Global Monitoring and Clear Communication Make Positive Difference
By Julie Crawshaw, Critical Care Plus Editor
What’s the single most important thing intensive care units can do to avoid the disasters that can happen when patients are transported to and from hospital departments? The most important factor is having a critical care doctor or head ICU nurse present to quarterback the move, says pediatrician Robert F. Patterson, MD, FAAP, critical care intensivist at Nemours Children’s Clinic in Pensacola, Fla.
"The fact is that every time you move a patient you run the risk of catastrophe because of the invasive nature of critical care," Patterson says. "The things that need to be attended to increase linearly with the degree of critical illness—and, following Murphy’s Law, if a tube or wire can become disconnected, it will."
ICU staffs deal with many devices and a patient can be highly dependent on each of them. Interrupting a life-sustaining infusion for even a few seconds can result in a life-threatening event, Patterson notes, but having one person monitoring each device can cause a traffic jam around the gurney.
What’s better than numbers is overview, Patterson says. "You need to have someone watching the whole patient. Unfortunately, too often the bedside nurse is left in charge of coordinating patient transport from bed to gurney to X-ray or operating room and back."
The critical care doctor, Patterson adds, isn’t going to be as proficient as the bedside nurse in knowing how long the chest tube is, where everything is connected, but is "pretty good at standing back and watching the whole patient."
Global Monitoring is Essential
What’s needed, Patterson says, is a global awareness of the intrinsic dangers of patient transport, and intensivists have a greater awareness than sub-specialists. "It’s one thing to order a CT scan knowing that you’re going to be somewhere else when transport occurs," he notes. "It’s another to be the intensivist who’s trying to keep track of the patient’s inotropic and ventilatory support."
Patterson emphasizes that the bedside nurse is the important person for managing the various devices, but he says it’s vitally important that the person in charge of transport is not actually touching the equipment. Because so much attention has to be paid to all the devices, tubes, and wires during a move, it’s easy to lose track of the patient’s condition, Patterson says, and patient condition is the first and most critical sign of a problem.
"My nurses know much better than I do how much extension tubing is on each catheter, how far away the IV pole can be from the patient before there’s a potential for disconnect," Patterson says, "But they may not be as good as I am at doing continuous evaluation."
Patterson says that when he oversees ICU patient transport he monitors patient condition and leaves watching the IV poles and chest tubes to others. Keeping track of vital signs without having to deal with transport logistics allows Patterson to know that the patient’s pulse is diminished and it’s time to look for a disconnect before an equipment alarm goes off.
Patterson recalls that as a resident he and a team were moving an ICU patient when an endotracheal tube dislodged long enough for the patient’s condition to deteriorate significantly. "Fortunately, the patient wound up okay," Patterson says, "But the problem could have been avoided had someone noticed the patient was turning blue."
Check all Equipment Before Leaving ICU
Ranna A. Rozenfeld, MD, assistant professor of pediatrics in pediatric critical care medicine at Children’s Memorial Hospital and Northwestern University Medical School in Chicago, stresses the importance of checking each piece of medical equipment the patient needs before leaving the IC. All ICU patients must have a well-functioning IV access in place before beginning transport, Rozenfeld says, and ICU patients should also be non-humanly monitored throughout transport, including arterial pressure monitoring if an arterial line is present.
Rozenfeld says transport equipment should include oxygen, ambu-bag with the appropriate size mask, and, if the patient is intubated, the appropriate size endotracheal tube and laryngoscope. Patients requiring frequent suctioning need a portable suction machine during transport. For those on inotropic support, transport teams should make sure that infusion pumps have adequate battery life and that personnel plug in the pumps when they arrive at the transport destination of the transport.
For neonates and infants it is especially important to keep the patient adequately covered, and possibly using a transportable radiant bed.
In addition to having an intensivist quarterback the process, good communication is essential to uneventful patient transport, Patterson says. "The people in the MRI unit are not going to be aware of the critical nature of the child I’m bringing down unless I tell them, so it behooves me as the team leader to communicate this."
Ongoing dialogue needs to happen so ICU doctors get good feedback, Patterson says. It doesn’t help the patient to use the best ventilating equipment available for transport if that ventilator can’t go in the MRI. If there’s no dialogue between the ICU and the department to which the patient must go, the patient can wind up in big trouble.
Communication should be interdepartmental at all times, not just episodic for transport, Patterson says. "I need to be cognizant of the needs of the surgical and anesthesiology departments where my child will be going to get the best benefit for what I know is a risky proposition," Patterson says. "It doesn’t benefit my patient to take this risk unless I’ve optimized everything I can to produce the best outcome."
Patterson notes that the processes for setting up good communication work differently in different hospitals. He adds that the best communication in his hospital happens during grand rounds, educational forums and medical records luncheons, and over coffee in the physicians’ lounge.
Nemours administrators support these activities and create social opportunities for doctors and nurses which helps improve inter-departmental communication. "Anytime there’s a problem we get people together and talk about it," Patterson says. "Both intra-departmental and inter-departmental communication need to take place." (For more information contact Robert Patterson at  473-4511, or Ranna Rozenfeld at  880-4780.)