Episode #258 Wheels of Risk: When Patient Safety Rolls Through Hospital Corridors

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. When was the last time that you were involved in transporting your patient from the operating room to the ICU or from the emergency department to radiology and then to the operating room? Anesthesia professionals are often involved in intrahospital patient transport. There are not many studies that focus on the outcomes of patients who need to undergo perioperative transport accompanied by anesthesia professionals. Most of the literature on intrahospital transport involves nurses and other care providers and does not focus on the perioperative population. Today, we are going to review the current literature and lessons learned from critical care and emergency medicine for how to keep patients safe during perioperative patient transport.

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

We are returning to the February 2025 APSF Newsletter today. Our featured article is “Intrahospital Patient Transport: Checklists, Adverse Events, and Other Considerations for the Anesthesia Professional” by Caroline Andrew and Michael Fitzsimons. 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 the link in the show notes as well.

We often talk about threats to anesthesia patient safety that may arise in the operating room. Today, we are going to focus on all the areas outside of the operating room where patients may need to be transported and where they are at risk for intrahospital adverse events during transport or within 24 hours of transport. Did you know that the incidence of these adverse events is almost 80%? In addition, the frequency of patients requiring medical intervention from intrahospital adverse events during transport is between 4-9%. The risk of perioperative patient transport has likely increased over the years with increased production pressure, decreased support personnel, and increased patient acuity. The APSF authors are asking the critical questions, “Is our approach to perioperative patient transport right and are we doing it safely?

These are great questions! Let’s discuss.

We are going to start with some definitions. Definitions for adverse events during transport include the following:

• “Any unintended event or outcome, which may have or did reduce the safety margin for the patient.”
• Or perhaps, “Any observation that fell outside of a pre-defined threshold, such as hypotension with systolic BP less than 100mmHg or hypertension with SBP greater than 160mmHg.”

These very different definitions means that it is hard to figure out the actual incidence of these adverse events during transport. The 2022 article, “Adverse events during intrahospital transport of critically ill patients: a systemic review and meta-analysis” offers some important insights. This study looked at safety and adverse events during intrahospital transport of critically ill patients and included over 12,000 transports and almost 2000 patients over 24 studies. Results included 26% pooled frequency of all adverse events with high heterogeneity and pooled frequency of death due to intrahospital transport and life-threatening adverse events was 0% and 1.47% respectively with high heterogeneity. Due to the high heterogeneity, it was difficult to accurately determine the incidence of intrahospital transport adverse events. Some of the studies did not clearly define these events or the definition was based on author team consensus. Another consideration is that patient changes during transport could represent adverse events or physiologic variability that happened to occur during transport. It may be challenging to distinguish between these two as well.

We have raised some important questions, but let’s turn our attention to what we know about intrahospital transport adverse events. These events may be categorised as respiratory, cardiovascular, neurological, and equipment related. Reported adverse events include the following:

• Hypertension
• Hypotension
• Arrythmias including cardiac arrest.
• Decreased arterial saturation.

Equipment related adverse events may involve equipment malfunction, accidental dislodgement of lines, tubes, and catheters, or empty oxygen cylinders.

Check out the I-Touch Study published in 2023. This was a multicentre, prospective, observational study of almost 900 patients and about 1000 transports out of the ICU. 102 adverse events occurred during the study time period and the most common adverse events included 30% cardiac, 17% airway or respiratory, 16% neurologic, and 12% equipment problems. The authors conclude that stabilization of patients before transport and using a standardized protocol may help decrease these events and improve patient safety. The citation is in the show notes so that you can check out the article.

Equipment related adverse events may be even move common, up to 1/3 of intrahospital adverse events in some studies and are related to unreliable functioning of transport equipment and errant management of this equipment by clinicians involved in the transport. Another consideration is that patient transport may put anaesthesia professionals and other clinicians at risk for physical harm due to ergonomic factors. Transport stretchers or beds may weigh between 100 and 700lbs. The bed width or length may invoke challenges with manoeuvring the bed while also management the airway or administering a medication. Anesthesia professionals  report a high rate of work-related musculoskeletal disorders and injuries requiring the use of analgesics or need to take sick leave. Intrahospital patient transport is a time when patient and clinician safety is at risk.

Check out Table 1 in the article for a list of adverse events and risk factors associated with patient transport. These may be patient-specific, equipment-related, or systematic. We are going to go through it now.

First up, general adverse events which includes complications related to staff musculoskeletal injury and general patient instability. Risk factors in this category include:

• Age
• Male gender
• Obesity
• Patient condition
• Higher APACHE score
• Emergent transport
• Longer transport time.
• Acidosis
• Elevated PaCO2
• Reduced pH
• And Higher ASA status.

Quick commercial break to review the APACHE score. This stands for Acute Physiology and Chronic Health Evaluation score that is used in the ICU to assess illness severity and predict survival. The score depends on the patient’s age as well as certain vital signs and lab values such as mean arterial blood pressure, pH, and potassium level.

Okay, back to the main program.

The second category is System and potential complications in this category include:

Loss of information

Transport to wrong location

Failure to respond to crisis.

Improper management of devices

Care Delay

Risk factors in this category include:

Less experienced transport team

Resident directing transport rather than attending physician.

Lack of checklists

The next category is Airway and Respiratory. Hypoventilation, pneumothorax, hypoxemia, and accidental extubation or displacement of endotracheal tube. Risk factors for these complications include:

Mechanical ventilation

Manual ventilation

Need for PEEP.

The fourth category is cardiovascular. Complications in this category include hyper and hypotension, arrhythmia, central line and arterial line displacement, and cardiac arrest. Risk factors for cardiovascular complications include the use of vasopressors or inotropic agents.

Next up is the neurologic category. Neurologic complications involve agitation, increased intracranial pressure, reduction in GCS, seizures, secondary brain injury, and patient discomfort. Risk factors for these complications include higher levels of sedation and inadequate monitoring during transport.

The final category is equipment and there are a lot of complications related to equipment including the following:

Non-functioning ventilator

Battery depletion

Oxygen depletion

Fluid depletion

Infusion pump failure

Equipment disconnection

Monitoring incompatibility or disconnection

Risk factors for these complications include higher number of monitors, poor preparation, inexperienced transport team, and inadequate monitor inspection prior to transport.

As you can see there are a lot of complications that may arise during intrahospital transport and a lot of risk factors. Anaesthesia professionals need to remain vigilant to help keep patient safe during transport. Patients with higher severity of illness scores, older age, the need for pharmacologic support especially sedative and vasopressor medications, mechanical ventilation especially with PEEP greater than 6mmHg, obesity, and reduced arterial oxygen saturation before transport are important patient-related factors that are associated with higher rates of complications during transport. The literature supports that critically ill patients in particular are at increased risk for intrahospital transfer adverse events. If we look a little closer a the system or situational risk factors for adverse events, there is an increased risk for adverse events associated with longer duration transport with greater than 60 minutes outside the ICU, poor hand-off communication, urgent or emergency transport, staffing shortages, and the use of less experienced health care or transport staff. Have you ever transported a patient through a cluttered hallway or been so focused on trying to drive the bed that it limited your ability to identify threats to patient safety during transport? These last two considerations have not been identified in the literature but often come up in discussion with anesthesia professionals about the challenges of intrahospital transport.

This week, we talked about the significant challenges when it comes to safely transporting patients in the hospital, especially critically ill patients. The good news is that the American College of Critical Care Medicine and the Society of Critical Care Medicine have developed guidelines for intrahospital transport of critically ill patients to and from the ICU. This is an important step for improving perioperative patient safety during transport. We are going to review these guidelines and more on the show next week, so mark your calendars.

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.

The APSF Newsletter is the official journal of the Anesthesia Patient Safety Foundation. Readers include anesthesia professionals, perioperative providers, key industry representatives, and risk managers. It is free of charge and available in a digital format with a focus on anesthesia-related perioperative patient safety issues. The June Newsletter has just been published, but the deadline for the October 2025 APSF Newsletter is right around the corner on July 1^st! Check out the guide for authors over at APSF.org for more information and I will include a link in the show notes as well. Who knows, you could be the next APSF Newsletter author, and we might be featuring your article on a future Anesthesia Patient Safety Podcast! So, what are you waiting for, go ahead and submit your article today!

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

© 2025, The Anesthesia Patient Safety Foundation