Letter to the Editor:

Intrahospital Transport of Critically Ill Patient Highlights Hazards

To the Editors:

We recently cared for a morbidly obese patient who was admitted to our ICU following a traumatic injury. The patient was difficult to ventilate due to elevated airway pressures and ventilator dyssynchrony, resulting in significant hypoxemia. The consulting surgeons requested further imaging for operative planning. Shortly after, the patient was transported to the Radiology Department on a transport ventilator with an ICU nurse, a critical care transport nurse, and a respiratory therapist. During the imaging study the patient suffered a cardiopulmonary arrest, became progressively difficult to ventilate, and underwent multiple attempts at CPR. In reviewing the case, reading the available literature, and discussing with colleagues, it became clear that the intrahospital transport of critically ill patients is a topic both with a relative paucity of literature and a low level of awareness among clinicians of multiple specialties. We believe this aspect of patient care has the potential for preventable adverse events.

There have been a number of negative outcomes reported to be associated with the intrahospital transport of critically ill patients, including death.1-9 While the percentage varies widely depending on the type of adverse event described, the incidence of such events occurring during transport or within the first 24 hours after transport may approach 68%.1-9 Furthermore, the incidence of adverse events requiring therapeutic intervention during transport has been reported to range from approximately 4-9%.1,2 The variability in incidence is likely related to the definition of “adverse event,” the patient’s severity of illness, and variable institutional practices. A recent observational study of mechanically ventilated patients reported a 50% incidence of complications during transport.3 The authors of this study postulated that many of these adverse events could have been prevented by proper planning, preparation, and standardized equipment checks.

Expert opinion from professional societies has guided the recommendations for intrahospital transport, most recently published by the American College of Critical Care Medicine and the Society of Critical Care Medicine.10 As outlined in these practice guidelines, the decision to transport a critically ill patient should be based on an assessment of the potential benefits of transport weighed against the potential risks of adverse events inherent to both the transport process itself and the intervention or diagnostic study being pursued. They suggest that the implementation of formal, written policies and procedures specifically addressing the principles of communication, personnel, equipment, and monitoring may help mitigate risks and improve safety, ultimately resulting in improved patient outcomes.10 There are few data to support these recommendations and still fewer instituted guidelines.

We believe that despite the recent focus on establishing safer transport practices for critically ill patients, the question of how to manage this high-risk population remains largely unresolved. The implementation of a system-wide practice of prophylactic anticipatory guidance, formal pre-transport timeout procedures, individualized patient plans of care, and specialized transport teams may represent the next step in further minimizing adverse events for this particularly vulnerable patient population. As such we would advocate for prospective studies in this area to help further guide our clinical practice and mitigate the potential for harm to our patients.


Bryan Romito, MD
Anahat Dhillon, MD
Joseph Meltzer, MD

The David Geffen School of Medicine at UCLA, Los Angeles, CA


References

  1. Fanara B, Manzon C, Barbot O, et al. Recommendations for the intra-hospital transport of critically ill patients. Crit Care 2010;14:R87.
  2. Papson JP, Russell KL, Taylor DM. Unexpected events during the intrahospital transport of critically ill patients. Acad Emerg Med 2007;14:574-7.
  3. Parmentier-Decrucq E, Poissy J, Favory R, et al. Adverse events during intrahospital transport of critically ill patients: incidence and risk factors. Ann Intensive Care 2013;3:10.
  4. Voigt LP, Pastores SM, Raoof ND, et al. Review of a large clinical series: intrahospital transport of critically ill patients: outcomes, timing, and patterns. J Intensive Care Med 2009;24:108-15.
  5. Beckmann U, Gillies DM, Berenholtz SM, et al. Incidents relating to the intra-hospital transfer of critically ill patients. An analysis of the reports submitted to the Australian Incident Monitoring Study in Intensive Care. Intensive Care Med 2004;30:1579-85.
  6. Picetti E, Antonini MV, Lucchetti MC, et al. Intra-hospital transport of brain-injured patients: a prospective, observational study. Neurocrit Care 2013;18:298-304.
  7. Waydhas C, Schneck G, Duswald KH. Deterioration of respiratory function after intra-hospital transport of critically ill surgical patients. Intensive Care Med 1995;21:784-9.
  8. Gillman L, Leslie G, Williams T, et al. Adverse events experienced while transferring the critically ill patient from the emergency department to the intensive care unit. Emerg Med J 2006;23:858-61.
  9. Lahner D, Nikolic A, Marhofer P, et al. Incidence of complications in intrahospital transport of critically ill patients--experience in an Austrian university hospital. Wien Klin Wochenschr 2007;119:412-6.
  10. Warren J, Fromm RE Jr, Orr RA, et al. Guidelines for the inter- and intrahospital transport of critically ill patients. Crit Care Med 2004;32:256-62.