12. Special considerations

9. Elevation of intracranial pressures

114 Vignettes in Patient Safety - Volume 3

and positional changes (e.g., head-of-bed elevation to at least 30

11. Risk assessment procedures and protocols

10. Equipment-related events

Among patients with traumatic brain injury, IHTs have been associated with significant elevations in both intracranial pressures (ICP) and reductions in cerebral perfusion pressures [61]. As alluded previously in this manuscript, this may be related to contributions from singular or combined factors, including primary hypotension, inadequate analgo-sedation, and unfavorable patient positioning changes during image acquisition (e.g., supine positioning for magnetic resonance imaging [MRI] or CT scan) [7, 61]. When ordering any diagnostic tests that may put patients with traumatic brain injury at risk, providers must always be aware of the potential for unexpected ICP elevations. A common source of technical complications for the patient being transported is the intracranial pressure monitor, usually an external ventricular drain (EVD) [62, 63]. Studies have shown that the EVD catheter may be subject to displacement, removal, or accidental blockage during patient transfer, particularly if the catheter contains a strain gauge rather than fiber optic sensor. The overall rate of catheter disturbance is estimated to be 5%, although these can be replaced or flushed as necessary [62, 63]. Further, all team members must be comfortable with basic therapeutic maneuvers for ICP normalization, including administration of analgo-sedation, mannitol, hypertonic saline, vasopressors, transient hyperventilation,

This heterogeneous group of IHT-related complications spans an entire spectrum from catheter dislodgements and/or kinking to failures of negative pressure wound dressings [5]. In a report of IHTs involving more than 250 critically ill patients, it was noted that a large proportion of unexpected occurrences were associated with some form of "equipment malfunction" [37]. In our review of the literature, common types of equipment failures included "oxygen probe displacement" [37], "physiologic and equipment alarm issues" [5, 22], "tube/drain dislodgement" [6], "loss of intravenous access" [65], "wound dressing integrity issues" [5], "battery-related problems" [22], and "loss of suction" [26]. Because some types of equipment malfunction can result in fatal outcome, appropriate provider/team training and careful planning prior to IHT are mandatory to avoid preventable complications [66–68], especially in patients whose management may be challenging to begin with [69]. Positioning changes can be especially risky for patients with multiple catheters or tubes, where each additional device adds an extra layer of complexity.

The need for major corrective steps has been reported in over one-third of all IHTs [70]. Coupled with the fact that adverse events of differing magnitude may occur in as many as 70% of IHTs [71], increasingly vocal calls are being made for improving PS during intrahospital trips. Beginning with team debriefing and equipment checks, the entire process should be conducted with utmost attention to the smallest detail. As outlined throughout the Vignettes in Patient Safety book

) [64].

Transport of critically ill patients from the emergency department (ED) to the ICU is among the better researched areas within the broader domain of IHTs. The most common adverse events occurring during IHTs of critically ill patients from the ED to the ICU were equipment problems such as oxygen saturation probe failures, monitoring lead and intravenous line entanglements, hemodynamic parameter excursions, and problems related to analgesia, sedation, and paralytic medications [19, 24]. The most common serious adverse events requiring intervention included severe hypotension, declining level of consciousness requiring intubation, and increased intracranial pressure in brain-injured patients [24]. Of note, delays in transport from the ED to ICU can significantly impact patient outcomes, including both increased lengths of stay and hospital mortality [73]. The interdisciplinary nature of the process cannot be overemphasized, and all members of the team must respect each other's expertise and the ever-present potential for mishaps [14].

Another important, yet often overlooked type of intrahospital critical care transport involves patients on extracorporeal membrane oxygenation (ECMO) circuits [74]. While intrahospital transfers involving patients with acute respiratory distress syndrome (ARDS) can be challenging, the addition of an ECMO circuit adds an extra layer of complexity that requires significantly greater amount of team/provider expertise during IHTs [74]. Despite recent advances in device design, including miniaturization and simplification of the overall transport framework, extreme caution is required during any kind of "more-than-minimal" change in patient environs [75–77]. Consequently, providers caring for ECMO patients who require intrahospital transfers during their active therapy period must be able to handle not only the routine "sets of challenges" associated with transporting critically ill patients but must additionally be able to successfully tackle issues specific to ECMO. When examining interhospital ECMO transfers in terms of safety and efficacy, outcomes of patients transported by an experienced ECMO team appear to be comparable to outcomes for non-transported ECMO patients [78]. These data are likely translatable to intrahospital transfers.
