the nurses' practice.

CONCLUSION

The findings indicate a clear need for clinical nurses' knowledge of IHT of critically ill patients, especially in the emergency department (ED) and ICU. In addition, nurses need to be more active in transporting critically ill patients. Managers should enhance nurses' confidence in the IHT of critically ill patients and promote clinical nurses to establish a correct and positive attitude.

IMPACT

The findings of this study benefit nursing managers in understanding the current situation of IHT of critically ill patients. Managers should apply new training methods to nursing education and develop a multi-level training program that is systematic, comprehensive and demand-oriented.

PATIENT OR PUBLIC CONTRIBUTION

The participants of this study were nurses and this contribution has been explained in the Data collection section. There was no patient contribution in this study.

Cerebral hemodynamics and optic nerve sheath diameter acquired via neurosonology in critical patients with severe coronavirus disease: experience of a national referral hospital in Peru

Aim

We aimed to describe the neurosonological findings related to cerebral hemodynamics acquired using transcranial Doppler and to determine the frequency of elevated ICP by optic nerve sheath diameter (ONSD) measurement in patients with severe coronavirus disease (COVID-19) hospitalized in the intensive care unit of a national referral hospital in Peru.

Methods

We included a retrospective cohort of adult patients hospitalized with severe COVID-19 and acute respiratory failure within the first 7 days of mechanical ventilation under deep sedoanalgesia, with or without neuromuscular blockade who underwent ocular ultrasound and transcranial Doppler. We determine the frequency of elevated ICP by measuring the diameter of the optic nerve sheath, choosing as best cut-off value a diameter equal to or >5.8 mm. We also determine the frequency of sonographic patterns obtained by transcranial Doppler. Through insonation of the middle cerebral artery. Likewise, we evaluated the associations of clinical, mechanical ventilator, and arterial blood gas variables with ONSD ≥5.8 mm and pulsatility index (PI) ≥1.1. We also evaluated the associations of hemodynamic findings and ONSD with mortality the effect size was estimated using Poisson regression models with robust variance.

Results

This study included 142 patients. The mean age was 51.39 ± 13.3 years, and 78.9% of patients were male. Vasopressors were used in 45.1% of patients, and mean arterial pressure was 81.87 ± 10.64 mmHg. The mean partial pressure of carbon dioxide (PaCO2) was elevated (54.08 ± 16.01 mmHg). Elevated intracranial pressure was seen in 83.1% of patients, as estimated based on ONSD ≥5.8 mm. A mortality rate of 16.2% was reported. In the multivariate analysis, age was associated with elevated ONSD (risk ratio [RR] = 1.07). PaCO2 was a protective factor (RR = 0.64) in the cases of PI ≥ 1.1. In the mortality analysis, the mean velocity was a risk factor for mortality (RR = 1.15).

Conclusions

A high rate of intracranial hypertension was reported, with ONSD measurement being the most reliable method for estimation. The increase in ICP measured by ONSD in patients with severe COVID-19 on mechanical ventilation is not associated to hypercapnia or elevated intrathoracic pressures derived from protective mechanical ventilation.

Simulated impact of lift car sizes on transport of critical care patients: Informing the design of the New Dunedin Hospital

The New Dunedin Hospital (NDH) is New Zealand's largest health infrastructure build. Here we describe the use of a simple simulation-based hospital design exercise to inform the appropriate lift car size for critical care intrahospital transfers in the NDH. The intensive care unit (ICU) user group tested a series of entries and exits of simulated complex patient transfers in mocked-up lift cars of three different dimensions. Time taken to enter and exit the lift were recorded, reflecting the relative difficulty of transfer. Qualitative assessments were made of ease and perceived safety of transfer. These simulations demonstrated that recommended standard patient lift cars, often proposed for critical care transfers, could not physically accommodate all complex ICU transfers. A size of 1800 mm wide (W) × 3000 mm deep (D) had the physical capacity to permit all simulated ICU transfers, but with staff and patient risk. As lift car size increased to 2200 mm W × 3300 mm D, the simulation demonstrated reduced transfer times, smoother entry and exit, improved access to the head end of the bed, and reduced risk of disconnection or dislodgement of lines and airway support. The resultant clinical recommendations for the dimensions of a critical care lift car surpass current international health architecture guidelines and may help to inform future updates. The NDH project benefited from an objective assessment of risk, in language familiar to clinicians and healthcare architects. The outcome was an upsizing of the two ICU-capable lifts.

Real emotional experience of family members of patients transported within hospital in neurosurgical intensive care unit: A descriptive qualitative study

AIM

To understand the real experience of family members of patients in neurosurgical intensive care unit (NICU) during intra-hospital transport (IHT), explore their inner needs and provide effective intervention measures for the construction of standardized IHT plan.

DESIGN

A descriptive qualitative study.

METHODS

For the purposes of this study, 10 family members of IHT patients were included using a purposive sampling method. Semi-structured in-depth interviews were used to collect the data, Nvivo 11 software was used to organize the data, and Colaizzi's 7-step descriptive phenomenology method was used to analyse the data.

RESULTS

A total of three themes and nine subthemes were extracted, namely: Experience of emotional changes at different stages (uncertainty before transfer, complex internal activity during transit, ambivalence after transfer); Perception of problems in IHT (poor doctor-patient communication, weak awareness of risk assessment, deficiencies in the transfer procedure); Consciousness of the real needs (emotional respect and closeness, stay informed of the progression of the disease, greater social support).

CONCLUSION

Family members of patients in the NICU have complex internal experiences and multiple support needs during IHT, reflecting the need for further standardization of the transport process. In the future, we should improve the mode of safe IHT involving doctors, nurses and family members of patients, ensure the safety of patient transport, meet the social support needs of family members and improve the experience of IHT and the medical satisfaction of family members.

Reliability and validity assessment of the Chinese version of the Intrahospital Transport Safety Scale (IHTSS) in intensive care units

BACKGROUND

Intrahospital transport of critically ill patients is a common practice in intensive care units (ICUs), where patients' safety is constantly challenged in high-intensity and dynamic environments. While Intrahospital Transport Safety Scale (IHTSS) is widely used internationally to evaluate the intrahospital transport safety, it has not been introduced in China.

OBJECTIVES

This study aimed to assess the reliability and validity of the Chinese version of the IHTSS scale among critical care nurses in China.

METHODS

A cross-sectional study was conducted using a cluster sampling method. A total of 544 critical care nurses from 25 ICUs in 10 tertiary hospitals were recruited. We employed exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) to examine the questionnaire's underlying factor structure, ensuring construct validity. Additionally, internal consistency was assessed using Cronbach's alpha coefficient, test-retest reliability, and corrected item-total correlation.

RESULTS

The Chinese version of the scale displayed robust psychometric properties, with a Cronbach's α coefficient of 0.976, a split-half reliability of 0.906, and a test-retest reliability of 0.856. EFA revealed a robust four-factor model that accounted for 75.970% of the variance, with the factor loadings of the items ranging from 0.433 to 0.951. CFA indicated a strong model fit, with a chi-square to degrees of freedom ratio (CMIN/DF) of 2.765, comparative fit index (CFI) of 0.943, incremental fit index (IFI) of 0.943, and goodness-of-fit index (GFI) of 0.845, supporting the efficacy of the four-factor model in assessing intrahospital transport safety for critically ill patients.

CONCLUSION

The Chinese version of the IHTSS demonstrated favourable reliability and validity among critical care nurses in China, making it a suitable tool for measuring the level of intrahospital transport safety for critically ill patients.

Use of an assessment system for the allocation of human resources in the intrahospital transport of the patient admitted to an intensive care unit

INTRODUCTION

Currently, in intensive care units (ICUs), the in-hospital transport (HIT) of patients is carried out without a unified criterion of personnel necessary for it.

OBJECTIVE

To evaluate the concordance of the Patient Assessment System for Transport-ICU (PAST-ICU) with the medical criteria (CM) to determine the Human Resources (HR) and identify Adverse Effects (AE).

METHODS

Descriptive, cross-sectional and prospective study of the IHT of patients admitted to an area of adult medical-surgical critical patients. The PAST-ICU instrument was created to recommend the HR of HIT. Through the assessment of clinical parameters, the Past-ICU indicates whether the HIT should be performed with (1) a stretcher-bearer (2) Stretcher-bearer/nurse or (3) stretcher-bearer/nurse/doctor. AE were recorded during the hospital transfer. Prior to the IHT, the nurse performed the PAST-ICU and the result was contrasted with the Medical Criteria (MC) responsible for the patient, the latter prevailing.

STUDY PERIOD

Phase 1: pilot test 2013-2014. Phase 2: 2015-2021.

VARIABLES

Reason and duration HIT, PAST-ICU sheet, checklist, AE.

RESULTS

Phase 1: 458 IHT were analyzed. The concordance index between the PAST-ICU and the MC was 84,9% (389 IHT). The Cohen Kappa of 58,5% and p < 0,001. There were a total of 16 AE. Phase 2: 3423 IHT. The Concordance index of 87,2% (2984 TIH). The Cohen Kappa of 63%and the P < 0,001. Registered 49 AE.

CONCLUSION

The PAST-ICU could be a useful, safe and reliable tool to adapt the necessary HR. There was good concordance between the PAST-ICU vs the MC to determine the HR in the HIT. The percentage of AE was low.

Bedside electrical impedance tomography to assist the management of pulmonary embolism: A case report

Background

Pulmonary embolism (PE) is a common worldwide disease with high mortality. Timely diagnosis and management of PE could significantly improve clinical outcomes. Electrical impedance tomography (EIT) is a novel noninvasive technique to monitor lung perfusion and help detect PE at the bedside. Here we present a case of clinical management of subsegmental PE with the help of the bilateral ventilation and perfusion(V/Q) asymmetry EIT image.

Case presentation

A 72-year-old cancer patient with respiratory failure and acute kidney injury in the intensive care unit was suspected of PE based on his clinical manifestation. The contraindication of computed tomography pulmonary angiography (CTPA) for PE diagnosis prevented escalating anticoagulation therapy. Besides EIT ventilation and perfusion monitoring showed an abnormal asymmetry V/Q match between the bilateral lungs which promoted our decision to start systemic continuous anticoagulation therapy and improved the patient clinically. The following CTPA which clarified the diagnosis of PE suggests that the patient has benefited from our decision.

Conclusion

For critically ill patients with suspected PE, the asymmetry of the EIT V/Q image may provide crucial objective information for clinical management.

The Role of Paramedics in Disclosure of Patient Safety Incidents: A Mixed Methods Study

OBJECTIVE

Critical care transport is a high-risk environment ripe for patient safety incidents (PSIs). Disclosure is the process by which a PSI is communicated to a patient or substitute decision maker. Little is known on paramedic perceptions on disclosure PSIs. This study evaluated the impact of a disclosure training program on the perceptions of paramedics on disclosing PSIs.

METHODS

This was a before-and-after mixed methods survey study on paramedic disclosure training at Ornge, the provincial critical care transport organization for Ontario, Canada. A paramedic disclosure training program was implemented at Ornge between 2020 and 2022. All paramedics were eligible for participation through pre- and posttraining surveys.

RESULTS

In total, 54 and 69 paramedics completed the pretraining and posttraining surveys, respectively, representing 25% to 30% of all active paramedics. All of the paramedics (100%) expressed a moral and professional responsibility to disclose PSIs. All paramedics felt disclosure training was somewhat to extremely useful. After training, more paramedics felt comfortable disclosing PSIs, and more paramedics felt disclosure could occur at the time of transport.

CONCLUSION

A training program on PSIs can improve paramedics' perceptions on disclosure. This study shows its feasible for paramedics to feel comfortable and participate in disclosure of PSIs within a critical care environment.

Intrahospital Transport of Critically Ill Patients with Subarachnoid Hemorrhage-Frequency, Timing, Complications, and Clinical Consequences

BACKGROUND

Patients with subarachnoid hemorrhage (SAH) often necessitate intra-hospital transport (IHT) during intensive care treatment. These transfers to facilities outside of the neurointensive care unit (NICU) pose challenges due to the inherent instability of the hemodynamic, respiratory, and neurological parameters that are typical in these patients.

METHODS

In this retrospective, single-center cohort study, a total of 108 IHTs were analyzed for demographics, transport rationale, clinical outcomes, and pre/post-IHT monitoring parameters. After establishing clinical thresholds, the frequency of complications was calculated, and predictors of thresholds violations were determined.

RESULTS

The mean age was 55.7 (+/-15.3) years, with 68.0% showing severe SAH (World Federation of Neurosurgical Societies Scale 5). IHTs with an emergency indication made up 30.8% of all transports. Direct therapeutic consequences from IHT were observed in 38.5%. On average, the first IHT occurred 1.5 (+/-2.0) days post-admission and patients were transported 4.3 (+/-1.8) times during their stay in the NICU. Significant parameter changes from pre- to post-IHT included mean arterial pressure, systolic blood pressure, oxygen saturation, blood glucose levels, temperature, dosages of propofol and ketamine, tidal volume, inspired oxygen concentration, Horovitz index, glucose, pH, intracranial pressure, and cerebral perfusion pressure. Relevant hemodynamic thresholds were violated in 31.5% of cases, while respiratory complications occurred in 63.9%, and neurological complications in 20.4%. For hemodynamic complications, a low heart rate with a threshold of 61/min (OR 0.96, 95% CI 0.93-0.99, p = 0.0165) and low doses of midazolam with a threshold of 17.5 mg/h (OR 0.97, 95% CI 0.95-1.00, p = 0.0232) significantly predicted adverse events. However, the model did not identify significant predictors for respiratory and neurological outcomes.

CONCLUSIONS

Conclusively, IHTs in SAH patients are associated with relevant changes in hemodynamic, respiratory, and neurological monitoring parameters, with direct therapeutic consequences in 4/10 IHTs. These findings underscore the importance of further studies on the clinical impact of IHTs.

Practice of 18F-FDG-PET/CT in ICU Patients: A Systematic Review

18F-FDG-PET/CT imaging has become a key tool to evaluate infectious and inflammatory diseases. However, application of 18F-FDG-PET/CT in patients in the intensive care unit (ICU) is limited, which is remarkable since the development of critical illness is closely linked to infection and inflammation. This limited use is caused by perceived complexity and risk of planning and executing 18F-FDG-PET/CT in such patients. The aim of this systematic review was to investigate the feasibility of 18F-FDG-PET/CT in ICU patients with special emphasis on patient preparation, transport logistics and safety. Therefore, a systematic search was performed in PubMed, Embase, and Web of Science using the search terms: intensive care, critically ill, positron emission tomography and 18F-FDG or derivates. A total of 1183 articles were found of which 10 were included. Three studies evaluated the pathophysiology of acute respiratory distress syndrome, acute lung injury and acute chest syndrome. Three other studies applied 18F-FDG-PET/CT to increase understanding of pathophysiology after traumatic brain injury. The remaining four studies evaluated infection of unknown origin. These four studies showed a sensitivity and specificity between 85%-100% and 57%-88%, respectively. A remarkable low adverse event rate of 2% was found during the entire 18F-FDG-PET/CT procedure, including desaturation and hypotension. In all studies, a team consisting of an intensive care physician and nurse was present during transport to ensure continuation of necessary critical care. Full monitoring during transport was used in patients requiring mechanical ventilation or vasopressor support. None of the studies used specific patient preparation for ICU patients. However, one article described specific recommendations in their discussion. In conclusion, 18F-FDG-PET/CT has been shown to be feasible and safe in ICU patients, even when ventilated or requiring vasopressors. Specific recommendations regarding patient preparation, logistics and scanning are needed. Including 18F-FDG-PET/CT in routine workup of infection of unknown origin in ICU patients showed potential to identify source of infection and might improve outcome.

Evaluation of the safety status of intrahospital transfer of critically ill patients from the perspective of emergency and ICU nurses: a cross-sectional study in Iran

OBJECTIVE

Critically ill patients often require intrahospital transfer (IHT) for diagnostic and therapeutic procedures. However, this process carries potential risks and can harm the patient's safety. This study aimed to assess the safety of IHT for critically ill patients by gathering feedback from emergency and intensive care unit (ICU) nurses.

DESIGN

A cross-sectional study.

SETTING

A study was conducted in Ardabil City, Iran's educational and medical hospitals. The study involved 288 emergency and ICU nurses. The data were collected through a paper-based form, which included demographic and work-related characteristics and an IHT safety scale.

RESULTS

The mean score of IHT was 75.2±15.53. The results of multiple regression analysis showed that work experience (B=0.291, p=0.011), perception of IHT safety (B=0.196, p=0.003), education level (B=-0.123, p=0.038) and equipment checker (B=-0.121, p=0.045), variables were the predictors of IHT safety.

CONCLUSION

The study found that the safety level during the interhospital transfer (IHT) was low. Hospitals aim to create a safe environment that minimises the risks associated with IHT. Therefore, they must identify potential risks during the transfer process and take necessary measures to mitigate them. Practical strategies that can be employed include using experienced nursing staff, conducting equipment checks, ensuring a complete understanding of the tools and technologies involved in the transfer process, and increasing awareness of IHT safety.

Potential application of ultra-low field portable MRI in the ICU to improve CT and MRI access in Canadian hospitals: a multi-center retrospective analysis

Background

To highlight the value of Portable MRI in ICU and to recommend use case scenarios for portable MRI in ICU patients that may increase capacity for fixed CT and MRI units. Urgent neuroimaging is commonly required in ICU. Typically, ICU patients are transported to Radiology for assessment in fixed CT and MRI units. Portable MRI use in Canadian ICU settings offers the potential advantages of reduced transport risk, earlier diagnosis, improved triaging, as well as the ability to perform frequent re-imaging at the bedside. This frees up time on fixed CT and MRI units, leading to enhanced capacity to perform CT and MRI on other patients. Portable MRI use case scenarios in Canadian institutions have not been established and potential beneficial effect on wait times has not been analyzed.

Methods

A retrospective semi-quantitative descriptive analysis was performed using all ICU neuroimaging requisitions (CT and MRI) over a 12-month period between January and December 2021, at Kingston Health Sciences Centre, Queen's University (Kingston, Ontario) and St. Michael's Hospital, Unity Health, University of Toronto (Toronto, Ontario). Indications for portable MRI in ICU patients were established. The number of ICU patients who could potentially undergo portable MRI was determined. Fixed CT and MRI scan times saved were calculated.

Results

In ICU patients, portable MRI could potentially replace fixed CT in 21% and fixed MRI in 26.5% of cases. This equates to annual capacity increase of 1,676 additional patients being able to undergo fixed CT scans and 324 additional patients being able to undergo fixed MRI.

Conclusion

Implementation of portable MRI in the ICU for select neurological indications can have a significant positive impact on CT and MRI wait times in Canadian hospitals.

The impact of atypical intrahospital transfers on patient outcomes: a mixed methods study

The architectural design of hospitals worldwide is centred around individual departments, which require the movement of patients between wards. However, patients do not always take the simplest route from admission to discharge, but can experience convoluted movement patterns, particularly when bed availability is low. Few studies have explored the impact of these rarer, atypical trajectories. Using a mixed-method explanatory sequential study design, we firstly used three continuous years of electronic health record data prior to the Covid-19 pandemic, from 55,152 patients admitted to a London hospital network to define the ward specialities by patient type using the Herfindahl-Hirschman index. We explored the impact of 'regular transfers' between pairs of wards with shared specialities, 'atypical transfers' between pairs of wards with no shared specialities and 'site transfers' between pairs of wards in different hospital site locations, on length of stay, 30-day readmission and mortality. Secondly, to understand the possible reasons behind atypical transfers we conducted three focus groups and three in-depth interviews with site nurse practitioners and bed managers within the same hospital network. We found that at least one atypical transfer was experienced by 12.9% of patients. Each atypical transfer is associated with a larger increase in length of stay, 2.84 days (95% CI 2.56-3.12), compared to regular transfers, 1.92 days (95% CI 1.82-2.03). No association was found between odds of mortality, or 30-day readmission and atypical transfers after adjusting for confounders. Atypical transfers appear to be driven by complex patient conditions, a lack of hospital capacity, the need to reach specific services and facilities, and more exceptionally, rare events such as major incidents. Our work provides an important first step in identifying unusual patient movement and its impacts on key patient outcomes using a system-wide, data-driven approach. The broader impact of moving patients between hospital wards, and possible downstream effects should be considered in hospital policy and service planning.

Adverse Events during Intrahospital Transport of Critically Ill Patients: A Multicenter, Prospective, Observational Study (I-TOUCH Study)

Background

Critically ill patients are frequently transported to various locations within the hospital for diagnostic and therapeutic purposes, which increases the risk of adverse events (AEs). This multicenter prospective observational study was undertaken to determine the incidence of AEs related to intrahospital transport, their severity, and their effects on patient outcomes.

Patients and methods

We included consecutive unstable critically ill patients requiring intrahospital transport, across 15 Indian tertiary care centers over 5 months (October 11, 2022-February 20, 2023). Apart from the demographics and severity of illness, data related to transport itself, such as indications and destination, incidence of AEs, their category and treatment required, and patient outcomes, were recorded in a standard form.

Results

Eight hundred and ninety-three patients were transported on 1065 occasions out of the intensive care unit (ICU). The mean (SD) acute physiology and chronic health evaluation II score of the patients was 15.38 (±7.35). One hundred and two AEs occurred, wherein cardiovascular instability was the most common occurrence (31, 30.4%). Two patients had cardiac arrest immediately after transport. Acute physiology and chronic health evaluation II [odds ratio (OR): 1.02, 95% confidence interval (CI) - 1.00-1.05, p = 0.04], emergent transport (OR: 5.11, 95% CI - 3.32-7.88, p = 0.00), and team composition (OR: 5.34, 95% CI - 1.63-17.5, p = 0.00) during transport were found to be independent predictors of AEs.

Conclusion

We found a high incidence of AEs during intrahospital transport of critically ill patients. These events were more common during emergent transports and when the patients were transported by doctors. Transport by itself was not related to ICU mortality. We feel that stabilization of the patients before transport and adherence to a standardized protocol may help in minimizing the AEs, thereby enhancing patient safety.

How to cite this article

Zirpe KG, Tiwari AM, Kulkarni AP, Govil D, Dixit SB, Munjal M, et al. Adverse Events during Intrahospital Transport of Critically Ill Patients: A Multicenter, Prospective, Observational Study (I-TOUCH Study). Indian J Crit Care Med 2023;27(9):635-641.

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.

Benchmarking Hospital Practices and Policies on Intrahospital Neurocritical Care Transport: The Safe-Neuro-Transport Study

An electronic survey was administered to multidisciplinary neurocritical care providers at 365 hospitals in 32 countries to describe intrahospital transport (IHT) practices of neurocritically ill patients at their institutions. The reported IHT practices were stratified by World Bank country income level. Variability between high-income (HIC) and low/middle-income (LMIC) groups, as well as variability between hospitals within countries, were expressed as counts/percentages and intracluster correlation coefficients (ICCs) with a 95% confidence interval (CI). A total of 246 hospitals (67% response rate; n = 103, 42% HIC and n = 143, 58% LMIC) participated. LMIC hospitals were less likely to report a portable CT scanner (RR 0.39, 95% CI [0.23; 0.67]), more likely to report a pre-IHT checklist (RR 2.18, 95% CI [1.53; 3.11]), and more likely to report that intensive care unit (ICU) physicians routinely participated in IHTs (RR 1.33, 95% CI [1.02; 1.72]). Between- and across-country variation were highest for pre-IHT external ventricular drain clamp tolerance (reported by 40% of the hospitals, ICC 0.22, 95% CI 0.00-0.46) and end-tidal carbon dioxide monitoring during IHT (reported by 29% of the hospitals, ICC 0.46, 95% CI 0.07-0.71). Brain tissue oxygenation monitoring during IHT was reported by only 9% of the participating hospitals. An IHT standard operating procedure (SOP)/hospital policy (HP) was reported by 37% (n = 90); HIC: 43% (n= 44) vs. LMIC: 32% (n = 46), p = 0.56. Amongst the IHT SOP/HPs reviewed (n = 13), 90% did not address the continuation of hemodynamic and neurophysiological monitoring during IHT. In conclusion, the development of a neurocritical-care-specific IHT SOP/HP as well as the alignment of practices related to the IHT of neurocritically ill patients are urgent unmet needs. Inconsistent standards related to neurophysiological monitoring during IHT warrant in-depth scrutiny across hospitals and suggest a need for international guidelines for neurocritical care IHT.

One hundred ECMO retrivals before and during the Covid-19 pandemic: an observational study

OBJECTIVES

Patients with severe acute respiratory distress syndrome may require veno-venous extracorporeal membrane oxygenation (V-V ECMO) support. For patients in peripheral hospitals, retrieval by mobile ECMO teams and transport to high-volume centers is associated with improved outcomes, including the recent COVID-19 pandemic. To enable a safe transport of patients, a specialised ECMO-retrieval program needs to be implemented. However, there is insufficient evidence on how to safely and efficiently perform ECMO retrievals. We report single-centre data from out-of-centre initiations of VV-ECMO before and during the COVID-19 pandemic.

DESIGN & SETTING

Single-centre retrospective study. We include all the retrievals performed by our ECMO centre between January 1st, 2014, and April 30th, 2021.

RESULTS

One hundred ECMO missions were performed in the study period, for a median retrieval volume of 13 (IQR: 9-16) missions per year. the cause of the acute respiratory distress syndrome was COVID-19 in 10 patients (10 %). 98 (98 %) patients were retrieved and transported to our ECMO centre. To allow safe transport, 91 of them were cannulated on-site and transported on V-V ECMO. The remaining seven patients were centralised without ECMO, but they were all connected to V-V ECMO in the first 24 hours. No complications occurred during patient transport. The median duration of the ECMO mission was 7 hours (IQR: 6-9, range: 2 - 17). Median duration of ECMO support was 14 days (IQR: 9-24), whereas the ICU stay was 24 days (IQR:18-44). Overall, 73 patients were alive at hospital discharge (74 %). Survival rate was similar in non-COVID-19 and COVID-19 group (73 % vs 80 %, p = 0.549).

CONCLUSION

In this single-centre experience, before and during COVID-19 era, retrieval and ground transportation of ECMO patients was feasible and was not associated with complications. Key factors of an ECMO retrieval program include a careful selection of the transport ambulance, training of a dedicated ECMO mobile team and preparation of specific checklists and standard operating procedures.

Effectiveness of the graded transport mode for the intrahospital transport of critically ill patients: A retrospective study

Aim

The purpose of this study was to evaluate the effectiveness of the graded transport mode in the intrahospital transport (IHT) of critically ill patients.

Methods

This is a retrospective study, including 800 patients and categorized them into control and observation groups. The control group included 420 critically ill patients who were transported via conventional methods from our emergency resuscitation unit from June 2017 to December 2017. The observation group included 380 critically ill patients who were transported through a graded transport mode from January 2018 to June 2018. We performed intergroup comparisons of the incidence rates and causes of adverse events (AEs), transport time, length of stay, and mortality rate.

Results

The observation group had significantly lower transport time and AE incidence rates than the control group. However, no significant differences were observed in terms of the length of stay and mortality rate between the two groups.

Conclusion

The most notable merits of the graded transport mode in the IHT of critical care patients include the fact that it significantly reduces the incidence of AEs during IHT, shortens the transport time, and improves transport efficiency, thereby ensuring the safety of critically ill patients.

Methodology for designing intrahospital transportation of patients with suspected infectious disease that limits infection spread risk in China

Aims

The transport of patients suspected of having COVID-19 requires careful consideration. Using paths selected at random and not accounting for person flow along the path are risk factors for infection spread. Intrahospital transportation (IHT) protocols and guidelines should be used to help reduce the risk of secondary virus transmission during transport. This study aimed to propose optimal IHT for patients with an infectious disease presenting in an out-patient area.

Design

The map of a West China Hospital was used. We also used field investigation findings and simulated person flow to establish pathway length and transportation time. We identified three optimum pathways and estimated safety boundary marks, including a patient transportation border (PTB) and safety transportation border (STB). Finally, IHT, PTB, and STP formed a virtual transport pipeline (VTP) and a traceable IHT management system, which can generate a virtual isolation space.

Results

The three pathways met efficiency, accessibility, and by-stander flow criteria. No facility characteristic modification was required.

Conclusions

Using virtual models to identify pathways through out-patient hospital areas may help reduce the risk of infection spread.

Serum biomarkers identify critically ill traumatic brain injury patients for MRI

BACKGROUND

Magnetic resonance imaging (MRI) carries prognostic importance after traumatic brain injury (TBI), especially when computed tomography (CT) fails to fully explain the level of unconsciousness. However, in critically ill patients, the risk of deterioration during transfer needs to be balanced against the benefit of detecting prognostically relevant information on MRI. We therefore aimed to assess if day of injury serum protein biomarkers could identify critically ill TBI patients in whom the risks of transfer are compensated by the likelihood of detecting management-altering neuroimaging findings.

METHODS

Data were obtained from the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study. Eligibility criteria included: TBI patients aged ≥ 16 years, Glasgow Coma Score (GCS) < 13 or patient intubated with unrecorded pre-intubation GCS, CT with Marshall score < 3, serum biomarkers (GFAP, NFL, NSE, S100B, Tau, UCH-L1) sampled ≤ 24 h of injury, MRI < 30 days of injury. The degree of axonal injury on MRI was graded using the Adams-Gentry classification. The association between serum concentrations of biomarkers and Adams-Gentry stage was assessed and the optimum threshold concentration identified, assuming different minimum sensitivities for the detection of brainstem injury (Adams-Gentry stage 3). A cost-benefit analysis for the USA and UK health care settings was also performed.

RESULTS

Among 65 included patients (30 moderate-severe, 35 unrecorded) axonal injury was detected in 54 (83%) and brainstem involvement in 33 (51%). In patients with moderate-severe TBI, brainstem injury was associated with higher concentrations of NSE, Tau, UCH-L1 and GFAP. If the clinician did not want to miss any brainstem injury, NSE could have avoided MRI transfers in up to 20% of patients. If a 94% sensitivity was accepted considering potential transfer-related complications, GFAP could have avoided 30% of transfers. There was no added net cost, with savings up to £99 (UK) or $612 (US). No associations between proteins and axonal injury were found in intubated patients without a recorded pre-intubation GCS.

CONCLUSIONS

Serum protein biomarkers show potential to safely reduce the number of transfers to MRI in critically ill patients with moderate-severe TBI at no added cost.

Predictive value of computed tomography for short-term mortality in patients with acute respiratory distress syndrome: a systematic review

The best available evidence and the predictive value of computed tomography (CT) findings for prognosis in patients with acute respiratory distress syndrome (ARDS) are unknown. We systematically searched three electronic databases (MEDLINE, CENTRAL, and ClinicalTrials.gov). A total of 410 patients from six observational studies were included in this systematic review. Of these, 143 patients (34.9%) died due to ARDS in short-term. As for CT grade, the CTs used ranged from 4- to 320-row. The index test included diffuse attenuations in one study, affected lung in one study, well-aerated lung region/predicted total lung capacity in one study, CT score in one study and high-resolution CT score in two studies. Considering the CT findings, pooled sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and diagnostic odds ratio were 62% (95% confidence interval [CI] 30–88%), 76% (95% CI 57–89%), 2.58 (95% CI 2.05–2.73), 0.50 (95% CI 0.21–0.79), and 5.16 (95% CI 2.59–3.46), respectively. This systematic review revealed that there were major differences in the definitions of CT findings, and that the integration of CT findings might not be adequate for predicting short-term mortality in ARDS. Standardisation of CT findings and accumulation of further studies by CT with unified standards are warranted.