Episode #159 Improving Pediatric Patient Safety During Hospital Transport
July 18, 2023Welcome 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.
Thank you so much to Anila Elliot for contributing audio clips to the show today.
So, how can we keep patients safe during transport? The authors recommend the following:
- Use of standardized handover tools
- Appropriate training of providers directly involved in transportation
- Close communication with ordering clinicians regarding the possible risks associated with transporting patients throughout the hospital.
Here are the citations to the articles that we review on the show today:
- Haydar B, Baetzel A, Stewart M, et al. Complications associated with the anesthesia transport of pediatric patients: an analysis of the Wake Up Safe database. Anesth Analg. 2020;131:245–254. PMID: 31569160
- Harish MM, Siddiqui SS, Prabu NR, et al. Benefits of and untoward events during intrahospital transport of pediatric intensive care unit patients.Indian J Crit Care Med. 2017;21:46–48. PMID: 28197051
- Papson JP, Russell KL, Taylor DM. Unexpected events during the intrahospital transport of critically ill patients. Acad Emerg Med.2007;14:574–577. PMID: 17535981
- Latzke M, Schiffinger M, Zellhofer D, Steyrer J. Soft factors, smooth transport? The role of safety climate and team processes in reducing adverse events during intrahospital transport in intensive care. Health Care Manage Rev.2020; 45:32–40. PMID: 29176495
We hope that you use this infographic to advance pediatric patient safety during transport at your institution.
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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 hope you tuned in last week to Part 1 of our two-part series on keeping pediatric patients safe during transport in the hospital. Today, we are continuing the conversation and talking about identifying and mitigating risk, effective communication and teamwork, and culture of safety.
Before we dive into the episode today, we’d like to recognize Edwards Lifesciences, a major corporate supporter of APSF. Edwards Lifesciences has generously provided unrestricted support to further our vision that “no one shall be harmed by anesthesia care”. Thank you, Edwards Lifesciences – we wouldn’t be able to do all that we do without you!”
Our featured article again 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.
Last week, we reviewed a couple of cases of complications during transport of critically ill pediatric patients from the Wakeup Safe Database. Then, we talked about airway and ventilation management risks. It is important to weight the risks and benefits when deciding on which endotracheal tube holder to use, how to ventilate during transport with an Ambu bag or with a transport ventilator, and administration of neuromuscular blocking and sedative medications.
This week, we are kicking off the show by talking about identifying and mitigating risk. The authors remind us that it is vital to consider the risks, benefits, and alternatives anytime a critically ill pediatric patient must be transported. Risks during transport include the following:
- Line dislodgement
- Hemodynamic changes
- Unplanned extubation
- Hypoxemia
- Hypo and hypercarbia
- Hemorrhage
- Pneumothorax,
- Elevation of ICP in at-risk patients
- Hypothermia
- And increased risk for hospital-acquired infections.
Transporting patients who require advanced methods of ventilation may be even more challenging. This includes patients who require high-frequency oscillatory or jet ventilation or extra-corporal membrane oxygenation or ECMO. For these patients, a multidisciplinary meeting should be held to discuss the risks of transportation to the radiology, procedural, or operating room suites compared to having the necessary diagnostic or therapeutic procedure performed at the bedside. For high-risk patients, bedside alternatives may be preferred.
Another important consideration is postoperative transport from the operating theatres to the intensive care unit. This is a high-risk time period with almost 75% of respiratory complications and 70% of cardiac arrests occurring during the postoperative period. Complications may be due to emergence from anesthesia during transport. In addition, patients may be extubated just prior to transport and respiratory adverse events may occur post-extubation during transport and be difficult to detect and treat. Keep in mind that anesthesia professionals have an increased cognitive load when responsible for transporting critically ill pediatric patients. It is not the same as providing care from the operating room at the head of the bed. There are hallways to navigate and elevators to use along with decreased availability of emergency equipment and help if needed. According to the 2020 study by Haydar and colleagues, “Complications associated with the anesthesia transport of pediatric patients: an analysis of the Wake Up Safe database” task overload was found to be a secondary contributor in these events. I will include the citation in the show notes as well.
So, how can we keep patients safe during transport? The authors recommend the following:
- Use of standardized handover tools
- Appropriate training of providers directly involved in transportation
- Close communication with ordering clinicians regarding the possible risks associated with transporting patients throughout the hospital.
Head over to the multi-center handoff collaborative for free and validated tools. I will include the link in the show notes as well. After the show, go check it out. There are general handoff tools including the handoff mnemonic resource table and a Handover Assessment Guide. Further down, there are ICU to OR tools like the ICU to OR Handover Pocket Checklist and OR to ICU tools including the following:
- OR to ICU Handover Improvement Toolkit
- Cardiac ICU Handover Template
- OR to ICU Handoff Checklist Infographic
- OR to CVICU Graphic Cognitive Aids
- OR to CVICU Nursing Phone Report
There are also OR to PACU resources that include a Handoff Wall Sign, SBAR structure, Handover communication tool, and an ID Badge Card. Have you implanted any of these at your institution? These are great resources for keeping patients safe during anesthesia care and beyond during transport.
Let’s get back into the article. Keeping patients safe during transport requires that each team member involve in transportation have an assigned and specific role which may include airway management, medication administration, and maneuvering the bed and other devices. Remember, even just another imaging study or a simple procedure in the operating room may have serious and catastrophic complications for the patients, families, clinicians, ancillary staff, and even visitors. Don’t forget that bedside alternative should be considered and may be preferred.
The use of checklists prior to and after transport may help to improve patient safety. Checklists can help make sure that vital information is transferred correctly and that necessary equipment and emergency medications are available. Using checklists can help to decrease task overload and prevent information loss. Performing a beside handover prior to transport may provide additional information about the frequency of interventions including fluid and medication boluses or infusion changes or endotracheal tube suction frequency. This information is vital for keeping patient safe during transport and after they get to their destination.
We know that during critical events such as cardiac arrest, life support, trauma, and complex resuscitations in the operating room, important components include clear leader, effective communication , and clear roles for team members. We can apply the same principles for safe patient transport. A team leader should be clearly identified and should not have any other tasks for unstable or complex patients. This allows the team leader to be hands off. The next step is to make sure that there are an appropriate number of skilled team members assigned to each required task during transportation. This may mean that team members are assigned to the following roles:
- Ventilator management
- Medication boluses for sedative, vasopressors, and fluids
- Vasoactive infusions
- And Mechanical circulatory support
The bed may be driven by ancillary staff so that the medical and nursing teams can focus on patient care.
Have you transported a critically ill pediatric patient recently? What was your role? Was there a clearly identified, hands off team leader? These communication and teamwork steps may go a long way towards improving patient safety.
The authors highlight that creating local standardized processes for transport and team training may help to improve the culture of safety around transport. Unfortunately, there are no national or international standards of care for intrahospital patient transport and there is limited data to guide the creation of these standards. It is imperative to perform a careful risk assessment prior to transport. What we do know is that critically ill patients who require lifesaving technology such as mechanical ventilation, vasoactive medications, or circulatory support, must have a transport team with the knowledge, skills, and experience to manage the patient and technologies with appropriate backup equipment and medications. If we look at the literature, two studies revealed that junior trainee physicians have higher rates of adverse events during intrahospital transport than senior trainees or faculty. Involving a senior member of the team during transport may help improve patient safety and provide necessary training for junior clinicians. According to the 2020 study, “Soft factors, smooth transport? The role of safety climate and team processes in reducing adverse events during intrahospital transport in intensive care,” having a positive safety climate, effective team processes, adequate team experience, and mandatory training led to decreased adverse events during intrahospital transport of critically-ill adults. I will include these citations in the show notes as well.
Intrahospital transport may be a very short time period, but it involves significant patient safety concerns including airway management, early recognition of clinical deterioration, communication, and teamwork and this time period may represent up to 5% of all pediatric adverse events during anesthesia care. WE must be especially vigilant for patients less than 6 months old and for pediatric patients with significant comorbidities.
That authors leave us with a call to action for standardized risk assessment, resources allocation, and structures handovers to improve patient care during this critical period.
For a great summary, check out the infographic in the article and you can find it in the show notes as well. This highlights important patients’ safety considerations during transport. The title is Teamwork and Communication Strategies to reduce risk during transport of pediatric intubated patients. Next, there are some important statistics: 40% of transport-related events occurred in patients less than 6 months and about 75% of respiratory complications occur in the postoperative period. Key points include Understanding airway and ventilation management risks which we talked about last week and Identifying and Mitigating risk, Effective communication and teamwork (remember checklists can help to prevent task overload) and culture of safety (remember a positive safety climate and effective team processes are associated with fewer adverse events during transport of critically ill patients.)
Before we wrap up for today, we are going to hear from Elliott again. I also asked her, what do you hope to see going forward. This is what she had to say.
[Elliott] “Moving forward, I hope to open up the dialogue regarding transportation of critically ill patients. I think all clinicians need to understand the risks of transportation and how it relates to the clinical status of the patient prior to making decisions regarding transportation for diagnostic tests or procedures, especially when the slightest movement can have detrimental consequences for the patient, and subsequently for the medical team caring for that patient. We focus on patient risk and harm in this paper and in general, but another undervalued component is the second victim effect that occurs when clinical team members are put in these high-risk scenarios. Patients, even critically ill ones, will continue to need to be transported to various locations across the hospital – but raising awareness for the risks associated with transportation, ensuring availability of appropriate resources and training of personnel involved in transport and that we are considering less risky or bedside alternatives is an important piece for us to mitigate risk and best serve our patient population.”
[Bechtel] Thank you so much to Elliott for contributing to the show for the past two weeks. We hope that you are able to implement some of these strategies into your practice the next time you find yourself preparing to transport a critically-ill pediatric patient.
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.
If you have not done so already, we hope that you will rate us and leave a review on iTunes or wherever you get your podcasts and feel free to share this podcast with your friends and colleagues and anyone that you know who is interested in anesthesia patient safety. Plus, you can let us know that you are listening by tagging us @APSForg using the hashtag #APSFpodcast.
Until next time, stay vigilant so that no one shall be harmed by anesthesia care.
© 2023, The Anesthesia Patient Safety Foundation