13. Improving the safety of IHT

Good clinical practices and common sense provide a solid platform for making IHTs safer, as well as efficient. It is important to note that although our focus on preventing adverse events related to diagnostic and procedural patient trips is centered mainly on the ICU setting, it is well documented that significant proportion of unexpected occurrences may in fact be associated with IHTs involving non-ICU patients [1]. Several tools have been developed to address various safety issues associated with IHTs. Perhaps the most obvious and straightforward tool is the use of patient care checklists [12, 79]. Fanara et al. describe a comprehensive checklist that includes

#### Equipment and patient preparation

Patient labels

Preparation and equipment adapted to procedure

Sufficient medication, O2, and electrical reserves

Breathing:

Intubation secured and position confirmed on CXR Mechanical ventilation adapted to patient Intubation equipment, bag + valve + mask, suction catheters, and monitors Nurses play a critical role in ensuring patient safety during IHTs through both adequate communication and meticulous patient monitoring, as well as managing patient handover protocols [25, 80]. A potentially helpful clinical intrahospital transport tool was described by Brunsveld-Reinders et al. [45]. The tool utilizes a pre-transport, intra-transport, and post-transport checklist in order to ensure proper functioning of equipment; adequate supply of medications, fluids, and oxygen; and continuous patient monitoring [45]. Pre-IHT patient assessment deserves further mention, especially when one considers that among patients who required medical emergency response while in a diagnostic department, nearly 40% of patients arrived receiving supplemental oxygen adminis-

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Hemodynamic and other forms of patient monitoring during transport are becoming more advanced, and the availability of clinical data can be leveraged to improve the quality and safety of IHTs. For example, when transporting brain-injured patients, more frequent or continuous neuromonitoring by using intracranial pressure and end-tidal CO2 determinations throughout the IHT duration has been proposed as a means to reduce both hemodynamic and neurological complications [81]. It has also been postulated that critically ill patients undergoing IHTs be accompanied by an intensivist or experienced attending physician in order to reduce adverse events [24, 37]. This particular aspect may be important for the most critically ill patients, where the impact of even the smallest errors, including omissions during

Finally, ensuring operational readiness of medical equipment, particularly mechanical ventilators, is crucial during the IHT of critically ill patients [6, 23, 79]. It has been suggested that hospital transport stretchers/beds incorporate key functional components (e.g., high-capacity batteries, monitoring equipment core units, built-in suction pumps) and intelligent sensing instrumentation to prevent the snagging and tangling of leads and lines and discontinuation of

Transporting critically ill patients is inherently associated with adverse events that have the potential to change the patient's medical condition; thus it is reasonable to treat transports in a manner similar to that of any other medical treatment. In respect of the patient's right to privacy and autonomy as well as compliance with the Patient Self-Determination Act [83, 84], the patient's wishes regarding communicating medical information to family members, the patient's advanced directive, and proxy appointment(s) should be established as part of general consent to treatment. If the patient is not competent to make a determination, then the patient's appointed proxy or next of kin should be consulted to give informed consent for the transport and procedure on the patient's behalf. Majority of patients express wishes that their families be kept informed regarding their condition, and when this is the case, medical personnel have a responsibility to communicate clearly and efficiently with families so that good understanding of key diagnostic and therapeutic issues exists [85]. When a critically ill patient requires potentially risky IHT, families should be made aware of the patient's condition, reasons for transport, and the risks and risk–benefit consideration associated with both the transport and procedure [5].

tration, almost 30% had tachypnea, and approximately one-third had tachycardia [1].

the handover process, may result in major clinical setbacks [46].

critical functionalities [24, 78, 82].

14. Family communication

Circulation:

Route for venous access isolated and secured Medication and fluid loading solutions Alarms adjusted and activated

Lines, cables, and drainage tubes

#### Transport team

Minimum of three escorts available including experienced doctor

#### Transport organization

Confirmation of timetable for procedure

Transport route clear, lifts, and emergency room available

Operational equipment for continuous treatment at sites of procedure

#### Clinical stability of patient

Preparation adapted to clinical status of each patient Breathing (as above) Circulation (as above)

Neurological status: GCS, pupils, and ICP

Sedation/analgesia

Breaks stabilized, burns, and wounds protected

Head raised if possible

#### Systematic check points following transport

A: airway = integrity of ventilation system

B: breathing = bilateral auscultation, insufflation pressure, spirometry, SpO2, and EtCO2

C: circulation = read monitor, check blood pressure, and isolate injection route

D: disconnect = plug O2 and electrical supplies into wall socket

E: eyes = monitors are visible to transport team

F: fulcrum = check points of support

CXR = chest radiograph; EtCO2 = end-tidal carbon dioxide; GCS = Glasgow Coma Scale; ICP = intracranial pressure; O2 = Oxygen; SpO2 = peripheral capillary oxygen saturation.

Table 1. Checklist for intrahospital transport of critically ill patients. Modified from Fanara et al. [79].

both patient and equipment assessment prior to transport, an evaluation of patient stability during transport, and a complete repeat assessment after the patient is moved (Table 1) [79].

Nurses play a critical role in ensuring patient safety during IHTs through both adequate communication and meticulous patient monitoring, as well as managing patient handover protocols [25, 80]. A potentially helpful clinical intrahospital transport tool was described by Brunsveld-Reinders et al. [45]. The tool utilizes a pre-transport, intra-transport, and post-transport checklist in order to ensure proper functioning of equipment; adequate supply of medications, fluids, and oxygen; and continuous patient monitoring [45]. Pre-IHT patient assessment deserves further mention, especially when one considers that among patients who required medical emergency response while in a diagnostic department, nearly 40% of patients arrived receiving supplemental oxygen administration, almost 30% had tachypnea, and approximately one-third had tachycardia [1].

Hemodynamic and other forms of patient monitoring during transport are becoming more advanced, and the availability of clinical data can be leveraged to improve the quality and safety of IHTs. For example, when transporting brain-injured patients, more frequent or continuous neuromonitoring by using intracranial pressure and end-tidal CO2 determinations throughout the IHT duration has been proposed as a means to reduce both hemodynamic and neurological complications [81]. It has also been postulated that critically ill patients undergoing IHTs be accompanied by an intensivist or experienced attending physician in order to reduce adverse events [24, 37]. This particular aspect may be important for the most critically ill patients, where the impact of even the smallest errors, including omissions during the handover process, may result in major clinical setbacks [46].

Finally, ensuring operational readiness of medical equipment, particularly mechanical ventilators, is crucial during the IHT of critically ill patients [6, 23, 79]. It has been suggested that hospital transport stretchers/beds incorporate key functional components (e.g., high-capacity batteries, monitoring equipment core units, built-in suction pumps) and intelligent sensing instrumentation to prevent the snagging and tangling of leads and lines and discontinuation of critical functionalities [24, 78, 82].

#### 14. Family communication

both patient and equipment assessment prior to transport, an evaluation of patient stability during transport, and a complete repeat assessment after the patient is moved (Table 1) [79].

CXR = chest radiograph; EtCO2 = end-tidal carbon dioxide; GCS = Glasgow Coma Scale; ICP = intracranial pressure;

Table 1. Checklist for intrahospital transport of critically ill patients. Modified from Fanara et al. [79].

Equipment and patient preparation

116 Vignettes in Patient Safety - Volume 3

Preparation and equipment adapted to procedure Sufficient medication, O2, and electrical reserves

Route for venous access isolated and secured Medication and fluid loading solutions Alarms adjusted and activated Lines, cables, and drainage tubes

Confirmation of timetable for procedure

Neurological status: GCS, pupils, and ICP

Systematic check points following transport A: airway = integrity of ventilation system

Breaks stabilized, burns, and wounds protected

E: eyes = monitors are visible to transport team

F: fulcrum = check points of support

Intubation secured and position confirmed on CXR Mechanical ventilation adapted to patient

Minimum of three escorts available including experienced doctor

Operational equipment for continuous treatment at sites of procedure

B: breathing = bilateral auscultation, insufflation pressure, spirometry, SpO2, and EtCO2

C: circulation = read monitor, check blood pressure, and isolate injection route

D: disconnect = plug O2 and electrical supplies into wall socket

O2 = Oxygen; SpO2 = peripheral capillary oxygen saturation.

Transport route clear, lifts, and emergency room available

Preparation adapted to clinical status of each patient

Intubation equipment, bag + valve + mask, suction catheters, and monitors

Patient labels

Breathing:

Circulation:

Transport team

Transport organization

Clinical stability of patient

Breathing (as above) Circulation (as above)

Sedation/analgesia

Head raised if possible

Transporting critically ill patients is inherently associated with adverse events that have the potential to change the patient's medical condition; thus it is reasonable to treat transports in a manner similar to that of any other medical treatment. In respect of the patient's right to privacy and autonomy as well as compliance with the Patient Self-Determination Act [83, 84], the patient's wishes regarding communicating medical information to family members, the patient's advanced directive, and proxy appointment(s) should be established as part of general consent to treatment. If the patient is not competent to make a determination, then the patient's appointed proxy or next of kin should be consulted to give informed consent for the transport and procedure on the patient's behalf. Majority of patients express wishes that their families be kept informed regarding their condition, and when this is the case, medical personnel have a responsibility to communicate clearly and efficiently with families so that good understanding of key diagnostic and therapeutic issues exists [85]. When a critically ill patient requires potentially risky IHT, families should be made aware of the patient's condition, reasons for transport, and the risks and risk–benefit consideration associated with both the transport and procedure [5].

Medical personnel should communicate with the family before the transport about the projected time, duration, destination, and expected benefit or outcome of the process. Thus, proper expectations can be met, and family members are provided with basic goals and parameters regarding the overall clinical context [86]. Prior to the transport, the patient's proxy or next of kin should be available, and their phone numbers should be obtained by the transport team in case of unexpected events, especially if the patient is not decisionally competent or becomes noncompetent during the transport or procedure. When the patient is stabilized at the destination or returned to the ICU, the patient's proxy and family members should be informed and updated on the patient's condition by a member of the transport team [86–88].

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