Adult and pediatric patients moving from one area of Johns Hopkins Hospital in Baltimore to another face less risk than might be found in other institutions because of a program ensuring that they will receive the same quality of care during transfer as they do on a unit.
Modeled on similar teams that move patients via ambulance or helicopter, specially trained Lifeline Intrahospital Transport Teams provide transport of critically ill patients from ICUs to other areas for treatment or diagnostic services, as well as moving all cardiac-monitored patients.
The Lifeline program was initiated in 1992, when there were few designated intra- or interhospital transport teams. It has since grown to include more units in the Hopkins system. The Lifeline teams perform more than 12,000 intrahospital transports each year, with an adverse event rate of less than 1% with critically ill patients.
The intrahospital transfer program grew out of the benefits realized from Hopkins’ early experience with improving interhospital transfers, explains James Scheulen, PA, chief administrative officer for emergency medicine and capacity management, and president of Johns Hopkins Emergency Medical Services in Baltimore. Hopkins leaders realized that patient care was suffering during transport from another hospital — particularly with severe cases like burns — because the referring hospital and ambulance service had little experience in treating those conditions.
“We started a retrieval system in which someone from the burn center would get on a helicopter and fly out to those hospitals and institute the appropriate care there, then bring the patient back,” Scheulen says. “We saw a tremendous change in patient outcomes, so then we thought the same thing applies to cardiac patients, stroke patients, and every other patient who needs to be stabilized and who needs a treatment plan carried out during the transportation from point A to point B.”
That was the general concept that led to Hopkins developing a program for critical care transport between hospitals and eventually applying the same idea in-house.
“We started to see that inside the hospital, moving patients from one side of our campus to another side for diagnostics or another service sometimes took as long as an ambulance ride from another hospital five or 10 miles away,” Scheulen says. “In most hospitals, the people who do transfers within the hospital for critical care patients are an intern and a nurse from the floor. We saw in one year a couple of sentinel events in which people were mistakenly extubated or lost central lines, and they had bad outcomes.”
High-Level Team Members
The hospital’s risk management department went to Scheulen and the other Lifeline leaders to ask if they could improve quality of care for transports within the hospital the same way they had done for outside transfers. The result was the Lifeline Intrahospital Transfer Program.
“Having an interhospital transport team is no longer a revolutionary concept, but I think the number of hospitals who use that same concept for intrahospital transport is still a very small number,” Scheulen says.
A Hopkins Lifeline Intrahospital Transport Team comprises these clinicians: an emergency medical technician-basic, an emergency medical technician-paramedic, and a registered nurse. A medical director oversees the team.
All team members are certified in Advanced Cardiac Life Support, Pediatric Advanced Life Support, Neonatal Resuscitation Program, and International Trauma Life Support, in addition to other advanced training. They can use and maintain almost any monitor or other device needed for the patient.
Selecting and recruiting the most appropriate team members is crucial to success, says Heidi Hubble, director of operations for Johns Hopkins Lifeline.
“An important lesson learned is the value of having the right people. We took the people who were already experts in transport from our interhospital program and had them apply those skills to the intrahospital program,” she says. “There is a huge difference when one of our teams is transporting a patient versus when staff from an ICU or a unit is transferring a patient. The difference is in their approach, their philosophy, what they’re looking for, and their comfort level.”
Patients Needing Advanced Care
Intrahospital transfers at Hopkins are categorized in four levels. Level I and Level II patients are stable and need no medical intervention or monitoring during the transfer, so they can be transported by patient escort. Patients in Level III typically require cardiac monitoring and are transferred by a two-person team of a paramedic and an EMT-basic.
The Lifeline team steps in for Level IV patients, who need advanced medical care and monitoring during transfer. This could include ventilation and infusions. The transport team stays with the patient through the diagnostic study, ready to provide whatever care might be needed.
Before the Lifeline program, intrahospital transfers at Hopkins usually required a registered nurse and sometimes a physician to attend the patient. The Lifeline team allows nurses to stay on their units without risking any deviation in the quality of care the patient receives, Scheulen says.
“We think we have made an enormous difference in the safety profile of moving patients within the hospital,” Scheulen says. “It’s the combination of the right people, the right technology, and the right experience that has made people feel very secure about moving patients into the hospital and within the hospital once they are here.”
Few Aborted Transfers
Scheulen co-authored a study showing the benefits of the Lifeline program, finding that in 3,383 intrahospital transports of adult patients in a six-month period, there were 59 clinically significant adverse events during transfer. (The study is available at: https://bit.ly/2SAsKQp.)
“Diagnostic radiology was the transport destination for 73% of those patients. With the inclusion of interventional radiology suites, 95% of those patients were ultimately transported to a location within the radiology department’s study areas,” the study authors wrote. “As for clinical needs, the transported patients who had a clinically significant adverse event all had a fairly high acuity level. At the time of transport, 71% of those patients were intubated (42/59), 41% had both an arterial and a central venous catheter (24/59), and 63% had at least one ongoing infusion of medication (37/59).”
According to the study, “The most common events (75%) were related to either hypoxia or hypotension.” However, only one patient was extubated, and only one code team was activated during the study period. The authors also noted that “Only 20% of transports that had adverse events were aborted.”
Start Small and Expand
The authors concluded that the benefit of an intrahospital transport team goes “beyond the reduction in the frequency of adverse events. It keeps nursing staff in their units to manage other patients; physician staff can focus on other duties while their patients are properly cared for in diagnostic areas; and diagnostic resources are better used because intended studies get completed.”
The Lifeline Intrahospital Transport Program provides a huge morale boost to nurses, Scheulen says.
Nurses are relieved that they do not have to leave their other patients to transport and care for one patient during diagnostic studies, he says.
Hopkins also found that the reliable availability of Lifeline Transport Teams improved scheduling so much that radiology could perform one or two more CT studies per day.
Hospital leaders who want to emulate Hopkins’ success with intrahospital transfers may want to start small and expand the program incrementally, Hubble suggests. That was the Hopkins strategy, and other hospitals might want to focus first on a subset of critically ill patients, such as those who are intubated or who require cardiac monitoring.
Once a process is established with those patients, the program could be expanded to include more, she suggests.
“We started with one of the ICUs to do proof of concept, worked out the kinks, and expanded from there,” Hubble says.