Episode #158 Keeping Patients Safe During Transport Around the Hospital

July 11, 2023

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Welcome to the next installment of the Anesthesia Patient Safety podcast hosted by Alli Bechtel.  This podcast will be an exciting journey towards improved anesthesia patient safety.

Our featured article today is from June 2023 APSF Newsletter. It is “A Review of Adverse Events Associated with Perioperative Intrahospital Transport of Pediatric Patients and Guidance on Improving Safety” by Anila B Elliott, Anne Baetzel, Jessica Kalata, and Bishr Haydar.

Here is the link for more information about Wake Up Safe, sponsored by the Society for Pediatric Anesthesia. This initiative is focused on improving outcomes for children during anesthesia care as well as disseminating knowledge and advancing science. This database has been used for research with numerous publications such as this APSF article. Wake Up Safe is a certified Patient Safety Organization by the Agency for Healthcare Research and Quality (AHRQ).

Using the Wake Up Safe data, several risk factors for transport-related events were identified:

  • Patients less than or equal to 6 months of age
  • American Society of Anesthesiologists status 3 or higher
  • Weight less than 4 kg

Important considerations prior to transport to keep patients safe:

  • Reviewing the most recent chest x-ray for positioning of the ETT in the mid-thoracic tracheal to decrease the risk for inadvertent dislodgement or mainstem intubation
  • Listening for bilateral breath sounds
  • Using continuous capnography
  • Using a pillow to stabilize the head
  • Taking care to avoid any tension on the tube during transport.

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© 2023, The Anesthesia Patient Safety Foundation

Hello and welcome back to the Anesthesia Patient Safety Podcast.  My name is Alli Bechtel, and I am your host. Thank you for joining us for another show. We are keeping the June 2023 APSF Newsletter open for our show today. Calling all anesthesia professionals who take care of critically ill patients and are involved in transporting these patients around the hospital. In the operating room, anesthesia professionals are called upon to be leaders and keep patients safe and this extends outside the operating room and while transporting critically ill patients throughout the hospital.

Before we dive into the episode today, we’d like to recognize Blink Device Company, a major corporate supporter of APSF. Blink Device Company has generously provided unrestricted support to further our vision that “no one shall be harmed by anesthesia care”. Thank you, Blink Device Company – we wouldn’t be able to do all that we do without you!”

Our featured article today is from June 2023 APSF Newsletter. It is “A Review of Adverse Events Associated with Perioperative Intrahospital Transport of Pediatric Patients and Guidance on Improving Safety” by Anila Elliott and colleagues. To follow along with us, head over to APSF.org and click on the Newsletter heading. First one down is the current issue. Then, scroll down until you get to our featured article today. I will include a link in the show notes as well.

To kick off the show today, we have exclusive content from one of the authors, Anila Elliot. I will let her introduce herself now.

[Elliott] “Hi, my name is Anila Elliott and I am a pediatric anesthesiologist at the University of Michigan in Ann Arbor, Michigan.  My training includes pediatric anesthesia, critical care medicine, and congenital cardiac anesthesia.”

[Bechtel] I asked Elliott what got her interested in this topic. Let’s take a listen to what she had to say.

[Elliott] “The transport of critically ill patients is something that happens on a daily basis, but it became clear to me in my role as both a pediatric anesthesiologist and intensivist that not everyone recognizes the potential risks of transport, especially those that are not actively participating in transportation.  As an anesthesiologist – I believe our profession is well suited to advocate for patient safety as we are in the driver’s seat when it comes to transporting critically ill patients.  Many other clinicians that are ordering the diagnostic tests and/or even caring for these patients on the wards are not always involved in actually getting them to those tests or procedures.  The anesthesia team is often involved and therefore plays a unique role in that regard.  We have to consider environmental hazards we may encounter such as elevators with uneven flooring, transporting through automatic doors that often close too soon, through hallways with equipment and chairs and workstations on wheels all acting as potential barriers. And ON TOP of those environmental hazards, we also have to be vigilant in managing our critically ill patients who may be unstable, on multiple medications that are necessary to sustain life, on a ventilator, inhaled medications or even extracorporeal circulation.  Our group reviewed the literature and wrote this piece to bring increased awareness to a high-risk event that often goes unrecognized due to the level of expertise and vigilance anesthesia teams have in the transportation of patients (both stable and critically ill) to various anesthetizing locations.”

[Bechtel] Thank you to Elliott for starting the conversation today and now it’s time to get into the article. Patients are often transported throughout the hospital and this includes critically ill patients. Did you know that critically ill pediatric patients experience one preventable adverse event at least once a week on average? When these patients require intrahospital transport, there is a further increased risk for preventable adverse events. This is a big threat to anesthesia patient safety. The authors acknowledge that while there are numerous risks during patient transport, there is not a lot of literature on pediatric intrahospital transport and related adverse events. Thus, the authors reviewed the Wake Up Safe database, remember this is the pediatric anesthesia quality improvement initiative that involves various institutions to develop best practices, well, the author’s reviewed this database to evaluate pediatric perioperative adverse events associated with anesthesia-directed transport.

Let’s start by reviewing a couple of cases of airway and ventilation management from the database. Here’s case #1 from the article:

A 2-week-old, former 32-week premature infant underwent a mostly uneventful exploratory laparotomy in the operating room for possible necrotizing enterocolitis. When the patient arrived in the ICU, the respiratory therapist helped to transition the infant to the ventilator. During the transition, the ventilator tubing fell which led to dislodging the endotracheal tube. The patient rapidly deteriorated requiring chest compressions and reintubation. After several minutes of CPR, return of spontaneous circulation was achieved. the patient stabilized over the next several hours.

Now, we’ll move on to case #2:

This case involves an 8-month-old infant with complex medical history including congenital hydrocephalus status post ventriculoperitoneal shunt placement, recurrent pneumonia, and current respiratory failure who was scheduled for tracheostomy placement. The patient was transported to the operating room with an ETT in place with a Jackson-Rees circuit while maintaining spontaneous ventilation.  After transferring the patient from the stretcher to the OR table, the anesthesia team started mechanical ventilation. Within one minute, the patient became difficult to ventilate, acutely hypoxemic, and then asystolic. The anesthesia team started CPR and there was a concern for a dislodged endotracheal tube. A repeat laryngoscopy was performed and the ETT was replaced. This led to a return to normal sinus rhythm. A team debriefing after the event diagnosed bronchospasm and noted that a routine morning chest x-ray from that day showed the ETT positioned in the right bronchus. Unfortunately, this study was not reviewed by the anesthesia team prior to transport, in part due to task overload.

We have time for another case and this one involves ventilatory changes after sedation and neuromuscular blockade. The patient is an 11 month old infant in the ICU with an endotracheal tube in place who required re-operation for bleeding after Tetralogy of Fallot repair earlier that day. Prior to transport to the OR, the anesthesia team administered midazolam and rocuronium. Shortly after, the patient became difficult to hand ventilate and then hypoxic, and then developed pulseless electrical activity. CPR was initiated. During the resuscitation, a large mucus plug was suctioned from the ETT. Ventilation improved after this and there was return of spontaneous circulation. Then, the patient was transferred to the operating room without further incident.

Now, let’s talk about the risks associated with airway and ventilation in critically ill pediatric patients. Most of the complications during transport are respiratory. Using the Wake Up Safe data, several risk factors for transport-related events were identified: patients less than or equal to 6 months of age, American Society of Anesthesiologists status 3 or higher, and weight less than 4 kg. In the neonatal ICU, the endotracheal tube is positioned between the first and second thoracic vertebrae, this has the benefits of reducing non-uniform lung aeration, localized pulmonary interstitial emphysema, and pneumothorax. The downside is that this may increase the risk for inadvertent extubation during extension of the head or neck from cephalad movement of the endotracheal tube. Positioning the endotracheal tube closer to the carina may lead to mainstem intubation with inadvertent caudad movement with resultant hypoxemia, hypercarbia, pneumothorax, and mucosal injury. It is so important to review the most recent chest x-ray for positioning of the ETT in the mid-thoracic tracheal prior to transport to decrease the risk for inadvertent dislodgement or mainstem intubation. Other important considerations include the following:

  • Listening for bilateral breath sounds
  • Using continuous capnography
  • Using a pillow to stabilize the head
  • Taking care to avoid any tension on the tube during transport.

In the ICU, ventilator circuit holders are often used to decrease tension, but these may be removed during transport leading to kinking of the ETT. Check out Figure 1a and Figure 1b in the article which demonstrate kinking of endotracheal tubes when attached to Ambu bags. It is vital to ensure that the endotracheal tube and circuit are positioned to avoid kinking during transport by off-loading the weight of the breathing circuit. Using a transport ventilator has the benefit of consistent minute ventilation to decrease the risk for hypo or hypercarbia, but it will not decrease the risk of dislodgement of the ETT, kinking, or obstruction. There are a variety of devices that may be used to secure the ETT to the face and the focus for many of these devices is to decrease skin breakdown while holding the ETT in place for a longer duration of time. What type of device do you use at your institution? Another important consideration is sympathetic stimulation when the patient is moved during transport. This may lead to tachycardia, agitation, and coughing which may cause bronchospasm as well as change pulmonary compliance making oxygenation and ventilation difficult.

Remember the third case that we talked about earlier with the large mucus plug. This is another important consideration during transport of critically ill pediatric patients. Risk factors for mucus plugging include the following:

  • Invasive ventilation
  • Impaired coughing and expelling mucus due to sedative and neuromuscular blocking agents.
  • Lack of heat and humidification of airway gases which may occur during transport

There are a couple of options for medication administration prior to transport. Administration of neuromuscular blocking agents and or sedation may be helpful prior to transport to decrease ventilator dyssynchrony. This may not be needed if a modern portable ventilator is used for transport. Neuromuscular blockade may help to prevent unplanned line or tube removal especially for agitated patients. This step may also help to decrease the workload for the team transporting the patient. Keep in mind that there may be some risks associated with using neuromuscular blockade. There is an increased risk of mucus plugging with the potential for inability to oxygenate and ventilate leading to cardiac arrest. Other complications include needing to change ventilator settings after removing the patient’s respiratory effort, increased leak around the endotracheal tube, and decreased basal metabolism leading to hypocarbia. Sedative medications may be needed during transport but there is a risk for decreased sympathetic tone and hypotension so careful monitoring is required.

It is important to consider the advantages and disadvantages of neuromuscular blockade and sedation in order to keep pediatric patients safe during transport.

We have so much more to talk about when it comes to safe pediatric patient transport throughout the hospital. We hope that you will tune in next week as we talk about identifying and mitigating risk, effective communication and teamwork, and culture of safety. Plus we will be hearing from Elliott again.

If you have any questions or comments from today’s show, please email us at [email protected]. Please keep in mind that the information in this show is provided for informational purposes only and does not constitute medical or legal advice. We hope that you will visit APSF.org for detailed information and check out the show notes for links to all the topics we discussed today.

Plus, did you know that the APSF has a YouTube Channel? You can listen to Anesthesia Patient Safety Podcasts and watch a collection of videos focused on high-yield anesthesia patient safety topics. We are bringing you the very best in perioperative anesthesia patient safety from our very own YouTube Channel. So, what are you waiting for? Go ahead, check it out and subscribe today.

Until next time, stay vigilant so that no one shall be harmed by anesthesia care.

© 2023, The Anesthesia Patient Safety Foundation