Article

A before- and after-intervention trial for reducing unexpected events during the intrahospital transport of emergency patients

Unlabelled imageAmerican Journal of Emergency Medicine (2012) 30, 1433-1440

Original Contribution

A before- and after-intervention trial for reducing unexpected events during the intrahospital transport of emergency patients

Hee Kang Choi RN a, Sang Do Shin MD b,?, Young Sun Ro MD c, Do Kyun Kim MD b,

Sun Hwa Shin RN a, Young Ho Kwak MD b

aemergency medical center, Seoul National University Hospital, Seoul, Korea

bDepartment of Emergency Medicine, Seoul National University College of Medicine, Seoul 110-744, Korea

cDepartment of Preventive Medicine, Graduate School of Public Health, Seoul National University, Seoul, Korea

Received 25 September 2011; revised 25 October 2011; accepted 26 October 2011

Abstract

Background: This study was aimed to explore the effect of intervention in safe Intrahospital transport on the incidence of unexpected events (UEs) occurring during the transport of emergency patients.

Methods: This study was performed in an urban Tertiary teaching hospital emergency department (ED) from May 17 to October 30, 2010. Patients older than 15 years who were transported to general wards; intensive care units; and magnetic resonance imaging, intervention, or operation rooms were enrolled. Demographics and data on all UEs related to the devices, clinical situations, and tubes or lines were measured by registered nurses at pre- and postintervention period. The intervention was that acting nurses were required to use a designed transport checklists before the patients were transported. Primary outcomes were the rate of all and serious UEs during the pre- and postintervention periods. Serious UEs were defined as any worsening of a patient’s clinical status. Statistical values were measured with 95% confidence intervals (CIs) and compared using Student t tests or ?2 tests.

Results: In total, there were 680 transports before interventions and 605 transports after interventions. Overall, UEs decreased significantly from a value of 36.8% (95% CI, 33.1-40.5) in the preintervention period to a value of 22.1% (95% CI, 18.9-25.7) in the postintervention period (P = .001). Serious UEs in clinical status also decreased significantly from 9.1% (95% CI, 7.1-11.5) in the preintervention period to a value of 5.2% (95% CI, 3.6-7.4) in the postintervention period (P = .005).

Conclusion: A significant reduction in the rate of total and serious UEs during intrahospital transport from the ED was found through using transport checklists.

(C) 2012

* Corresponding author. Tel.: +82 2 2072 3257; fax: +82 2 741 7855.

E-mail addresses: [email protected] (H.K. Choi), [email protected] (S.D. Shin), [email protected] (Y.S. Ro), [email protected] (D.K. Kim), [email protected] (S.H. Shin), [email protected] (Y.H. Kwak).

Background

Introduction

The intrahospital transport of critically ill patients is an inevitable part of emergency department (ED) practice [1].

0735-6757/$ – see front matter (C) 2012 doi:10.1016/j.ajem.2011.10.027

For intensive care unit (ICU) patients, the transport of critically ill patients for procedures or tests is potentially hazardous, and the transport process must be sufficiently organized and efficient to address specific concerns [2]. The minimal standards recommended by the Society of Critical Care Medicine, including concepts such as the pretransport stabilization of the patient, careful preparation of the equipment, and proper education of the accompanying personnel, have become essential for the organization of and outcomes of such transport events for ICU patients [3]. Some aspects of Patient transport are different for emergency patients. Intrahospital transport events are inevitable for all critically ill patients in the ED unless the patients die while in the resuscitation room. Patients with a moderate to severe level of acuity are also transported to locations such as emergency radiology departments, operation rooms, angiographic intervention rooms, hemodialysis rooms, and inpatient wards for definite care. Transport events for emergency patients in the ED are more complicated and variable. Emergency departments are very different from ICU settings. Most EDs have become overcrowded, which is one of the most important health care issues of this decade [4]. In crowded EDs, patients, families, and health care providers become unsatisfied and exhausted [5,6]. Moreover, the quality of medical care itself is compromised in these situations. Patients have to suffer for longer periods before receiving proper analgesics [7], and they wait longer to receive evidence-basED treatments that are closely related to their clinical outcomes. As a consequence of ED overcrowding, the lack of medical resources and unexpected events (UEs) may lead to a longer length of stay and an increased mortality [8-10]. Intrahospital transport events from these overcrowded EDs are routine and are among the most

common practices in these EDs.

Importance

Most studies concerning intrahospital transport have focused on ICU patients rather than on emergency patients. However, emergency patients are exposed to much more hostile environments and have to depend on limited resources. There have been few studies concerning the incidence of adverse outcomes or UEs on the intrahospital transport of emergency patients. In addition, the effect of intervention on reducing the intrahospital transport-associated UEs for emergency patients has received little attention.

Goal of this investigation

The goal of this study was to explore the effect of intervention using a checklist program for safe intrahospital transport on the incidence of UEs incurred during the transport of emergency patients.

Methods

Study design and settings

This study was conducted both before and after an interventional trial. The study protocol was reviewed and approved by the institutional review board of the study hospital, and a waiver of the requirement for a written consent from all participants was approved.

This study was performed in an urban tertiary teaching hospital and adult ED that typically receives approximately 50 000 visits annually. Approximately 25% of patients admitted to this hospital each day are admitted to general wards or to the ICU. A total of 14 Attending emergency physicians, 14 emergency residents, 9 other specialty department residents, 18 general physicians, 120 registered nurses, and 14 emergency technicians worked in this ED at the time of the study, and 11 transporter employees transported patients between the ED and the wards, between the ED and ICU, and between the ED and the radiologic study or intervention or operation rooms in this hospital. No specific license or education certificate is required to be a transporter. The study hospital has 1 medical ICU, 1 surgical ICU, 1 coronary care unit, 1 stroke unit, 1 angiographic intervention room, 2 computed tomographic scan rooms, and 4 magnetic resonance imaging (MRI) rooms outside the ED. The ED has 2 computed tomography rooms, 1 ICU room, and 1 general

ward on the same floor for emergency patients.

No change to the human and ED resources occurred during the study period.

Study participants

Patients older than 15 years who were clinically required to be transported to any of the following rooms for admission were defined as eligible patients: the radiology rooms (the MRI room or the angiographic intervention room), the ICUs (the surgical or coronary care units), the endoscopic room, the coronary catheterization room, the holding area for emergency surgery, or any of the 5 general wards. General wards were selected based on the previous daily admission case number.

Data were collected from May 17 to October 30, 2010, at daytime from 9 AM to 6 PM. Study coordinators collected all eligible patients based on nursing records in which patients were transported to study sites or not. Study participants and transporters were fully blinded that they were being studied.

Development of transport checklists

A registry including transport checklists (TCLs) on safe transport was developed based on previous studies in ICUs or trauma centers [11,12]. The TCLs included the following 28 items: 2 general items (a wrist band with an identification number and a confirmed consent), 8 items related to transport

equipment (an oxygen supply, an 3-lead electrocardiograph- ic [ECG] monitor, a noninvasive blood pressure [NIBP] monitor, a patient monitor, and an infusion pump), 7 measurements related to the patients’ clinical status (blood pressure, oxygen saturation, respiratory rate, and mental status), 8 items related to tubes and lines (an inserted endotracheal tube, a peripheral intravenous line, a Central venous line, and an inserted drainage tube), and 3 items related to stretchers (the positions of side rail and the presence of attached machines).

We defined the UEs as the following: (1) any missing wrist band with an identification number or a confirmed consent;

(2) a disconnected line for oxygen supply, displaced oxygen tank from stretcher bar, insufficient residual oxygen less than 15 MPa enough to use for 1 hour with 6 L/min, disconnected probe of oxygen saturation monitor, disconnected ECG electrode, disconnected NIBP cuff, out-of-order patient monitor with noisy alarm, or out-of-order infusion pump with noisy alarm; (3) any decrease of systolic blood pressure below 90 mm Hg, any increase of systolic blood pressure above 200 mm Hg, any decrease of oxygen saturation below 90%, any worsening of dyspnea symptoms, not-being- sedated patient under endotracheal intubation, or any worsening of mental status scale (alert, drowsy, stuporous, in a semicoma, or in a coma); (4) a loose-fitting endotracheal tube (loosed attachment of tube to face), disconnected intravenous lines, central catheter lines or specific tubes, kinked intravenous lines, obstructed intravenous lines, or changed speed of fluid infusion; and (5) not-being-elevated side rail, not-fixed wheels, or unstable attachment of device to stretcher cart. We defined UEs in clinical status like above number 3 as serious UEs. A loose-fitting endotracheal tube was defined as being able to put a finger easily between the skin/face of the patient and the ETT holding device (string, tape, etc), or loose-fitting ETT was defined as a tube that could be moved more than 1 in in any direction (superior, inferior, right, or left). Transport checklists also included checklists on the need for a patient to be accompanied by physician.

Study protocol

The study period was divided into pre- and postinterven- tion periods. The preintervention period was defined as the period from May 17 to August 5, 2010 (81 days). Registered nurses at target rooms, wards, and ICUs who participated in this study were requested to check the same items with TCLs when the patient was transported to their working place during the pre- and postintervention period. Survey by nurses at study sites was performed during 9 AM to 6 PM from Monday to Friday. Registered nurses, not technicians, participated in this study in all sites including ICU, radiologic rooms, and waiting rooms for operations as well as wards.

The postintervention period was defined as the period from August 13 to October 30, 2010 (80 days). Target rooms, wards, and ICUs were the same as those used during

the preinterventional period. In addition to preintervention period protocol, emergency nurses used the TCLs for all patients needed to be transported and prepared routinely the transport. They checked all items based on TCLs and solved the problems before transport if needed. From August 5 to August 12, emergency nurses were educated on using TCLs during a 1-hour session.

Two study coordinators reviewed the patients’ logs of ED every day and selected the patients who were eligible. Emergency nurses at EDs who called the transporter and asked patients to be transported were blinded to this survey. All transporters were also unaware of this study. The day after a transport took place, 2 study coordinators visited the location where the patients had been transported and collected the data on the UEs, which had been already checked by registered nurses at target sites.

Intervention

The intervention was conducted in 2 parts. The first part consisted of educating the transporters. Four specialty emergency nurses and 1 intensive care nurse under the supervision by 2 emergency physicians developed educa- tional materials for transporters, which included safe transport guidelines and essential skills. The guidelines indicated the need for the education of transporters, as well as a pretransport check of devices and equipment used during transport, the patient’s emergency situation and responding standing order, a brief evaluation of relevant procedures, and equipment needed for basic life support during cardiac arrest. Between the pre- and postintervention periods, all trans- porters were given a 4-hour lesson on safe transport guidelines, which included information on didactic session and skill training for basic life support. To evaluate the effectiveness of the lesson, written examinations were given after the lesson.

The second intervention required that all ED nurses check the designed TCLs before calling the transporters to transport the patients from the ED. In addition, the ED nurses were instructed to go over the accompanying physician criteria for intrahospital transport, which are required by the ED of this hospital when the patient’s condition includes 1 of following criteria: (a) intubation; (b) a respiratory rate of less than 12 or more than 30 breaths per minute; (c) an oxygen saturation reading of less than 92% during any kind of oxygen supply;

(d) a Glasgow Coma Scale of less than 8; (e) systolic blood pressure less than 90 mm Hg in spite of vasopressor infusion;

(f) obvious major bleeding; (g) severe multiple trauma (more than 2 major bone fractures or internal Organ injuries); (h) acute myocardial infarction or stroke; (i) requirement of specific equipment, such as a transcutaneous pacing device, thumper, or portable ventilator; (j) sedation; or (k) other conditions requested by the attending physician. Accompa- nying physicians were usually general internship physicians rather than specialty care physicians. Internship physicians usually experience the primary emergency care at ED for 1 or

2 months during their full 1-year rotating schedule in this study setting.

Outcome measure

Primary and secondary end points evaluated in this study were total UEs and serious UEs, which were surveyed by registered nurses working in ward rooms and ICUs. Tertiary end points examined in this study included the proportion of physicians accompanying transport, which can reflect the adherence to clinical guideline for precheck before patients were transported.

Sample size and statistical analysis

The sample size was calculated using an ? error of .05 and a power of 0.80. Known proportions of UEs in previous studies varied from 15.5% for ICU patients [13] to 67.7% for emergency patients [11]. The proportion of serious UEs was reported to be approximately 8.9% of all transportations [11]. We determined the sample size by using a proportion of 8.5% of serious UEs as a reference value and anticipated that 4.5% of serious UEs would occur after intervention. The sample size for each period was 596, whereas 5% of data were anticipated to be missing. The target number of cases for the pre- and postintervention group was 626.

Demographic findings were measured using means and proportions with 95% confidence intervals (CI) and were compared using a ?2 test for categorical variables and Student t test for continuous variables between the preintervention and postintervention groups. Serious UEs and total UEs were compared using a ?2 test at a significance level of .05.

Results

Demographic findings

In total, 1482 patients among 8807 emergency patients were eligible for evaluation during the preintervention period. Of these, 597 (40.3%) patients were included, and 680 transport events were successfully surveyed. During the postintervention period, 8605 patients visited the ED. Of these, 1541 patients were eligible, and 539 patients (35.0%) and 605 transport events were included (Fig. 1).

Table 1 shows the demographic findings of patients enrolled in this study. Within the preintervention period, significant differences in ambulance use (P = .007) were observed between surveyed and nonsurveyed patients, whereas no differences were observed during the postinter- vention period. Significant differences in diastolic blood pressure (P = .048) and respiratory rate (P b .001) were observed between the pre- and postintervention study groups, whereas the other factors were found to be similar between the 2 participant groups.

Fig. 1 Patients enrolled in the study during the pre- and postintervention periods. demographic factors such as sex, age, and ESI of patients were not significantly different between periods (all P N .05).

Table 2 shows demographic findings of transported participants between the pre- and postintervention groups. The locations to which patients were transported differed significantly between the 2 groups. During the preinterven- tion period, the number of surveyed patients transported to general wards was larger than that in the postintervention period, whereas transports to the ICU, MRI room, interven- tion room, and operation units were larger during the postintervention period (P = .005). The Emergency Severity Index of patients was similar between the 2 groups. A pretransport check using TCLs was conducted in only 56.7% of the postintervention group, and the others were not checked by emergency nurses and transported to study sites.

Primary outcome: UEs

Table 3 shows the proportion of UEs for each item of TCLs. The proportion of patients who experienced any of the following during the postintervention period was lower than that of the preintervention period: a disconnection of the oxygen supply, a displaced oxygen tank, an insufficient residual oxygen, an out-of-ordered infusion pump, an loose- fitting endotracheal tube, an obstructed intravenous line, an incorrect speed of fluid infusion, a kinked tube, a lowered side rail of stretcher, or an unsafe attachment of a medical device to the stretcher.

Table 4 shows the comparisons in the proportions of UEs between the 2 study periods. When all patients were analyzed together, UEs decreased significantly from 36.8% (95% CI, 33.1-40.5) to 22.1% (95% CI, 18.9-25.7) (P = .001). Serious

UEs in that affected the clinical status of a patient were also significantly lower, decreasing from 9.1% (95% CI, 7.1- 11.5) to 5.2% (95% CI, 3.6-7.4) (P = .005). All types of UEs

showed a significant decrease during the postintervention period in comparison with the preintervention period.

Total

Surveyed

Not surveyed

P ?

Total

Surveyed

Not surveyed

P ?

n

n %

n %

n

n %

n %

Total

1482

597

100.0

885

100.0

1541

1002

100.0

539

100.0

Sex

Male

835

329

55.1

506

57.2

.431

882

576

57.5

306

56.8

.787

.573

Female

647

268

44.9

379

42.8

659

426

42.5

233

43.2

Age

Mean +- STD

60.6

15.7

59.2

15.4

.091

59.8

15.1

59.8

15.0

.976

.482

EMS

Prehosptial

246

120

20.1

126

14.2

.007

268

167

16.7

101

18.7

.221

.799

Interhospital

234

97

16.2

137

15.5

243

150

15.0

93

17.3

by walk

1002

380

63.7

622

70.3

1030

685

68.4

345

64.0

SBP

Mean +- STD

130.5

28.7

131.0

28.1

.704

136.0

40.6

133.5

29.8

.200

.156

DBP

Mean +- STD

76.3

15.1

77.6

15.5

.124

77.4

33.0

75.8

15.7

.267

.048

PR

Mean +- STD

87.9

20.8

86.3

19.6

.136

88.2

35.3

85.6

21.5

.119

.586

RR

Mean +- STD

19.3

3.0

19.5

2.6

.240

18.7

2.9

18.7

3.1

.749

b.001

AVPU

Alert

1340

532

89.1

808

91.3

.396

1407

917

91.5

490

90.9

.317

.406

Verbal response

97

45

7.5

52

5.9

92

62

6.2

30

5.6

Pain response

28

14

2.3

14

1.6

32

16

1.6

16

3.0

Unresponsive

17

6

1.0

11

1.2

10

7

0.7

3

0.6

Hospital mortality

Survival

1446

580

97.2

866

97.9

.390

1512

986

98.4

526

97.6

.262

.647

Mortality

36

17

2.8

19

2.1

29

16

1.6

13

2.4

Comparison of physicians accompanying transport

Table 1 Demographic factors of study participants

Preintervention

Postintervention

P +

AVPU indicates a measure of a patient’s responsiveness: Alert, Responds to Verbal order, Responds to Painful stimuli, Unresponsive; EMS indicates emergency medical service; SBP, systolic blood pressure (in mm Hg); DBP, diastolic blood pressure (in mm Hg); PR, pulse rate per minute; RR, respiratory rate per minute; STD, Standard deviation.

* P values were calculated between surveyed and nonsurveyed groups using ?2 tests or independent t tests.

+ The P value represents comparisons between the preintervention and postintervention survey group.

Table 5 shows the proportion of transport events in which accompanying physicians were present during the 2

study periods. For the level 1 and 2 groups, the proportion was significantly higher during the postintervention period (P = .019), whereas no difference was observed in the level 3 and 4 groups before and after the intervention periods.

Table 2 Baseline characteristics of surveyed transport patients and events

Total

Preintervention

Postintervention

P

n

n

%

n

%

Total

1285

680

100.0

605

100.0

Sex

.303

Male

724

374

55.0

350

57.9

Female

561

306

45.0

255

42.1

ESI

.358

Level 1

39

23

3.4

16

2.6

Level 2

427

237

34.9

190

31.4

Level 3

799

408

60.0

391

64.6

Level 4

20

12

1.8

8

1.3

Site

.005

General ward

349

213

31.3

136

22.5

ICU

127

63

9.3

64

10.6

MRI room

563

282

41.5

282

46.6

Intervention or operation unit

246

123

18.1

123

20.3

Pretransport check

b.001

No

942

680

100.0

262

43.3

Yes

343

0

0.0

343

56.7

Table 3 Unexpected events occurring during transport according to TCLs in the pre- and postintervention groups

Categories Checklist Preintervention

(n = 680)

Postintervention P

(n = 605)

Eligible patients

Positive event

Eligible patients

Positive event

n

n

%

n

n

%

Basic item

Has the patient the identification band?

680

26

3.8

605

2

0.3

.001

Basic item

Has the patient the informed consent for

538

38

7.1

503

19

3.8

.141

procedures or admission?

Device

Is the line disconnected for oxygen supply?

129

13

10.1

116

3

2.6

.019

Device

Is the oxygen tank displaced from attachment bar?

127

48

37.8

115

25

21.7

.015

Device

Is the amount of residual oxygen insufficient?

124

19

15.3

116

5

4.3

.007

Device

Is the probe of oxygen saturation device

90

7

7.8

87

3

3.4

.223

disconnected or displaced?

Device

Is the electrode of ECG disconnected?

60

3

5.0

72

2

2.8

.555

Device

Is the NIBP cuff disconnected?

61

3

4.9

68

4

5.9

.436

Device

Is the monitor out of order?

74

3

4.1

83

3

3.6

.600

Device

Is the infusion pump out of order?

83

10

12.0

90

4

4.4

.013

Clinical status

Was there any decrease of blood pressure

429

7

1.6

342

6

1.8

.585

below 90 mm Hg?

Clinical status

Was there any increase of blood pressure

429

2

0.5

341

3

0.9

.445

above 200 mm Hg?

Clinical status

Was there any decrease of oxygen saturation

418

10

2.4

332

10

3.0

.483

below 90%?

Clinical status

Was there any increase of dyspnea symptom?

430

10

2.3

325

8

2.5

.507

Clinical status

Is the patient not sedated under endotracheal

45

1

2.2

17

0

0.0

.529

intubation?

Clinical status

Was there any worsening of mental status?

387

4

1.0

293

3

1.0

.564

Tubes or lines

Is the endotracheal tube loosely attached

54

36

66.7

24

12

50.0

.001

to the face?

Tubes or lines

Is the intravenous line disconnected?

654

3

0.5

595

2

0.3

.555

Tubes or lines

Is the intravenous line obstructed?

653

36

5.5

595

18

3.0

.026

Tubes or lines

Is the intravenous line kinked?

644

24

3.7

592

17

2.9

.284

Tubes or lines

Is the central venous catheter line disconnected?

72

0

0.0

36

0

0.0

Not

applicable

Tubes or lines

Is the central venous catheter line kinked?

67

4

6.0

36

0

0.0

.078

Tubes or lines

Is the speed of fluid infusion not corrected?

613

92

15.0

568

35

6.2

.001

Tubes or lines

Is the specific tube disconnected?

174

1

0.6

110

1

0.9

.720

Tubes or lines

Is the specific tube kinked?

174

5

2.9

110

0

0.0

.041

Stretcher

Is the side rail of stretcher not elevated?

456

11

2.4

385

1

0.3

.005

Stretcher

Is the portable stretcher not fixed?

471

11

2.3

511

5

1.0

.153

Stretcher

Is the medical device attached to

166

17

10.2

147

5

3.4

.016

stretcher unsafe?

Limitations

This study was conducted at a single ED; thus, there are some limitations in terms of the generalization of these study results to other EDs. These limitations are also related to study design, which was a nonrandomized intervention study.

Some factors between surveyed patients and nonsurveyed patients, as well as between participants in the pre- and postintervention periods, were significantly different. This means that selection bias could affect the results. The postintervention group showed a higher proportion of transport to the ICU, MRI room, and other intervention

and operational units. Medical care in these units may have different tendencies for UEs than those in other units. We selected the patients used in this study using a convenient sampling method.

Study designs examining before and after certain events or changes cannot control Environmental factors, such as the human resources working at the ED or the patient characteristics associated with seasonal variation during a short study period.

Another limitation of the study would be that there is no standard definition of what constitutes a UE or a serious UE during intrahospital transport. The more criteria used by a study to define a UE likely result in higher proportions of

UEs

Before (n = 680)

After (n = 605)

P

n %

95% CI

n %

95% CI

Total

250

36.8

33.1

40.5

134

22.1

18.9

25.7

.001

Basic items

62

9.1

7.1

11.5

26

4.3

2.8

6.2

.001

Device

64

9.4

7.3

11.9

38

6.3

4.9

8.5

.024

Tubes and lines

129

19.0

16.1

22.1

52

8.6

6.5

11.1

.001

Stretcher

31

4.6

3.1

6.4

11

1.8

0.9

3.2

.004

Clinical status

62

9.1

7.1

11.5

32

5.2

3.6

7.4

.005

Statistical analysis was conducted using a ?2 test. Each value with 95% CIs for each category showed significant reductions in the proportion of UEs occurring within the postintervention group.

UEs reported. This may account for the large variation of proportions of UEs seen in published studies.

Table 4 Comparison of UEs between pre- and postintervention periods according to survey categories

Discussions

We found significant decreases in UEs for all survey categories, including clinical status. The proportions of total UEs and serious UEs were found to be 36.8% and 9.1% in this study. Previous studies showed very different results for UEs. For 139 pediatric patients transported to radiology units or operation rooms, the proportion of UEs was very high (76.1%) [14]. For 56 multiple Trauma victims and 83 surgical or traumatic patients transported to radiology units, the proportion of UEs was very high, 68% [15] and 66% [16], respectively. Other studies showed UE rates as low as 10% during the transport of 20 medical and surgical ICU patients

[17] or 5.9% during the transport of 175 surgical patients [18]. These discrepancies might have occurred because of the population being studied or the small sample size. An exact description of the severity of these complications is lacking in many studies, and definitions differ between studies. However, major adverse effects with life-threatening distur- bances that require intervention, such as the administration of vasoactive drugs, fluid boluses, or even cardiopulmonary resuscitation, as well as those related to the disconnection of ventilation, intravenous, or intraArterial lines, may be as high as 8% [14,18].

Our study was conducted using patients transported from the ED to general wards, ICU, MRI room, or other intervention or surgical operation rooms. The total UE rate

was 40.6%, which comprised events related to physiologic deterioration (26%), equipment-related mishaps (10.4%), and critical incidents (4.2%) [11]. Although a median of 1.0 UE per transport in the above study was higher than our study (0.4 per transport in preintervention), the rate of serious UEs was comparable (8.9%) to that of our study (9.1%). Outcome measurement tools were very similar in both studies, whereas the observation methods were very different. In the present study, the rate of UEs surveyed by the registered nurses working at the different sites (general ward, ICUs, MRI room, and intervention and operation rooms) and the rate of UEs occurring while accompanying physicians were present were similar to the rate of UEs observed in a previous study [11]. The different methods used during these studies could have caused this difference in incident rate.

Although we measured the incidence of change in the clinical status of patients during this study, we did not measure the direct quantitative change of vital signs. Many other studies have measured direct vital signs, such as the respiratory rate or Arterial oxygen saturation [15,16]. These studies usually transported critically ill patients who were dependent on a ventilator and who were consequently monitored when they were transported. However, our study enrolled a few severe patients, only 3.4% of ESI level 1 patients in the preintervention period, and only 2.6% were enrolled in the postintervention period.

Most of the problems encountered during patient transport were related to the equipment or the monitoring process itself. Electrocardiogram lead disconnection (23%), monitor power failure (14%), a combination of the 2 previous issues (10%), intravenous line or vasoactive drug infusion disconnection

Total

n

%

Total

n

%

Total

680

132

19.4

605

118

19.5

.967

Table 5 Proportions of transport events accompanied by physicians in the pre- and postintervention periods relative to ESI levels

ESI Preintervention Postintervention P

(9% and 5%, respectively), and disconnection from the

ventilator (3%) were among the most frequently observed problems. Most mishaps were noted at the destination site either before or during the procedure but not during the actual transport event. Equipment-related mishaps occurred in 10% of patient transports in a previous study [14], whereas our

study showed a much higher incidence rate of equipment-

Levels 1 and 2

260

73

10.7

206

79

13.1

.019

related UEs (4.1%-37.8% in the preintervention period).

Levels 3 and 4

420

59

8.7

399

39

6.4

.059

Unlike in other studies, we compared the incidence rate

between pre- and postintervention periods. We found a

significant improvement in the UE rate after 2 interventions. The first intervention consisted of educating and training the transporter (in a 4-hour course) using safe transport guidelines developed by emergency nursing staff. In the second intervention, emergency nurses were required to read through the TCLs when they called the transporter. These 2 interventions were very simple to apply. When the ED was crowded, however, the TCL was not used by the acting nurse. During the postintervention period, the acting nurse went through the TCLs with the transporters in only 56.7% of transport events. Intervention trials studying UEs during intrahospital transport are extremely rare. A few reports on observational studies using specialty care teams for intra- hospital critical care transport were found. A previous study showed that specialty nursing staff showed very low UE rates of 15.5% (1.8% of severe UEs) [13]. We did not assign a specialty care nurse. Assigning new staff may result in increased costs. We used very simple TCLs, which lead to a decrease in the UEs. If all transport events were checked by the acting nurse, the UEs would likely be decreased further. Many guidelines for the transfer of critically ill patients were reported by a consensus committee formed by representatives from several major critical care societies [2,19]. This committee proposed requirements for pretran- sport coordination and communication, as well as for the personnel who accompany patients, for the equipment needed and for monitoring during transport. To prevent UEs, a minimum of 2 people, one of which is a critical care nurse, should accompany the ICU patient. A physician may be required to accompany patient transport in patients with unstable physiology who might require acute interventions. It should also be emphasized that personnel involved in the transport of critically ill patients may benefit from specific training [20]. We also developed recommendation protocols for conditions in which physicians should accompany patients during transport. We found a significant increase in the number of physicians accompanying patients during transport for level 1 and 2 patients during the postintervention period. The acting nurse used the checklist and determined whether a physician was required to accompany transport before calling the transporter. These kinds of pretransport preparations (checking the lists or outlining situations when physicians should be called) should be an essential clinical component of critical care for emergency patients as well as

ICU patients.

Conclusion

This pre- and postintervention study produced a significant decrease in the rate of total and serious UEs occurring during intrahospital transport from the ED. Requiring acting nurses to check TCLs and educating transporter is an easy but efficient intervention that can be used to decrease UEs.

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