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

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.

MRI and the Critical Care Patient: Clinical, Operational, and Financial Challenges

Neuroimaging in conjunction with a neurologic examination has become a valuable resource for today's intensive care unit (ICU) physicians. Imaging provides critical information during the assessment and ongoing neuromonitoring of patients for toxic-metabolic or structural injury of the brain. A patient's condition can change rapidly, and interventions may require imaging. When making this determination, the benefit must be weighed against possible risks associated with intrahospital transport. The patient's condition is assessed to decide if they are stable enough to leave the ICU for an extended period. Intrahospital transport risks include adverse events related to the physical nature of the transport, the change in the environment, or relocating equipment used to monitor the patient. Adverse events can be categorized as minor (e.g., clinical decompensation) or major (e.g., requiring immediate intervention) and may occur in preparation or during transport. Regardless of the type of event experienced, any intervention during transport impacts the patient and may lead to delayed treatment and disruption of critical care. This review summarizes the commentary on the current literature on the associated risks and provides insight into the costs as well as provider experiences. Approximately, one-third of patients who are transported from the ICU to an imaging suite may experience an adverse event. This creates an additional risk for extending a patient's stay in the ICU. The delay in obtaining imaging can negatively impact the patient's treatment plan and affect long-term outcomes as increased disability or mortality. Disruption of ICU therapy can decrease respiratory function after the patient returns from transport. Because of the complex care team needed for patient transport, the staff time alone can cost $200 or more. New technologies and advancements are needed to reduce patient risk and improve safety.

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.

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.

Effects of using a cognitive aid on content and feasibility of debriefings of simulated emergencies

Background: Adverse events in patient care are often caused by failures in teamwork. Simulation training and its debriefing can contribute to improving teamwork and thus patient care. When conducting debriefings, there are several design factors that can potentially influence learning outcomes. This study examines the use of a cognitive aid to help structure the content of debriefings and compares it with debriefings that are merely roughly structured. In addition, the feasibility of the debriefing, the satisfaction of the participants and their teamwork during the training are investigated. Methods: In a simulated night shift, seven teams of four to five medical students (n=32) took part in six cases that simulated common situations in an emergency medicine environment and received a debriefing on their teamwork after each case, either in the intervention condition with the help of the TeamTAG tool - a cognitive aid focusing on selected teamwork principles from Crisis Resource Management (CRM) - or in the control condition without it. The facilitators noted the topics of the debriefings and rated their experience of conducting them; the participants indicated their satisfaction with the debriefings, as well as their assessment of the importance of CRM principles. In addition, the quality of teamwork was assessed using the Team Emergency Assessment Measure (TEAM). Results: The analysis showed no difference in the number of teamwork principles discussed between the control and intervention conditions, but topics were repeated more frequently in the control group. The TeamTAG guideline was focused on and implemented by the tutors, who discussed the CRM principles included in the TeamTAG more consistently than in the control condition. The tutors in both conditions were satisfied with the implementation, and the use of TeamTAG facilitated time management. There were no differences in participants' satisfaction, their assessment of the importance of the teamwork principles, or the quality of teamwork between conditions. Conclusion: The use of a cognitive aid can help to direct the focus on certain topics or learning objectives and facilitate time management through pre-structuring; however, a difference in learning outcomes (in terms of the quality of teamwork) could not be identified. Besides the influence of a certain structure or script, a strong influence from the individual guiding the debriefing is likely.

A fully automated inpatient transport system

BACKGROUND

The transport of the inpatients to and from locations inside the hospital can vary in complexity depending on the patient location, status, and logistical needs. Most transport systems have not developed at the same speed as other medically related technologies. We conducted a pilot study of a new automated transport system for patients within the hospital.

METHODS

Our innovative system was introduced in January 2020. We present a retrospective case review of all in-patient transport request during April 15, 2020 through May 30, 2020 at the Shaare Zedek Medical Center, Jerusalem, Israel. The system is fully automated and works via smartphone and electronic medical record integration. Transfer requests are processed on the basis of priority, proximity, and availably.

RESULTS

During the study period there were 15, 581 transfer requests. Mean times to hospital destinations ranged from 9:25 to 28:02 minutes. Overall, mean times were quicker for emergency and surgical services. Trip times by priority code were likely influence by unmeasured confounders. There were no reported patient identification adverse events. Peak requests occurred during 0900-1500, and at the beginning of the week.

CONCLUSION

Our automated in-patient transfer system appears to be efficient, safe, well received, and capable of servicing our large tertiary care medical center. Future controlled studies are needed to assess efficacy, adverse events, and clinical outcomes.

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.

The Effects of ICU Crisis Reorganization on Outcomes in Patients Not Infected With Coronavirus Disease 2019 During the Initial Surge of the Coronavirus Disease 2019 Pandemic

To determine if ICU reorganization due to the coronavirus disease 2019 pandemic affected outcomes in critically ill patients who were not infected with coronavirus disease 2019.

Design

This was a Before-After study, with coronavirus disease 2019-induced ICU reorganization as the intervention. A retrospective chart review of adult patients admitted to a reorganized ICU during the coronavirus disease 2019 surge (from March 23, 2020, to May 06, 2020: intervention group) was compared with patients admitted to the ICU prior to coronavirus disease 2019 surge (from January 10, 2020, to February 23, 2020: before group).

Setting

High-intensity cardiac, medical, and surgical ICUs of a community hospital in metropolitan Missouri.

PATIENTS

All patients admitted to the ICU during the before and intervention period were included. Patients younger than 18 years old and those admitted after an elective procedure or surgery were excluded. Patients with coronavirus disease 2019 were excluded.

Interventions

None.

Measurements and Main Results

We identified a total of 524 eligible patients: 342 patients in the before group and 182 in the intervention group. The 28-day mortality was 25.1% (86/342) and 28.6% (52/182), respectively (p = 0.40). The ICU length of stay, ventilator length of stay, and ventilator-free days were similar in both groups. Rates of patient adverse events including falls, inadvertent endotracheal tube removal, reintubation within 48 hours of extubation, and hospital acquired pressure ulcers occurred more frequently in the study group (20 events, 11%) versus control group (12 events, 3.5%) (p = 0.001).

Conclusions

Twenty-eight-day mortality, in patients who required ICU care and were not infected with coronavirus disease 2019, was not significantly affected by ICU reorganization during a pandemic.

Construction and validation of indicators for patient safety in intrahospital transport

ABSTRACT Objective: To construct and validate an indicator plan for measuring and assessing patient safety in intrahospital transport. Method: Methodological study, developed in three stages, between July 2018 and July 2019. The content validity included the participation of nurses from the State of Bahia and experts from different regions of the country. For data analysis and interpretation, descriptive statistics were used. Results: After a pre-test round and two rounds of expert consultations, using the Delphi technique, the general content validity index that assessed the clarity of the indicators was measured at 1.00 and the representativeness was 0.97. Conclusion: The indicators make a significant contribution to the field of health and nursing, as it constitutes an instrument that will contribute to the professional practice of nurses, to patient safety and will still be viable for the practice of auditing or assessing the intrahospital transport process.

Development and initial psychometric testing of the Intrahospital Transport Safety Scale in intensive care

OBJECTIVE

To develop and evaluate the psychometric properties of a scale measuring patient safety during the intrahospital transport process for intensive care.

DESIGN

The scale was developed based on a theoretical model of the work system and patient safety, and items generated from participant observations. A Delphi study with international experts was used to establish content validity. Next, a cross-sectional study was undertaken to inform item reduction and evaluate construct validity and internal consistency.

SETTING

The questionnaire was distributed to healthcare practitioners at 12 intensive care units in Sweden.

PARTICIPANTS

A total of 315 questionnaires were completed. Eligible participants were healthcare practitioners in the included units that performed an intrahospital transport during the study period. Inclusion criteria were (1) transports of patients within the hospital to undergo an examination or intervention, and (2) transports performed by staff from the intensive care unit. We excluded transports to a step-down unit or hospital ward.

OUTCOME MEASURES

Psychometric evaluation, including item analysis, validity and reliability testing.

RESULTS

Items were reduced from 55 to 24, informed by distributional statistics, initial reliabilities, factor loadings and communalities. The final factor model consisted of five factors, accounting for 59% of variance. All items loaded significantly on only one factor (>0.35). The original conceptual model of teamwork, transport-related tasks, tools and technologies, environment, and organisation was maintained with regrouping of items. Cronbach's alpha ranged from 0.72 to 0.82 for each subscale (ie, factor).

CONCLUSIONS

The present study provides a self-report questionnaire to assess patient safety during intrahospital transport of patients in intensive care. The results indicate acceptable validity and reliability of the scale among a sample of Swedish healthcare practitioners. If further confirmatory testing supports the present results, this scale could be a useful tool to better understand safety prerequisites and improve clinical practice.

A Quality Initiative Reducing Adverse Outcomes in Pediatric Patients with DKA During Intrafacility Transit

Introduction

Treatment of diabetic ketoacidosis (DKA) requires close and timely monitoring to prevent serious adverse events. This quality improvement project details how our institution improved blood glucose monitoring around hospital admission. The project aimed to increase the blood glucose assessments for children with DKA receiving insulin in the emergency department (ED) within 30 minutes before transitioning to an inpatient unit.

Methods

We implemented a series of Plan-Do-Survey-Act (PDSA) cycles established by a multidisciplinary team for this project, with the primary outcome of obtaining the blood glucose level within 30 minutes before leaving the ED and secondarily preventing episodes of hypoglycemia. These PDSAs harnessed the electronic health record, to prompt and direct the medical staff, to improve blood glucose monitoring.

Results

From March 2015 to November 2017, we saw 640 patients in our ED for DKA. Of these, we admitted 629 to the inpatient unit with treatment that included continuous infusion of insulin. Over this period, we increased blood glucose monitoring for these patients within 30 minutes before the transition from 56% to >90%. Following the final PDSA cycle, we observed no reported episodes of hypoglycemia.

Conclusion

Using the functionality of the electronic health record, we showed significant, rapid, and sustained increases in compliance with the International Society for Pediatric and Adolescent Diabetes guideline by alerting ED staff caring for patients receiving continuous insulin around the time of care-team transitions. We believe that this program is easily replicable, cost-effective, and safety enhancing.