MOVING PAINSDr Santosh Tiwari

What's This?

• Transfers of Patients within the hospital premises for different reasons, as deemed necessary for treatment of the sick and also the transfer of the patient outside the hospital facility post discharge or post referral to another facility fall in this category

TYPES OF TRANSFERS

INTRAHOSPITAL – Within the same facilityINTERHOSPITAL – Within two different facilitiesFROM HOSPITAL TO HOME – Post Discharge/ After Referral to other type of Healthcare delivery Setups

Intrahospital Transfers

• From Emergency to Wards• From Emergency to OT/ ICUs• From Wards to OT/ ICUs• From Wards to Radiology for Imaging• From Wards to Wards• From One ICU to other ICU

Interhospital Transfers

• From Hospital to home, post Discharge• From one facility to other in same city• From one facility to other in different city• From Hospital to other healthcare

delivery centre, Government Hospitals, Geriatric care, End of life care facilities, Nursing homes etc

INTRAHOSPITAL TRANSFERS

FOR CRITICALLY ILL PATIENTSFOR NON CRITICALLY ILL PATIENTS

FOR CRITICALLY ILL PATIENTS

The Literature Search

• Protecting critically ill patients from harm by constant monitoring and prompt intervention is a primary responsibility of Hospital.

• This concept goes back to period of Florence Nightingale, credited as the first to use an “ICU” by placing the sickest patients nearest the nursing station for closer monitoring.

• Today, the ICU is considered the safest place with the highest level of monitoring for critically ill patients.

Cont…• But what about when the patient leaves the

ICU for diagnostic or therapeutic procedures?• The transport of critically ill patients always

involves some degree of risk to the patient and sometimes to the accompanying personnel. It is Stressful

• Therefore, the decision to transport must be based on an assessment of the potential benefits* of transport weighed against the potential risks*.

Cont…

• The data available is Scarce• Its not updated• Most of the studies in fact all are conducted in

western countries• I have certain reported studies with

conclusions from 1999 to 2009-10• The summary is as follows…..(Table 1)

Table 1

TO SUMMARIZE

Adverse Events occur in upto 70% of Transport62% of Transports Reported Complications45% of these related to Equipments and Transport Environment, 31% related to Patients and 15% to bothIncrease in VAP rates as compared to Non Transported PatientsNotable Risk to more sick patients and urgent TransfersExperienced Transporters have fewer side effectsLonger stay in ICU for Transported Patients24 % of Transported patients reported change in plan of treatment

Mishaps During Transfers

• Mishaps, (Table 2) during transport are categorized as systems based or patient based.

• Systems-based mishaps may be further subdivided into 2 groups, equipment based and human based, both often resulting from poor preplanning.

• Examples of equipment-based mishaps include battery failure of portable equipment, monitor malfunction, and depletion of portable oxygen supplies.

• The reported prevalence of equipment-related mishaps during critical care transport is from 11% to 34%.

Patient-Based Mishaps• Patient-based mishaps refer to physiological

deterioration related to critical illness.• The sicker the patient, the greater the chance

of problems during transport.• Based on the patient’s acuity, these problems

could have happened as readily in the ICU as during transport.

• Sicker patients require more frequent transport for diagnostics/procedures, especially during the first 24 hours after admission to the ICU.

Table 2

Adverse Events During Transfers

• Extubation,• Code team activation, • Death,• Sustained arrhythmia,• Hypoxia exceeding 5 minutes,• Hypotension exceeding 20% of baseline

systolic or diastolic blood pressure and requiring intervention,

• Use of physical restraints,• Acute change in mental status.

Study in American Journal of Critical Care

• The reported incidence of adverse events during Intrahospital transport ranges from 6% to as high as 70%.

• When the definition of adverse events is restricted to clinically significant events such as changes in vital signs, unplanned extubation, or cardiac arrest, the adverse event rates reported have been as high as 8%

Adverse Events during Transfers

THEN WHAT SHOULD WE DO?Considering the Mishaps and Adverse events related to the transfers of ICU patients, the Guidelines for Safe transfer can be very useful

WHY?WHY THE PATIENT IS TO BE TRANSFERED?

Physiologic Red Flags

Transport Risk/ Benefit

WHO IS THE PATIENT?WHO WILL CARE FOR THE PATIENT?

IS HANDOFF REQUIRED FOR DIRECT CARE RESPONSIBILITY?

WHAT EQUIPMENTS WE REQUIRE TO SAFELY TRANSFER THE PATIENT?

Suggested Equipments Required

DOPE Monitoring During Transfers

Monitoring During Transfers

PROPER TIMING IS VERY CRUCIAL FOR THE TRANSPORT

SAFEST MOST EFFICIENT ROUTE TO BE IDENTIFIED

5 Wh Questions before Transfers

Interfacilty Transfers

Interhospital or Interfacility Transfers

Transfer of Non ICU Patients

• Literature shows that there are no formal Guidelines for the safe transfer of Non serious or Non ICU patients.

• Every facility has to make its own policies and Guidelines that ensures safe transfers.

• A study by Pennsylvania Patient Safety Authority came out with following issues while Non ICU patient Transfers,

Patient Transport IssuesIn a study of 280 Non ICU transfers

• TRANSPORT ISSUES NUMBER OF REPORTS• Communication issues 115 (41%)• Intravenous lines/tubes 93 (33%)• Monitoring/techniques 47 (17%)• Other 25 (9%)

Total 280 (100%)

Questions in Assessing Transport Policies and Procedures

Which patients are being transported?• Focus initial efforts on the most frequent source

units and patient types (ages, clinical diagnoses).To which locations are most patients transported?• Are these destinations in the main hospital,

adjacent buildings, across the street? Are there special safety hazards in any of the

units (e.g., MRI [magnetic resonance imaging] magnets)?

Pre-transport patient assessments

• Criteria used to determine patient stability, patient risk, and level of monitoring during transport

• Responsible for this assessment• Recommended timing for this assessment• Inclusions of Risk Factors• Possibility of decline in clinical condition and the

need for escalating support• Assessment communication to the care team, the

transport personnel, and the destination personnel• Finally, compliance monitoring

Transfers after Discharge

• Very Important, but attracts least concern• Studies have shown that readmission rates

have reduced, if hospitals ensure safe patient transfers to homes after discharge

• In India, unfortunately we don’t care much for this aspect of transfers

• Institute of Healthcare Improvement has developed a roadmap for safe hospital to home transfers to reduce Readmissions

Roadmap for Safe Hospital to Home Transfers

DISASTER PATIENT TRANSFERS

Some Equipments for Patient Transfer

NOTHING IS POSSIBLE WITHOUT SUPPORT, AFFECTION & LOVE

What Pays is Teamwork

FOR PATIENCE AND OPPURTUNITY