7. Cardiac and pulmonary complications

As discussed earlier in this chapter, cardiac and pulmonary complications are among the most serious and clinically impactful events during IHTs. This group of heterogeneous occurrences can take multiple manifestations, from acute respiratory failure to permanent cardiac or pulmonary impairment (e.g., pulmonary embolism and its sequelae). It is now well established that IHTs are associated with significant risk of healthcare-associated pneumonia [35]. In fact, the odds of this serious complication increase 3.1-fold among ventilated patients undergoing IHTs during their ICU stay [35]. Moreover, IHTs were associated with increased risk of thromboembolic phenomena, thus predisposing affected patients to a broad range of both acute and more chronic cardiovascular and pulmonary complications [39]. Cardiac arrests and severe dysrhythmias during IHTs have been reported, and despite their usually grave nature, attributable deaths have fortunately been uncommon [19, 24].

#### 8. Hemodynamic parameter excursions

preclude transporting personnel from effectively tending to other patients. If the intended diagnostic or therapeutic procedure is lengthy and the receiving team has the personnel and resources to adequately care for the patient, then care can be transferred via direct personnel communication and written documentation of the patient's condition, treatments, and transfer details [13, 44]. If the approximate time spent at the destination is short or that particular department does not have the staff or resources needed to adequately care for the patient, then the transfer team should remain with the patient for the entire duration of the procedure and

Effective navigation of the physical landscape of the hospital, including hallways, building connectors, and elevators requires careful planning and attention to detail. Excellent knowledge of the facility, including any potential construction or maintenance activities, is needed to avoid unexpected delays and/or dangerous backtracking. For example, some multibuilding medical centers feature connecting bridges only on certain floors, and travel on the incorrect level may result in unnecessary delays. It has indeed been noted that a small, but by no means trivial, number of IHTs were complicated by the team becoming either "lost" en route to their destination or unexpectedly "trapped" in an enclosed space, such as an elevator [24]. This is especially important when using battery-operated equipment that provides vital support to the patient. Communication regarding the overall status of the process is also crucial to the safe transport of patients [6, 46]. Finally, providers must be cognizant that while substantial proportion of adverse events involving IHTs occurs in radiology departments, the most susceptible type of diagnostic

At this juncture, we will highlight specific IHT complication groups and types. Because the overall topic is quite vast, we will only "scratch the surface" of the different categories of patient safety events that can occur during intrahospital transfers. Rich referencing will be provided so that the reader can consult with source studies and manuscripts. To further compensate for lack of granularity, we will encourage our readers to think more broadly and to instead apply the principles learned throughout this and the other chapters of the Vignettes

As discussed earlier in this chapter, cardiac and pulmonary complications are among the most serious and clinically impactful events during IHTs. This group of heterogeneous occurrences can take multiple manifestations, from acute respiratory failure to permanent cardiac or pulmonary impairment (e.g., pulmonary embolism and its sequelae). It is now well established that IHTs are associated with significant risk of healthcare-associated pneumonia [35]. In fact, the odds of this serious complication increase 3.1-fold among ventilated patients undergoing IHTs during their ICU stay [35]. Moreover, IHTs were associated with increased risk of

transport back to the point of origin (e.g., ICU) [43].

112 Vignettes in Patient Safety - Volume 3

6. Overview of IHT complication types

7. Cardiac and pulmonary complications

in Patient Safety cycle.

test appears to be computed tomography (CT, 42% of occurrences) [1].

An extension of the preceding paragraph on cardiopulmonary complications, this section will briefly discuss the potential occurrence of unplanned blood pressure and heart rate gyrations during IHTs. The importance of hemodynamic parameter excursions is highlighted by the fact that approximately one in six patients who experienced adverse events during IHTs had a cardiovascular diagnosis and that nearly 40% of reported events were cardiac in nature [1]. Both high and low blood pressures can have deleterious effects on the patient's clinical condition, and both extremes can be attributable to common factors. For example, elevations of blood pressure can be due to intravenous pump malfunction resulting in interruption of analgesic infusion, yet the same patient during the continuation of the same scenario can then become profoundly hypotensive as multiple doses of analgesic medication are given to compensate for the severe pain that initially led to hypertension. If not promptly treated, severe hypertension can be associated with end-organ damage [47, 48], highlighting the need for immediate recognition and management of unplanned blood pressure elevations during IHTs.

A cause for great concern in the critically ill patient, hypotension is an all-too-common complication during IHTs. This adverse event can occur as a result of multiple inciting events, including malfunctioning infusion pumps (e.g., during active infusion of vasopressor), airway dislodgment (e.g., the presence of acute hypoxia), impromptu medication boluses (e.g., beta blocker or calcium channel blocker administration for atrial fibrillation), worsening sepsis (e.g., immediately following deep abscess drainage), cardiopulmonary factors (e.g., hemodynamic device disconnection), and many other potential causes [49]. It has been noted that hypotension is among key secondary insults that affect outcomes in patients with traumatic brain injury [7]. In addition, episodic hypotension results in intermittent hypoperfusion of vital organs, including but not limited to the heart, kidneys, bowel, and liver [50, 51].

Episodic heart rate gyrations, especially those outside of the generally accepted normal range, can be associated with systemic hypoperfusion [52–54]. These potentially dangerous occurrences can be due to intrinsic cardiac causes (e.g., aberrant conduction pathways) or a plethora of extrinsic factors (e.g., tachycardia secondary to vasoactive medication infusion or uncontrolled pain, bradycardia associated with beta adrenergic blockade or acute vasovagal response). Various commonly used vasoactive infusions and intermittent medications have the potential to contribute to both heart rate and blood pressure gyrations, leading to potentially harmful hemodynamic manifestations [55–57]. In addition, pre-IHT abnormalities in blood pressure or heart rate may be a harbinger of adverse events during the trip. Thus, personnel accompanying the patient during IHTs should conduct close monitoring of vital signs, medication infusion rates, and the functional status of infusion pumps [58–60].

#### 9. Elevation of intracranial pressures

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, and positional changes (e.g., head-of-bed elevation to at least 30 ) [64].

cycle, strict adherence to established PS protocols helps reduce the incidence of adverse events

Adverse Events during Intrahospital Transfers: Focus on Patient Safety

http://dx.doi.org/10.5772/intechopen.76777

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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

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

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

and improves a broad range of associated clinical outcomes [8, 72].

12. Special considerations

ever-present potential for mishaps [14].

likely translatable to intrahospital transfers.

13. Improving the safety of IHT

#### 10. Equipment-related events

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.

#### 11. Risk assessment procedures and protocols

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 cycle, strict adherence to established PS protocols helps reduce the incidence of adverse events and improves a broad range of associated clinical outcomes [8, 72].
