Intra-Hospital Transport of ICU Patients: Traveler Beware!

Abstract & Commentary

Synopsis: In this study of anonymously reported adverse occurrences related to intra-hospital transportation of critically ill patients, problems were related to equipment in 39% and to patient/staff management issues in 61%; 31% of the incidents had serious adverse outcomes.

Source: Beckmann U, et al. Intensive Care Med. 2004;30:1579-1585.

This collaborative cross-sectional study by Beckmann and colleagues at Johns Hopkins and John Hunter Hospitals, the latter in Newcastle, NSW, Australia, examined incident reports relating to the intra-hospital transport of ICU patients that were submitted to the Australian Incident Monitoring Study in Intensive Care from 1993 through 1999. Any ICU staff member could submit a report, which was anonymous and voluntary.

Of more than 11,000 incidents described in 7525 individual reports from 93 ICUs during the study period, 176 reports (191 incidents) from 37 ICUs concerned incidents that occurred during transportation within hospital. They classified the 191 incidents into equipment problems (75 cases, 39%) and patient/staff management issues (116 cases, 61%). Common equipment-related problems involved access to elevators (18 incidents), drug delivery systems (18), battery/power supply (14), monitors (12), intubation equipment (7), transport ventilators (4), and oxygen supply (3). Common patient-staff management problems included communication/liaison, airway management (securing; accidental extubation; unplanned reintubation), vascular line use, patient monitoring and positioning, and set-up of equipment.

Most incidents occurred en route to or from the operating room (36%), the radiology department (35%), a hospital ward (12%), or the emergency department (9%). In 61 cases (35%), the transport occurred as part of the initial ICU admission; in 78 (44%) it occurred during on-going ICU care, and in 14 (8%) during an emergency intervention.

Significant adverse outcomes occurred in 59 cases (31%). These included major physiological derangement (26 cases), patient/relative dissatisfaction (12), prolonged hospital stay (7), physical or psychological injury (6), and death (4).

Factors contributing to the incident during transport were classified as system-based factors (such as work practices, equipment problems, and aspects of the physical environment infrastructure) in 46%, and human-based factors (errors related to knowledge, hospital rules, skills, or technique) in 54% of cases. Equipment-related incidents were felt to be due to communication problems, inadequate protocols, inservicing or other training, or the equipment itself. Management-related incidents were most commonly errors of problem recognition and judgment, failure to follow protocols, inadequate patient preparation, haste, and inattention. They conclude that intra-hospital transport poses an important risk to ICU patients, that standards are needed, and that monitoring of incidents occurring in this context is important.

Comment by David J. Pierson, MD

Transporting a critically ill patient from the ICU to another area of the hospital for a surgical procedure or diagnostic study is a dangerous undertaking. This is clear to anyone who cares for such patients, and has also been documented in numerous studies. This study sheds light on the types of incidents that happen commonly, and some of the factors associated with them. It demonstrates that transport-related adverse incidents are a complex problem. Lots of different things can go wrong, and for lots of different reasons. Minimizing transport-related problems is one of the major challenges facing both clinicians and administrators in today’s practice of critical care.

This study has a number of limitations. The database used relies on voluntary, anonymous incident reports, whose accuracy can seldom be verified. Submitted reports undoubtedly underestimate the true incidence of the events being examined, and there are likely a variety of selection and reporting biases at work. However, despite these limitations, which the authors acknowledge, this study’s findings are important as reminders of the frequency, variety, and seriousness of transport-related adverse incidents.

This study has another important implication for clinicians. Being in the ICU is dangerous for patients, but taking them away from it to have something done in another part of the hospital is probably even more so. Therefore, the reason for the trip needs to be pretty important. While there is no question that many surgical interventions and diagnostic procedures are both necessary and emergent, some transports can probably be delayed until conditions are optimized, combined with trips for other procedures, or avoided altogether. Recognizing that moving patients to other parts of the hospital is often unavoidable, making sure that they are not taken from the resources and stability of the ICU unless this is truly necessary is one of the greatest challenges in the practice of critical care medicine.

David J. Pierson, MD, Pulmonary and Critical Care Medicine, Harborview Medical Center, University of Washington, is Editor of Critical Care Alert.