Recommendations for the intra-hospital transport of critically ill patients

Inter hospital transfers in rotor wing aircraft. Patterns and challenges. Protocol for a scoping review

BACKGROUND

Inter-hospital transfer is necessary for the transport of patients to specialized treatment. Rotor-wing aircraft may be used in lieu of ambulances in time-critical conditions over long distances and when specialist team skills are called for. The purpose of the review is to assess the current scientific literature that describes the scenario to develop a national guideline for inter-hospital transfers using rotor-wing aircraft. The aim is to describe the patterns and challenges.

METHODS AND ANALYSIS

The authors will conduct a scoping review as per Joanna Briggs Institute guideline. The protocol for the scoping review will adhere to the Open Science Framework guideline for scoping reviews and we will report the findings of the scoping review as per PRISMA-ScR guideline. We have developed the search strategy with the help of a research librarian and will conduct search in relevant electronic databases and include gray literature as well, using the PRESS and PRISMA-S guidelines. Two authors will independently screen titles and abstracts for inclusion as per eligibility criteria and conflicts will be resolved by a third reviewer. Full text retrieval will be conducted accordingly. We will analyze the extracted data using validated statistical methods.

ETHICS AND DISSEMINATION

According to Danish law, scoping reviews are exempt from ethics committee approval. The findings of this scoping review will provide the scientific foundation for a national guideline on rotor-wing aircraft conveyed inter-hospital transfers in Denmark. Furthermore, we will publish the results of the scoping review in a relevant scientific journal.

Developing and Validating a Bundle for Safe Intra-Hospital Transporting of the Critically Ill Patients: Mixed Qualitative Design With Delphi Approach

The aim of this study was to develop a bundle to increase safety of intra-hospital transport in critically ill patients. A qualitative design with Delphi approach was conducted for creation of an intra-hospital transport bundle in 3 steps. First, doctors and nurses were questioned about their encounters with intra-hospital transport incidents. Second, several databases were looked through to find published checklists and recommendations for intra-hospital transport. Third, using this strategy, a bundle was created and reviewed with subject matter experts. The content validity index (CVI), which assesses the degree of expert agreement, was utilized to evaluate each item in the generated bundle. Two evaluation cycles were required before a minimal index could be reached. We looked at the content validity and important weighting of the items. The scale-CVI was calculated using the average of all the elements, and it was 1. The created bundle serves as a framework for directing doctors and nurses during intra-hospital transportation and offers continuity of care to improve patient safety. The techniques suggested in this study can be used to adapt this bundle to the needs of other hospitals.

Functional near-infrared spectroscopy: A novel tool for detecting consciousness after acute severe brain injury

Recent advancements in functional neuroimaging have demonstrated that some unresponsive patients in the intensive care unit retain a level of consciousness that is inconsistent with their behavioral diagnosis of awareness. Functional near-infrared spectroscopy (fNIRS) is a portable optical neuroimaging method that can be used to measure neural activity with good temporal and spatial resolution. However, the reliability of fNIRS for detecting the neural correlates of consciousness remains to be established. In a series of studies, we evaluated whether fNIRS can record sensory, perceptual, and command-driven neural processing in healthy participants and in behaviorally nonresponsive patients. At the individual healthy subject level, we demonstrate that fNIRS can detect commonly studied resting state networks, sensorimotor processing, speech-specific auditory processing, and volitional command-driven brain activity to a motor imagery task. We then tested fNIRS with three acutely brain injured patients and found that one could willfully modulate their brain activity when instructed to imagine playing a game of tennis-providing evidence of preserved consciousness despite no observable behavioral signs of awareness. The successful application of fNIRS for detecting preserved awareness among behaviorally nonresponsive patients highlights its potential as a valuable tool for uncovering hidden cognitive states in critical care settings.

Intrahospital transport of critically ill patients: Nurse anaesthetists' and specialist ICU nurses' experiences

BACKGROUND

Intrahospital transport (IHT) is often performed by nurse anaesthetists and specialist intensive care nurses. Studies have shown that IHT increases the risk of mortality and morbidity, with up to 71% negative incidents. Using checklists when preparing for an IHT is important. Several international guidelines exist to ensure IHT safety and reduce the risk of complications. However, existing guidelines are often problematic in clinical practice.

AIM

This study aimed to describe the experiences of nurse anaesthetists and specialized intensive care nurses during the IHT of adult patients with critical illnesses.

STUDY DESIGN

This study adopted a mixed-methods approach.

METHODS

Data were collected through a questionnaire completed by 66 nurses with specialist education in anaesthesia or intensive care. The data were analysed with qualitative content analysis, and the quantitative data were analysed with descriptive statistics.

RESULTS

Two categories with two subcategories each emerged from the analysis of the responses of nurse anaesthetists and specialist intensive care nurses regarding their IHT experiences: creating good circumstances (subcategories: being risk-conscious and the importance of meticulous preparations) and the importance of routines and education (subcategories: following guidelines and having adequate training).

CONCLUSION

IHT was described as a high risk for patient safety and complications. Routines with good compliance and education can positively impact patient safety during IHT. Checklists and scenario training can better prepare nurse anaesthetists and specialist intensive care nurses to manage complications that may arise during IHT, resulting in safer patient care.

RELEVANCE FOR CLINICAL PRACTICE

The findings underscore the importance of written guidelines for IHT, emphasizing awareness and adherence by the entire team. Careful pre-IHT preparations, coupled with an understanding of potential risks, are vital for ensuring patient safety. Clinical training and discussions following incidents during IHT play a crucial role in raising the collective awareness of patient safety within the entire team. Written guidelines about IHT are of utmost importance, and everyone in the team should be aware of and follow the guidelines. It is important to make careful preparations before IHT and to be aware of the possible risks to patient safety. Clinical training and discussions about IHT where patient safety has been impaired are important to increase the whole team's awareness of patient safety during IHT.

Imaging the Lung in ARDS: A Primer

Despite periodic changes in the clinical definition of ARDS, imaging of the lung remains a central component of its diagnostic identification. Several imaging modalities are available to the clinician to establish a diagnosis of the syndrome, monitor its clinical course, or assess the impact of treatment and management strategies. Each imaging modality provides unique insight into ARDS from structural and/or functional perspectives. This review will highlight several methods for lung imaging in ARDS, emphasizing basic operational and physical principles for the respiratory therapist. Advantages and disadvantages of each modality will be discussed in the context of their utility for clinical management and decision-making.

Feasibility and Cost Analysis of Portable MRI Implementation in a Remote Setting in Canada

OBJECTIVE

To conduct feasibility and cost analysis of portable MRI implementation in a remote setting where MRI access is otherwise unavailable.

METHODS

Portable MRI (ultra-low field, 0.064T) was installed in Weeneebayko General Hospital, Moose Factory, Ontario. Adult patients, presenting with any indication for neuroimaging, were eligible for study inclusion. Scanning period was from November 14, 2021, to September 6, 2022. Images were sent via a secure PACS network for Neuroradiologist interpretation, available 24/7. Clinical indications, image quality, and report turnaround time were recorded. A cost analysis was conducted from a healthcare system's perspective in 2022 Canadian dollars, comparing cost of portable MRI implementation to transporting patients to a center with fixed MRI.

RESULTS

Portable MRI was successfully implemented in a remote Canadian location. Twenty-five patients received a portable MRI scan. All studies were of diagnostic quality. No clinically significant pathologies were identified on any of the studies. However, based on clinical presentation and limitations of portable MRI resolution, it is estimated that 11 (44%) of patients would require transfer to a center with fixed MRI for further imaging workup. Cost savings were $854,841 based on 50 patients receiving portable MRI over 1 year. Five-year budget impact analysis showed nearly $8 million dollars saved.

CONCLUSIONS

Portable MRI implementation in a remote setting is feasible, with significant cost savings compared to fixed MRI. This study may serve as a model to democratize MRI access, offer timely care and improved triaging in remote areas where conventional MRI is unavailable.

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.

Detection of Acute Brain Injury in Intensive Care Unit Patients on ECMO Support Using Ultra-Low-Field Portable MRI: A Retrospective Analysis Compared to Head CT

Early detection of acute brain injury (ABI) is critical to intensive care unit (ICU) patient management and intervention to decrease major complications. Head CT (HCT) is the standard of care for the assessment of ABI in ICU patients; however, it has limited sensitivity compared to MRI. We retrospectively compared the ability of ultra-low-field portable MR (ULF-pMR) and head HCT, acquired within 24 h of each other, to detect ABI in ICU patients supported on extracorporeal membrane oxygenation (ECMO). A total of 17 adult patients (median age 55 years; 47% male) were included in the analysis. Of the 17 patients assessed, ABI was not observed on either ULF-pMR or HCT in eight patients (47%). ABI was observed in the remaining nine patients with a total of 10 events (8 ischemic, 2 hemorrhagic). Of the eight ischemic events, ULF-pMR observed all eight, while HCT only observed four events. Regarding hemorrhagic stroke, ULF-pMR observed only one of them, while HCT observed both. ULF-pMR outperformed HCT for the detection of ABI, especially ischemic injury, and may offer diagnostic advantages for ICU patients. The lack of sensitivity to hemorrhage may improve with modification of the imaging acquisition program.

Unit-to-unit transfer due to shortage of intensive care beds in Sweden 2015-2019 was associated with a lower risk of death but a longer intensive care stay compared to no transfer: a registry study

BACKGROUND

Intensive care unit-to-unit transfer due to temporary shortage of beds is increasing in Sweden. Transportation induces practical hazards, and the change of health care provider may prolong the length of stay in intensive care. We previously showed that the risk of death at 90 days did not differ between patients transferred due to a shortage of beds and non-transferred patients with a similar burden of illness in a tertiary intensive care unit. The aim of this study was to widen the analysis to a nation-wide cohort of critically ill patients transferred to another intensive care unit in Sweden due to shortage of intensive care beds.

METHODS

Retrospective comparison between capacity transferred and non-transferred patients, based on data from the Swedish Intensive Care Registry during a 5-year period before the COVID-19 pandemic. Patients with insufficient data entries or a recurring capacity transfer within 90 days were excluded. To assess the association between capacity transfer and death as well as intensive care stay within 90 days after ICU admission, logistic regression models with step-wise adjustment for SAPS3 score, primary ICD-10 ICU diagnosis and the number of days in the intensive care unit before transfer were applied.

RESULTS

From 161,140 eligible intensive care admissions, 2912 capacity transfers were compared to 135,641 discharges or deaths in the intensive care unit. Ninety days after ICU admission, 28% of transferred and 21% of non-transferred patients were deceased. In the fully adjusted model, capacity transfer was associated with a lower risk of death within 90 days than no transfer; OR (95% CI) 0.71 (0.65-0.69) and the number of days spent in intensive care was longer: 12.4 [95% CI 12.2-12.5] vs 3.3 [3.3-3.3].

CONCLUSIONS

Intensive care unit-to-unit transfer due to shortage of bed capacity as compared to no transfer during a 5-year period preceding the COVID-19 pandemic in Sweden was associated with lower risk of death within 90 days but with longer stay in intensive care.

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.

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.

Acoustic Lung Imaging Utilized in Continual Assessment of Patients with Obstructed Airway: A Systematic Review

Smart respiratory therapy is enabled by continual assessment of lung functions. This systematic review provides an overview of the suitability of equipment-to-patient acoustic imaging in continual assessment of lung conditions. The literature search was conducted using Scopus, PubMed, ScienceDirect, Web of Science, SciELO Preprints, and Google Scholar. Fifteen studies remained for additional examination after the screening process. Two imaging modalities, lung ultrasound (LUS) and vibration imaging response (VRI), were identified. The most common outcome obtained from eleven studies was positive observations of changes to the geographical lung area, sound energy, or both, while positive observation of lung consolidation was reported in the remaining four studies. Two different modalities of lung assessment were used in eight studies, with one study comparing VRI against chest X-ray, one study comparing VRI with LUS, two studies comparing LUS to chest X-ray, and four studies comparing LUS in contrast to computed tomography. Our findings indicate that the acoustic imaging approach could assess and provide regional information on lung function. No technology has been shown to be better than another for measuring obstructed airways; hence, more research is required on acoustic imaging in detecting obstructed airways regionally in the application of enabling smart therapy.

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.

Establishment of a simplified score for predicting risk during intrahospital transport of critical patients: A prospective cohort study

AIMS AND OBJECTIVES

To establish a simple score that enables nurses to quickly, conveniently and accurately identify patients whose condition may change during intrahospital transport.

BACKGROUND

Critically ill patients may experience various complications during intrahospital transport; therefore, it is important to predict their risk before they leave the emergency department. The existing scoring systems were not developed for this population.

DESIGN

A prospective cohort study.

METHODS

This study used convenience sampling and continuous enrolment from 1 January, 2019, to 30 June, 2021, and 584 critically ill patients were included. The collected data included vital signs and any condition change during transfer. The STROBE checklist was used.

RESULTS

The median age of the modelling group was 74 (62, 83) years; 93 (19.7%) patients were included in the changed group, and 379 (80.3%) were included in the stable group. The five independent model variables (respiration, pulse, oxygen saturation, systolic pressure and consciousness) were statistically significant (p < .05). The above model was simplified based on beta coefficient values, and each variable was assigned 1 point, for a total score of 0-5 points. The AUC of the simplified score in the modelling group was 0.724 (95% CI: 0.682-0.764); the AUC of the simplified score in the validation group (112 patients) was 0.657 (95% CI: 0.566-0.741).

CONCLUSIONS

This study preliminarily established a simplified scoring system for the prediction of risk during intrahospital transport from the emergency department to the intensive care unit. It provides emergency nursing staff with a simple assessment tool to quickly, conveniently and accurately identify a patient's transport risk.

RELEVANCE TO CLINICAL PRACTICE

This study suggested the importance of strengthening the evaluation of the status of critical patients before intrahospital transport, and a simple score was formed to guide emergency department nurses in evaluating patients.

Functional Neuroimaging as an Assessment Tool in Critically Ill Patients

OBJECTIVE

Little is known about residual cognitive function in the earliest stages of serious brain injury. Functional neuroimaging has yielded valuable diagnostic and prognostic information in chronic disorders of consciousness, such as the vegetative state (also termed unresponsive wakefulness syndrome). The objective of the current study was to determine if functional neuroimaging could be efficacious in the assessment of cognitive function in acute disorders of consciousness, such as coma, where decisions about the withdrawal of life-sustaining therapies are often made.

METHODS

A hierarchical functional magnetic resonance imaging (fMRI) approach assessed sound perception, speech perception, language comprehension, and covert command following in 17 critically ill patients admitted to the intensive care unit (ICU).

RESULTS

Preserved auditory function was observed in 15 patients (88%), whereas 5 (29%) also had preserved higher-order language comprehension. Notably, one patient could willfully modulate his brain activity when instructed to do so, suggesting a level of covert conscious awareness that was entirely inconsistent with his clinical diagnosis at the time of the scan. Across patients, a positive relationship was also observed between fMRI responsivity and the level of functional recovery, such that patients with the greatest functional recovery had neural responses most similar to those observed in healthy control participants.

INTERPRETATION

These results suggest that fMRI may provide important diagnostic and prognostic information beyond standard clinical assessment in acutely unresponsive patients, which may aid discussions surrounding the continuation or removal of life-sustaining therapies during the early post-injury period. ANN NEUROL 2023;93:131-141.

Preparing the Patient for ICU Transfer: What Is the Anesthesiologist’s Role?

Purpose of Review

This review summarizes the anesthesiologist’s role in transferring critically ill surgical patients at different phases of care.

Recent Findings

Early recognition of patients at high intraoperative and postoperative risk is one of the most important first steps, followed by preoperative and intraoperative stabilization measures depending on the individual needs. It mainly is the anesthesiologist’s responsibility to decide on postoperative ICU admission. The transfer of the critically ill should be planned; the ICU staff has to be informed as early as possible. Locally developed checklists should be used during the preparation of patient transport. Trained, dedicated staff should be made available in every institution. A detailed handover using dedicated institutional flowcharts should ensure patient safety upon arrival to the ICU.

Summary

Transfer of critically ill patients from the OR to the ICU is an interdisciplinary task with a high probability of eventual incidents. Anesthesiologists should play a key role in all phases of the procedure to improve patient outcomes.

Interventional Pulmonology and the Esophagus: Tracheostomy and Percutaneous Endoscopic Gastrostomy Placement

Tracheostomy is a procedure commonly performed in intensive care units (ICU) for patients who are unable to be weaned from mechanical ventilation. Both percutaneous and surgical techniques have been validated and are chosen based on the local expertise available. A primary advantage to the percutaneous technique is the ability to perform this procedure in the ICU without transporting the patient to a procedure suite or operating room; this has become particularly important with the novel coronavirus disease 2019 (COVID-19) pandemic. An additional advantage is the ability to perform both the tracheostomy and the gastrostomy tube placement, if needed, during the same anesthetic episode. This decreases the need for additional sedation, interruption of anticoagulation, repeat transfusion, and coordination of care between multiple services. In the context of COVID-19, combined tracheostomy and gastrostomy placement exposes less health care providers overall and minimizes transportation needs.

Digital tomography in the diagnosis of a posterior pneumothorax in the intensive care unit

Portable chest radiography is a valuable tool in the intensive care unit. However, the supine position causes superposition of anatomical structures resulting in less reliable detection of certain abnormalities. Recently, a portable digital tomosynthesis (pDTS) prototype with a modified motorized X-ray device was developed. We aimed to compare the diagnostic value of pDTS to standard bedside chest radiography in the diagnosis of a posterior pneumothorax. A modified motorized X-ray device was developed to perform 15 radiographic projections while translating the X-ray tube 25 cm (10 cm ramp up and 15 cm during X-ray exposure) with a total radiation dose of 0.54 mSv. This new technique of pDTS was performed in addition to standard bedside chest X-ray in a patient with a confirmed posterior hydropneumothorax. The images were compared with the standard bedside chest X-ray and computed tomography (CT) images by two experienced radiologists. The posterior hydropneumothorax previously identified with CT was visible on tomosynthesis images but not with standard bedside imaging. Combining the digital tomosynthesis technique with the portable X-ray machine could increase the diagnostic value of bedside chest radiography for the diagnosis of posterior pneumothoraces while avoiding intrahospital transport and limiting radiation exposure compared to CT.

Intensive care unit to unit capacity transfers are associated with increased mortality: an observational cohort study on patient transfers in the Swedish Intensive Care Register

Background

Transfers from one intensive care unit (ICU) to another ICU are associated with increased length of intensive care and hospital stay. Inter-hospital ICU transfers are carried out for three main reasons: clinical transfers, capacity transfers and repatriations. The aim of the study was to show that different ICU transfers differ in risk-adjusted mortality rate with repatriations having the least risk.

Results

Observational cohort study of adult patients transferred between Swedish ICUs during 3 years (2016–2018) with follow-up ending September 2019. Primary and secondary end-points were survival to 30 days and 180 days after discharge from the first ICU. Data from 75 ICUs in the Swedish Intensive Care Register, a nationwide intensive care register, were used for analysis (89% of all Swedish ICUs), covering local community hospitals, district general hospitals and tertiary care hospitals. We included adult patients (16 years or older) admitted to ICU and subsequently discharged by transfer to another ICU. Only the first admission was used. Exposure was discharge to any other ICU (ICU-to-ICU transfer), whether in the same or in another hospital. Transfers were grouped into three predefined categories: clinical transfer, capacity transfer, and repatriation. We identified 15,588 transfers among 112,860 admissions (14.8%) and analysed 11,176 after excluding 4112 repeat transfer of the same individual and 300 with missing risk adjustment. The majority were clinical transfers (62.7%), followed by repatriations (21.5%) and capacity transfers (15.8%). Unadjusted 30-day mortality was 25.0% among capacity transfers compared to 14.5% and 16.2% for clinical transfers and repatriations, respectively. Adjusted odds ratio (OR) for 30-day mortality were 1.25 (95% CI 1.06–1.49 p = 0.01) for capacity transfers and 1.17 (95% CI 1.02–1.36 p = 0.03) for clinical transfers using repatriation as reference. The differences remained 180 days post-discharge.

Conclusions

There was a large proportion of ICU-to-ICU transfers and an increased odds of dying for those transferred due to other reasons than repatriation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13613-022-01003-x.

Intrahospital transport of critically ill patients: A cross-sectional survey of Nurses' attitudes and experiences in adult intensive care units

AIMS

To describe adult intensive care nurses' experiences and attitudes towards intrahospital transport (IHT) of critically ill patients and to assess the relationship between nurses' characteristics, attitudes and experiences.

DESIGN

Cross-sectional survey.

METHODS

Factor analysis identified factors within the attitudinal and experience domains. Univariate analysis was performed to demonstrate the relationship between attitudinal and experience factors and demographic and professional characteristics of the participants. Multiple regression equations were applied to determine associations between nurses' experiences and attitudes. The study took place from July to August 2019.

RESULTS

A total of 480 nurses from 12 adult intensive care units in China participated, with a response rate of 65%. Most respondents had a baccalaureate nursing degree (75%). The majority (80%) had participated in IHT of critically ill more than five times in the previous 12 months and 90% agreed that checklists led to an improvement in patient safety during transport. However, 75% of respondents expressed that transport increased the workload of the nurses who accompany patients off unit and those who remained in the intensive care unit (66%). Variables that were associated with a favourable perception of transport competency and checklists/tool use were nurses' prior transport experiences and knowledge/training.

CONCLUSION

Nurses perceived IHT was a sourse of stress and increased workload. Checklists and training were beneficial for patient safety during IHT.

IMPACT

The findings point out a clear need for ICU nurse training, standardised policy/procedure and customisation of existing intrahospital transfer checklists according to hospital procedures and local circumstances. New research is needed to evaluate the impact of novel IHT interventions on patient safety and nurses' stress.

Detection of cerebral hypoperfusion with a dynamic hyperoxia test using brain oxygenation pressure monitoring

Introduction

Brain multimodal monitoring including intracranial pressure (ICP) and brain tissue oxygen pressure (PbtO2) is more accurate than ICP alone in detecting cerebral hypoperfusion after traumatic brain injury (TBI). No data are available for the predictive role of a dynamic hyperoxia test in brain-injured patients from diverse etiology.

Aim

To examine the accuracy of ICP, PbtO2 and the oxygen ratio (OxR) in detecting regional cerebral hypoperfusion, assessed using perfusion cerebral computed tomography (CTP) in patients with acute brain injury.

Methods

Single-center study including patients with TBI, subarachnoid hemorrhage (SAH) and intracranial hemorrhage (ICH) undergoing cerebral blood flow (CBF) measurements using CTP, concomitantly to ICP and PbtO2 monitoring. Before CTP, FiO2 was increased directly from baseline to 100% for a period of 20 min under stable conditions to test the PbtO2 catheter, as a standard of care. Cerebral monitoring data were recorded and samples were taken, allowing the measurement of arterial oxygen pressure (PaO2) and PbtO2 at FiO2 100% as well as calculation of OxR (= ΔPbtO2/ΔPaO2). Regional CBF (rCBF) was measured using CTP in the tissue area around intracranial monitoring by an independent radiologist, who was blind to the PbtO2 values. The accuracy of different monitoring tools to predict cerebral hypoperfusion (i.e., CBF < 35 mL/100 g × min) was assessed using area under the receiver-operating characteristic curves (AUCs).

Results

Eighty-seven CTPs were performed in 53 patients (median age 52 [41–63] years—TBI, n = 17; SAH, n = 29; ICH, n = 7). Cerebral hypoperfusion was observed in 56 (64%) CTPs: ICP, PbtO2 and OxR were significantly different between CTP with and without hypoperfusion. Also, rCBF was correlated with ICP (r = − 0.27; p = 0.01), PbtO2 (r = 0.36; p < 0.01) and OxR (r = 0.57; p < 0.01). Compared with ICP alone (AUC = 0.65 [95% CI, 0.53–0.76]), monitoring ICP + PbO2 (AUC = 0.78 [0.68–0.87]) or ICP + PbtO2 + OxR (AUC = 0.80 (0.70–0.91) was significantly more accurate in predicting cerebral hypoperfusion. The accuracy was not significantly different among different etiologies of brain injury.

Conclusions

The combination of ICP and PbtO2 monitoring provides a better detection of cerebral hypoperfusion than ICP alone in patients with acute brain injury. The use of dynamic hyperoxia test could not significantly increase the diagnostic accuracy.

Interhospital transport of critically ill patients: A prospective observational study of patient and transport characteristics

BACKGROUND

The cohort of critically ill patients transported between Intensive Care Units (ICUs) in Norway has not been studied previously. The aim of this study was to describe the characteristics of patients and transports for different types of interhospital transfers and explore whether there were differences in morbidity and mortality between the different transfer categories and the general Norwegian ICU population.

METHODS

All transports of critically ill adult patients transferred between two geographically different Intensive Care Units during a one-year period were registered. Patient and transport data were obtained from The Norwegian Intensive Care Registry, The Norwegian Cause of Death Registry, the hospital Electronic Patient Journal, the Air Ambulance Journal System, and the Emergency Medical Communication Centre database.

RESULTS

821 transports of 788 surgical and medical patients were enrolled. Simplified Acute Physiology Scores (SAPSII) were 43, 36 and 38 for urgent secondary transport, non-urgent secondary transport and return transfers, respectively. These were comparable to nationwide SAPSII scores that were 40 for university hospitals and 34 for local hospitals during the same time period. The return transfers had a median SOFA-score of 4.7 and 53% were mechanically ventilated. Only 33% of return transfers were performed by established teams.

CONCLUSION

Intensive care patients transferred between ICUs are as critically ill as the rest of the ICU population, with a similar morbidity and mortality. The return transfers of ICU-patients appear under-triaged compared to secondary transports in terms of allocated resources.

In situ simulation training for a better interprofessional team performance in transferring critically ill patients with COVID-19: a prospective randomised control trial

Background

Transferring critically ill patients with COVID-19 is a challenging task; therefore, well-trained medical team is needed. This study aimed to determine the role of in situ simulation training during pandemic by using high-fidelity manikin to improve interprofessional communication, skills and teamwork in transferring critically ill patients with COVID-19.

Methods

This single-blinded randomised control trial included 40 subjects allocated into standard low-fidelity simulator (LFS) and high-fidelity simulator (HFS) groups. Subjects, who were not members of multiprofessional team taking care of patients with COVID-19, in each group were assigned into small groups and joined an online interactive lecture session, two sessions of in-situ simulation and a debriefing session with strict health protocols. The first simulation aimed to teach participants the skills and steps needed. The second simulation aimed to assess transfer skills, communication and teamwork performance, that participants had learnt using a validated, comprehensive assessment tool. Data were analysed using unpaired t test or Mann-Whitney test.

Results

The HFS group showed significantly better overall transfer and communication skills than LFS group (89.70±4.65 vs 77.19±3.6, <0.05 and 100 vs 88.34 (63.33–100), p=0.022, respectively). The HFS group also demonstrated significantly better teamwork performance than the standard LFS group (90 (80–900) vs 80 (70–90), p=0.028).

Conclusion

In situ simulation training using HFS significantly showed better performance than the standard training using LFS in regards to overall transfer and communication skills as well as teamwork performance. The training using HFS may provide a valuable adjunct to improve interprofessional skills, communication and teamwork performance in transferring critically ill patients with COVID-19.

Trial registration number

NCT05113823.

Is It Beneficial to Optimize Vital Signs Before Embolization for Pelvic Fractures? A Dilemma Between Resuscitation and Hemostasis

Purpose

Adequate resuscitation and definitive hemostasis are both important in the management of hemorrhage related to pelvic fracture. The goal of this study was to analyze the relationship between the amount of blood transfused before transcatheter arterial embolization (TAE) and the clinical outcome later in the disease course.

Methods

Patients with pelvic fractures who underwent TAE for hemostasis from January 2018 to December 2019 were studied. The characteristics of patients who received blood transfusions of >2 U (1000 mL) and ≤2 U before TAE were compared. The mortality rate, blood transfusion-related complications, and length of stay were compared between these two groups.

Results

Among the 75 studied patients, 39 (52.0%) received blood transfusions of ≤2 U before TAE, and the other 36 (48.0%) patients received blood transfusions of >2 U before TAE. The incidence rates of systemic inflammatory response syndrome, sepsis, and coagulopathy were significantly higher in the >2 U group (97.2% vs 81.1%, P = .027; 50.0% vs 27.0%, P = .045; and 44.4% vs 5.4%, P < .01, respectively). After nonsurvivors were excluded, the >2 U group had a significantly higher proportion (43.8% vs 14.7%, P < .001) of prolonged intensive care unit (ICU) length of stay (7 days or more) and a longer hospital length of stay (33.8 ± 15.1 vs 21.9 ± 94.0, P < .01) than the ≤2 U group. Pre-TAE blood transfusion >2 U serves as an independent risk factor for prolonged ICU length of stay and increased hospital length of stay.

Conclusion

Early hemostasis for pelvic fracture-related hemorrhage is suggested to prevent pre-TAE blood transfusion-associated adverse effects of blood transfusion.

Adverse Events and Associated Factors During Intrahospital Transport of Newborn Infants

OBJECTIVE

To determine the frequency, type, and severity of adverse events (AEs) during intrahospital transport of newborn infants and to identify associated factors.

STUDY DESIGN

We conducted a prospective observational study in a tertiary care academic neonatal unit. All patients hospitalized in the neonatal unit and undergoing intrahospital transport between June 1, 2015, and May 31, 2017 were included. Transports from other hospitals and the delivery room were not included.

RESULTS

Data from 990 intrahospital transports performed in 293 newborn infants were analyzed. The median postnatal age at transport was 13 days (Q1-Q3, 5-44). Adverse events occurred in 25% of transports (248/990) and were mainly related to instability of cardiovascular and respiratory systems, agitation, and temperature control. Adverse events were associated with no harm in 207 transports (207/990, 21%), mild harm in 37 transports (37/990, 4%), and moderate harm in 4 transports (4/990, 0.4%). There was no severe or lethal adverse event. Hemodynamic support with catecholamines, the presence of a central venous catheter, and a longer duration of transport were independent predictors for the occurrence of adverse events during transport.

CONCLUSIONS

Intrahospital transports of newborns are associated with a substantial proportion of adverse events of low-to-moderate severity. Our data have implications to inform clinical practice, for benchmarking and quality improvement initiatives, and for the development of specific guidelines.

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

INTRODUCTION

Intrahospital transport of critically ill patients is often necessary for diagnostic procedures, therapeutic procedures, or admission to the intensive care unit. The aim of this study was to investigate and describe safety and adverse events during intrahospital transport of critically ill patients.

MATERIAL AND METHODS

A systematic search was performed of MEDLINE and the Cochrane Central Register of Controlled Trials for studies published up to June 3, 2020, and of the International Clinical Trials Platform Search Portal and ClinicalTrials.gov for ongoing trials. We selected prospective and retrospective cohort studies published in English on intrahospital transport of critically ill patients, and then performed a meta-analysis. The primary outcome was the incidence of all adverse events that occurred during intrahospital transport. The secondary outcomes were death due to intrahospital transport or life-threatening adverse events, minor events in vital signs, adverse events related to equipment, durations of ICU and hospital stay, and costs.

RESULTS

A total of 12,313 intrahospital transports and 1898 patients from 24 studies were included in the meta-analysis. Among 24 studies that evaluated the primary outcome, the pooled frequency of all adverse events was 26.2% (95% CI: 15.0-39.2) and the heterogeneity among these studies was high (I2 = 99.5%). The pooled frequency of death due to intrahospital transport and life-threatening adverse events was 0% and 1.47% each, but heterogeneity was also high.

CONCLUSIONS

Our findings suggest that adverse events can occur during intrahospital transport of critically ill patients, and that the frequency of critical adverse events is relatively low. The results of this meta-analysis could assist in risk-benefit analysis of diagnostic or therapeutic procedures requiring intrahospital transport of critically ill patients.

TRIAL REGISTRATION

UMIN000040963.

Incidents related to critical patient safety during in-hospital transfer

OBJECTIVE

To analyze the incidents related to patient safety (IRSP) and their risk factors during in-hospital transfer (IHT) of critical patients after the application of a protocol, and to evaluate safety during transfer using quality indicators.

DESIGN

A prospective, observational and non-intervention cohort study was carried out.

SETTING

A 10-bed multipurpose Intensive Care Unit (ICU) of a second level university hospital.

PATIENTS

All IHTs of critical patients in the ICU for diagnostic tests and to the operating room between March 2011 and March 2017 were included in the study.

MAIN MEASUREMENTS

Demographic variables, patient severity, transfer priority, moment of the day, reason and type of transfer team. Pre-transport checklist items and IRSP were collected. A biannual analysis was made of quality indicators designed for IHT.

RESULTS

A total of 805 transfers were registered, mostly of an urgent nature (53.7%) and for diagnostic tests (77%). In turn, 112 transfers (13.9%) presented some type of IRSP; 54% related to the equipment and 30% related to team and organization. Adverse events occurred in 19 (2.4%) transfers. Risk factors identified in the multivariate analysis were mechanical ventilation and the transport team. The evolution of the indicators related to transport was significantly favorable.

CONCLUSIONS

After the application of an IHT protocol, IRSP are low. The main risk factor is invasive mechanical ventilation. The experience of the team performing IHT influences the detection of a greater number of incidents.

Feasibility of the Ultrasound-Guided Insertion of the Peripherally Inserted Central Catheter (PICC) by the Vascular Surgeon at the Bedside in the Trauma Intensive Care Unit

BACKGROUND

This study analyzed the outcomes of the ultrasound-guided insertion of the peripherally inserted central venous catheter (PICC) by experienced vascular surgeons at the bedside of the trauma intensive care unit (ICU) and compared the outcomes with those of fluoroscopy-guided PICC performed by radiologists in the interventional suite.

METHODS

Between May 1, 2016, and April 30, 2021, 97 patients who were hospitalized in the trauma ICU and underwent PICC insertion were enrolled in the study. Forty-two out of the 97 patients underwent PICC insertion by interventional radiologists in the interventional radiology suite under fluoroscopy guidance, while the remaining 55 cases underwent ultrasound-guided PICC insertion by the vascular surgeon at the trauma ICU bedside.

RESULTS

The technical failure (P = 0.504) and malposition (P = 0.127) rates were not significantly different between the 2 groups. However, it took significantly less time for the vascular surgeon to complete the PICC insertion procedure (P < 0.001). Significantly more patients of the ultrasound-guided group required inotropes (P = 0.012) and mechanical ventilation (P = 0.003) at the time of the procedure. In addition, the ultrasound-guided group appeared to be in critical condition in terms of kidney function according to laboratory data (P = 0.014). Meanwhile, the ultrasound-guided group maintained the central line catheter for a shorter time (P < 0.001).

CONCLUSIONS

In trauma patients, ultrasound-guided PICC insertion at the bedside by experienced vascular surgeons at the trauma ICU was feasible compared to fluoroscopy-guided insertion performed by interventional radiologists.

Proactive risk assessment of intrahospital transport of critically ill patients from emergency department to intensive care unit in a teaching hospital and its implications

AIMS AND OBJECTIVES

To explore the effects of the health failure mode and effect analysis (HFMEA) used in intrahospital transport (IHT) of critically ill patients from emergency department (ED) to the intensive care unit (ICU).

BACKGROUND

Patients who were transported from ED to ICU is highly critical. IHT of these patients is potentially risky, which may associate with adverse events (AEs). The concern of safe IHT can be addressed by performing proactive risk assessments using HFMEA and implementing the findings after the ED of our hospital being reconstructed.

DESIGN

A qualitative action research study combined with a quantitative cross-sectional method.

METHODS

According to the HFMEA method, the failure modes of IHT were identified and analysed, and the effect of alterations was verified. We built a project team, drawn up a IHT flow chart, defined steps of IHT, classified the failure modes, calculated risk priority number and analysed by the decision tree, then formulated an action plan and verified the effects of the alterations. Incidence of AEs of transport was compared before and after HFMEA.SQUIRE 2.0 checklist was chosen on reporting the study process.

RESULTS

The HFMEA outlined a total of 5 major steps and 16 sub-steps in the IHT process. From this, 64 potential failure modes were identified, with 17 modes having a RPN score higher than 8. Determined by the decision tree, there were 20 priority control failure modes, of which 16 involved 8 IHT alterations. Notable work-flow alterations included use of a three-stage hierarchical transport strategy based on patients' condition assisted by the intelligent assessment system. Incidence of AEs was significantly decreased from 19.64% to 7.14% after the implementation of HFMEA (p < 0.05).

CONCLUSION

Application of the HFMEA in optimising IHT process can improve the safety of transportation, which is worthy of promotion. Hierarchical transport scheme can reduce the incidence of AEs in IHT of critical emergency patients, which mainly includes the integration and construction of the transport team, equipment configuration and patient information system based on the classification of patients' condition.

RELEVANCE TO CLINICAL PRACTICE

Nurses play a crucial role in the IHT process. HFMEA can be adopted for proactive risk assessment of critically ill patients' IHT from ED to ICU which involves multiple processes. The IHT hierarchical strategy based on the results of failure mode analysis should be more widely used to further verify its clinical effects.

Interhospital Transfer of Patients With Acute Pulmonary Embolism (PE): Challenges and Opportunities

Acute pulmonary embolism (PE) is associated with significant morbidity and mortality. The management paradigm for acute PE has evolved in recent years with wider availability of advanced treatment modalities ranging from catheter-directed reperfusion therapies to mechanical circulatory support. This evolution has coincided with the development and implementation of institutional pulmonary embolism response teams (PERT) nationwide and internationally. Because most institutions are not equipped or staffed for advanced PE care, patients often require transfer to centers with more comprehensive resources, including PERT expertise. One of the unmet needs in current PE care is an organized approach to the process of interhospital transfer (IHT) of critically ill PE patients. In this review, we discuss medical optimization and support of patients before and during transfer, transfer checklists, defined roles of emergency medical services, and the roles and responsibilities of referring and receiving centers involved in the IHT of acute PE patients.

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.

Risk prediction using the National Early Warning Score and the Worthing Physiological Scoring System in patients who were transported to the Intensive Care Unit from the Emergency Department: A cohort study

OBJECTIVES

The aim of this study was to assess the value of the National Early Warning Score and Worthing Physiological Scoring System for predicting changes in the condition of critical cases during transfer from the emergency department to the intensive care unit.

METHODS

This prospective single-centre study was conducted at a 1759-bed hospital in Beijing. We recorded the vital signs in the cases before leaving the emergency department and their changes in condition during transit.

RESULTS

A total of 258 critically ill cases were included. Forty-four cases (17.05%) exhibited changes in their condition during transit. Compared with cases with NEWS ≤ 5, cases with NEWS > 5 were more likely to experience changes with an OR of 5.744 (95% CI 2.888-11.426). Compared with cases with WPS ≤ 2, cases with WPS > 2 were more likely to experience changes with an OR of 7.217 (95% CI 3.575-14.569). The difference between the areas under the curve of the NEWS (0.751 ± 0.045) and the WPS (0.736 ± 0.045) was not statistically significant (P = 0.4518).

CONCLUSION

In our study, the Worthing Physiological Scoring System and National Early Warning Score both exhibited good discriminatory power, but the Worthing Physiological Scoring System is simpler to use and more suitable for use in a busy emergency department.

Caring for critically ill patients during interhospital transfers: A qualitative study

BACKGROUND

The coronavirus pandemic has resulted in an increased number of interhospital transfers of patients with artificial airways. The transfer of these patients is associated with risks and has been experienced as highly challenging, which needs to be further explored.

AIMS AND OBJECTIVES

To describe critical care nurses' experiences of caring for critically ill patients with artificial airways during interhospital transfers.

DESIGN

A cross-sectional study using a qualitative approach was conducted during spring 2020. Participants were critical care nurses (n = 7) from different hospitals (n = 2).

METHODS

The data were collected through semi-structured interviews based on an interview guide. A qualitative content analysis using an inductive approach was performed.

RESULTS

The analysis resulted in one main theme, "Preserving the safety in an unknown environment," and three sub-themes, "Being adequately prepared is essential to feel secure," "Feeling abandoned and overwhelmingly responsible," and "Being challenged in an unfamiliar and risky environment."

CONCLUSIONS

Critical care nurses experienced interhospital transfers of critically ill patients with artificial airways as complex and risky. It is essential to have an overall plan in order to prevent any unpredictable and acute events. Adequate communication and good teamwork are key to the safe transfer of a critically ill patient in that potential complications and dangers to the patient can be prevented.

RELEVANCE TO CLINICAL PRACTICE

Standardized checklists need to be created to guide the transfers of critically ill patients with different conditions. This would prevent failures based on human or system factors, such as lack of experience and lack of good teamwork.

The design and evaluation of a pre-procedure checklist specific to the cardiac catheterisation laboratory

BACKGROUND

With the increasing complexity of procedures being performed in the cardiac catheterisation laboratory, the multidisciplinary team has the challenge of providing safe care to patients who present with a multitude of healthcare needs. Although the use of a surgical safety checklist has become standard practice in operating theatres worldwide, the use of a pre-procedure checklist has not been routinely adopted into interventional cardiology.

OBJECTIVE

The aim of this study was to design and evaluate a pre-procedure checklist specific to the cardiac catheterisation laboratory.

METHOD

A descriptive, exploratory design was used to develop a specifically designed pre-procedure checklist for use in the cardiac catheterisation laboratory in a private hospital in Melbourne, Australia. The pre-procedure checklist was developed by exploring the multidisciplinary team's opinion regarding the organisation's previous surgical pre-procedure checklist through a pre-implementation survey and focus groups. Following an expert review, and implementation of the proposed pre-procedure checklist, a post-implementation survey was completed.

RESULTS

Thirty-five (70%) cardiac catheterisation laboratory healthcare professionals completed the pre-implementation survey, with 31 (62%) completing the post-implementation survey. Ninety-one per cent of participants agreed that important clinical information required for interventional procedures was not documented on the previous surgical checklist. A specific checklist was developed from the results of the survey and six focus groups (N = 25) and implemented in the cardiac catheterisation laboratory. In the post-implementation survey, participants identified that the cardiac catheterisation laboratory specific pre-procedure checklist included all relevant clinical information and improved documentation of patient information.

CONCLUSION

The development of a specific cardiac catheterisation laboratory pre-procedure checklist has led to an improved transfer of pertinent clinical information required prior to procedures being performed in the unit. The outcome of this study has implications for other cardiac catheterisation laboratories with the potential to standardise practice within interventional cardiology practice and improve patient safety outcomes.

Descriptive record of the activity of military critical care transfer teams deployed to London in April 2020 to undertake transfer of patients with COVID-19

In the face of the COVID-19 outbreak, military healthcare teams were deployed to London to assist the London Ambulance Service t transfer ventilated patients between medical facilities. This paper describes the preparation and activity of these military teams, records the lessons identified (LI) and reviews the complications encountered'. The teams each had two members. A consultant or registrar in emergency medicine (EM) and pre-hospitalemergency medicine (PHEM)E or anaesthesia and an emergency nurse or paramedic. Following a period of training, the teams undertook 52 transfers over a 14-day period. LI centred around minimising both interruption to ventilation and risk of aerosolisation of infectious particles and thus the risk of transmission of COVID-19 to the treating clinicians. Three patient-related complications (6% of all transfers) were identified. This was the first occasion on which the Defence Medical Services (DMS) were the main focus of a large-scale clinical military aid to the civil authorities. It demonstrated that DMS personnel have the flexibility to deliver a novel effect and the ability to seamlessly and rapidly integrate with a civilian organisation. It highlighted some clinical lessons that may be useful for future prehospital emergency care taskings where patients may have a transmissible respiratory pathogen. It also showed that clinicians from different backgrounds are able to safely undertake secondary transfer of ventilated patients. This approacmay enhance flexibility in future operational patient care pathways.

Critical care transfers and COVID-19: Managing capacity challenges through critical care networks

The intensive care units in North West London are part of one of the oldest critical care networks in the UK, forming a mature and established strategic alliance to share resources, experience and knowledge for the benefit of its patients. North West London saw an early surge in COVID-19 admissions, which urgently threatened the capacity of some of its intensive care units even before the UK government announced lockdown. The pre-existing relationships and culture within the network allowed its members to unite and work rapidly to develop agile and innovative solutions, protecting any individual unit from becoming overwhelmed, and ultimately protecting its patients. Within a short 50-day period 223 patients were transferred within the network to distribute pressures. This unprecedented number of critical care transfers, combined with the creation of extra capacity and new pathways, allowed the region to continue to offer timely and unrationed access to critical care for all patients who would benefit from admission. This extraordinary response is a testament to the power and benefits of a regionally networked approach to critical care, and the lessons learned may benefit other healthcare providers, managers and policy makers, especially in regions currently facing new outbreaks of COVID-19.

Risk factors and events in the adult intensive care unit associated with pain as self-reported at the end of the intensive care unit stay

Background

The short-term and long-term consequences of the most frequent painful procedures performed in the ICU are unclear. This study aimed to identify the risk factors associated with pain-related discomfort perceived by critically ill patients during the whole ICU stay as self-reported by patients at the end of their ICU stay.

Methods

The study involved 34 ICUs. Adult patients who survived an ICU stay of 3 calendar days or more were eligible for inclusion. Discomforts, including the pain-related discomfort, were assessed using the French 18-item questionnaire on discomfort in ICU patients, the “Inconforts des Patients de REAnimation” (IPREA). Patients scored each item from 0 (minimal discomfort) to 10 (maximal discomfort). Associations between patient characteristics at ICU admission, life support therapies and main potentially painful procedures performed during the ICU stay and pain-related discomfort scores assessed at the end of the ICU stay were analyzed.

Results

Patients with complete IPREA questionnaires (n = 2130) were included. The median pain-related discomfort score was 3 (IQR 0–5). From the univariate analysis, pain-related discomfort scores were negatively correlated with age and positively correlated with ICU stay duration; surgical patients reported significant higher pain-related discomfort scores than medical patients; chest drain insertion, chest drain removal, use of bladder catheter, central venous catheter (CVC) insertion, complex dressing change, and intra-hospital transport were associated with pain-related discomfort scores. From the multivariate analyses using generalized estimating equations models, only age, chest drain removal, use of a bladder catheter, CVC insertion, and intra-hospital transport were the main risk factors associated with pain-related discomfort scores.

Conclusion

Patients who underwent chest drain removal, bladder catheter, CVC insertion, and intra-hospital transport during their ICU stay reported higher pain-related discomfort scores (with respect to the whole ICU stay and assessed at the end of their ICU stay) than patients who did not experience these events. This study may pave the way for further targeted studies aiming at investigating a causal link between these common procedures in the ICU and adult critically ill patients’ perceptions of their ICU stay regarding recalled pain.

Trial Registration: Clinicaltrials.gov Identifier NCT02442934, retrospectively registered on May 13, 2015

Simulation study on flow rate accuracy of infusion pumps in vibration conditions during emergency patient transport

Infusion pumps are frequently used when transferring critically ill patients via patient transport cart, ambulance, or helicopter. However, the performance of various infusion pumps under these circumstances has not been explored. The aim of this study was to evaluate the flow rate accuracy of infusion pumps under various clinical vibration conditions. Experiments were conducted with four different types of pumps, including two conventional syringe pumps (Injectomat MC Agilia, Fresenius Kabi and TE-331, Terumo), one conventional peristaltic pump (Volumed μVP7000; Arcomed), and one new cylinder pump (H-100, Meinntech). The flow rate was measured using an infusion pump analyzer on a stable table (0 m/s²) for 1 h with 1 ml/h and 5 ml/h. Experiments were repeated in mild vibration (2 m/s²) (representing vibration of patients in a moving stretcher or ambulance), and in moderate vibration (6 m/s²) (representing vibration in helicopter transport). Any accidental bolus occurrence in extreme vibration situations (20 m/s²) was also analyzed. Simulated vibrations were reproduced by a custom-made vibration table. In the resting state without vibration and in mild vibration conditions, all pumps maintained good performance. However, in moderate vibration, flow rates in syringe pumps increased beyond their known error ranges, while flow rates in peristaltic pumps remained stable. In extreme vibration, accidental fluid bolus occurred in syringe pumps but not in peristaltic pumps. The newly developed cylinder pump maintained stable performance and was unaffected by external vibration environments.

The mortality of critically ill patients was not associated with inter-hospital transfer due to a shortage of ICU beds - a single-centre retrospective analysis

Background

Patients in the intensive care unit (ICU) are increasingly being transferred between ICUs due to a shortage of ICU beds, although this practice is potentially harmful. However, in tertiary units, the transfer of patients who are not in need of highly specialized care is often necessary. The aim of this study was to assess the association between a 90-day mortality and inter-hospital transfer due to a shortage of ICU beds in a tertiary centre.

Methods

Data were retrieved from the local ICU database from December 2011 to September 2019. The primary analysis was a risk-adjusted logistic regression model. Secondary analyses comprised case/control (transfer/non-transfer) matching.

Results

A total of 573 patients were transferred due to a shortage of ICU beds, and 8106 patients were not transferred. Crude 90-day mortality was higher in patients transferred due to a shortage of beds (189 patients (33%) vs 2188 patients (27%), p = 0.002). In the primary, risk-adjusted analysis, the risk of death at 90 days was similar between the groups (odds ratio 0.923, 95% confidence interval 0.75–1.14, p = 0.461). In the secondary analyses, a 90-day mortality was similar in transferred and non-transferred patients matched according to SAPS 3-score, age, days in the ICU and ICU diagnosis (p = 0.407); SOFA score on the day of discharge, ICU diagnosis and age (p = 0.634); or in a propensity score model (p = 0.229).

Conclusion

Mortality at 90 days in critically ill patients treated in a tertiary centre was not affected by transfer to another intensive care units due to a shortage of beds. We found this conclusion to be valid under the assumption that patients are carefully selected and that the transports are safely performed.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40560-020-00501-z.

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.

Adverse Events During Intrahospital Transport of Critically Ill Children: A Systematic Review

Intrahospital transport of a critically ill patient is often required to achieve a diagnostic and/or therapeutic objective. However, clinicians who recommend a procedure that requires transport are often not fully aware of the risks of transport. Clinicians involved in the care of critically ill children may therefore benefit from a clear enumeration of adverse events that have occurred during transport, risk factors for those events, and guidance for event prevention. The objective of this review was to collect all published harm and adverse events that occurred in critically ill children in the context of transport within a medical center, as well as the incidence of each type of event. A secondary objective was to identify what interventions have been previously studied that reduce events and to collect recommendations for harm prevention from study authors. Ovid MEDLINE, Cochrane Central Register of Controlled Trials, Embase, and CINAHL were searched in January 2018 and again in December 2018. Terms indicating pediatric patients, intrahospital transport, critical illness, and adverse events were used. Titles and abstracts were screened and full text was reviewed for any article meeting inclusion criteria. If articles included both children and adults, incidence data were collected only if the number of pediatric patients could be ascertained. Of 471 full-text articles reviewed, 40 met inclusion criteria, of which 24 included only children, totaling 4104 patient transports. Heterogeneity was high, owing to a wide range of populations, settings, data collection methods, and outcomes. The incidence of adverse events varied widely between studies. Examples of harm included emergent tracheostomy, pneumothorax, and cardiac arrest requiring chest compressions. Respiratory and airway events were the most common type of adverse event. Hypothermia was common in infants. One transport-associated death was reported. When causation was assessed, most events were judged to have been preventable or potentially mitigated by improved double-checks and usage of checklists. Prospective studies demonstrated the superiority of mechanical ventilation over manual ventilation for intubated patients. Risk of adverse events during critical care transport appears to relate to the patient's underlying illness and degree of respiratory support. Recommendations for reducing these adverse events have frequently included the use of checklists. Other recommendations include optimization of the patient's physiological status before transport, training with transport equipment, double-checking of equipment before transport, and having experienced clinicians accompany the patient. All available recommendations for reducing transport-associated adverse events in included articles were collated and included.

Complications Associated With the Anesthesia Transport of Pediatric Patients: An Analysis of the Wake Up Safe Database

BACKGROUND

Transporting patients under anesthesia care incurs numerous potential risks, especially for those with critical illness. The purpose of this study is to identify and report all pediatric anesthesia transport-associated adverse events from a preexisting database of perioperative adverse events.

METHODS

An extract of the Wake Up Safe database was obtained on December 14, 2017, and screened for anesthesia transport-associated complications. This was defined as events occurring during or immediately after transport or movement of a pediatric patient during or in proximity to their care by anesthesiologists, including repositioning and transfer to recovery or an inpatient unit, if the cause was noted to be associated with anesthesia or handover. Events were excluded if the narrative clearly states that an event was ongoing and not impacted by anesthesia transport, such as a patient who develops cardiac arrest that then requires emergent transfer to the operating room. The search methodology included specific existing data elements that indicate transport of the patient, handover or intensive care status preoperatively as well as a free-text search of the narrative for fragments of words indicating movement. Screened events were reviewed by 3 anesthesiologists for inclusion, and all data elements were extracted for analysis.

RESULTS

Of 2971 events in the database extract, 63.8% met screening criteria and 5.0% (148 events) were related to transport. Events were primarily respiratory in nature. Nearly 40% of all reported events occurred in infants age ≤6 months. A total of 59.7% of events were at least somewhat preventable and 36.4% were associated with patient harm, usually temporary. Of the 86 reported cardiac arrests, 50 (58.1%) had respiratory causes, of which 74% related to anesthesia or perioperative team factors. Respiratory events occurred at all stages of care, with 21.4% during preoperative transport and 75.5% postoperatively. Ninety-three percent of unplanned extubations occurred in patients 6 months and younger. Ten medication events were noted, 2 of which resulted in cardiac arrest. Root causes in all events related primarily to provider and patient factors, with occasional references to verbal miscommunication.

CONCLUSIONS

Five percent of reported pediatric anesthesia adverse events are associated with transport. Learning points highlight the risk of emergence from anesthesia during transport to recovery or intensive care unit (ICU). ICU patients undergoing anesthesia transport face risks relating to transitions in providers, equipment, sedation, and physical positioning. Sedation and neuromuscular blockade may be necessary for transport in some patients but has been associated with adverse events in others.