Introduction

The chosen topic for the case study is the delivery of care in transferring critically ill patients in Intensive Care Unit. It is related to core competency 3 aspect of care on Hygiene, Mobility and Tissue Viability. Martin (2012) stated that transportation of critically ill patients has deranged physiology, require organ support and invasive monitoring, it poses an important risk (Beckmann et al,2004). The aim of this assignment is to evaluate causes, outcomes and preventing factors associated with adverse incidents on intra hospital and inter hospital transport. Critical analysis and evaluation will be done in conjunction with the nursing and medical intervention based on best practice guidelines and gold standard evidenced based research to provide safe transfer.

The patient will be named Jude to safeguard his privacy and confidentiality, in accordance with the Nursing and Midwifery Council Code of Professional Standards and Behaviour (NMC,2015). Jude is an 88-year-old gentleman admitted with type 1 respiratory failure secondary to aspiration pneumonia. According to Marik (2001) aspiration pneumonia is an infectious process caused by inhalation of oropharyngeal secretions that are colonised by pathogenic bacteria. Therefore, admission to Intensive Care is essential to provide mechanical ventilator support, to normalise arterial blood gas levels and acid base imbalance by delivering adequate ventilation and oxygenation (Grossbach et al,2011). Patient was on sedation to minimise discomfort to be able to tolerate the endotracheal tube (Whitehouse,2014). The patient needed to undergo a Computerised Tomography (CT) scan of the chest. Adverse incidents happened before and during patient transfer. It involved ineffective communication with the porters collecting the patient not on the agreed time and patient was not stabilised for transfer. Insufficient time to prepare and connect the patient to the equipment needed for safe transfer. Accompanying the patient is a transfer competent nurse, and had to wait for the availability of an airway trained doctor. During the transfer, there was an equipment malfunction with the infusion pump due to low battery. Inotrope infusion was being administered, inotropes is a group of medication that increases the myocardial contraction improving cardiac output thereby increasing mean arterial blood pressure and maintaining perfusion to vital organs and tissues (Berry and Mc Kenzie,2010). Patient became hypotensive and needed to immediately restart the backup infusion to restore blood pressure.

Critical Analysis

Martin (2012) stated that there are approximately 300 critical care units in the United Kingdom and more than 10,000 intensive care patients are transferred annually. The high frequency of transfer of critically ill patients is primarily due to escalating complexity of healthcare, relative lack of intensive care beds and the concentration of skills into specialised regional centres.

Intra hospital transport of the critically ill patients is frequently required to either admit the patient in ICU or to obtain diagnostic tests or procedures that cannot be undertaken in the ICU. According to Warren (2004) inter hospital transport of critically ill patients may be indicated if additional care, it can be cognitive, technical and procedural, is not available to existing location. The risks should be weighed against its potential benefit for each individual critically ill patient (Flavouris et al,2006).

Handy et al (2007) stated that intra hospital transfer needs to be given the same importance as that of the inter hospital transfer. Whether going to CT scan or transferring to a different hospital, the preparation and equipment will be the same.

The transport process is associated with a risk of physiological deterioration and adverse events. Droogh et al (2015) cited that the incidence of adverse events is proportional to the duration of the transfer, severity of illness and to the inexperience of the accompanying escorts. Critically ill patients are prone to changes in their medical condition even without being transported. The goal every transfer should be the continuation of high quality ICU care, preventing deterioration and adverse events. Prevention is best achieved whilst transport by limiting hard braking, head up tilt and smooth slow journey. “Full patients travel better”, well filled patients tolerate transfer better than those who are hypovolaemic (Handy,2005).

 According to Intensive Care Society (3rd edition 2011) Critical Care Networks should consider the development and use of dedicated transport team, it is appropriate to best meet the transport needs of their patient population.

All acute hospitals must have systems and resources in place to resuscitate and stabilise critically ill patients and carry out time critical transfers when needed (ICS,2013). The Intensive Care Society guidelines on safe transfer encourages improvement in standards of care during transfer of critically ill patients in the United Kingdom.

Guidelines have been developed to increase the safety of intra hospital and inter hospital transport of critically ill patients, however there is still a lack of clinical evidence on factors determining the appropriateness of transportability of these patients (Fan,2005). Decision making on transferring involves appraisal of several factors including patient characteristics, level of escort, indication for transfer and transport facilities (Gray,2004)).

A study in the Netherlands participated by 95 medical ICU heads were surveyed regarding the importance of clinical and transport related factors in physician’s decision making in the inter hospital transport of critically ill patients. The questionnaire consists of 2 parts (Appendix 1). Results on the study (Lishout 2008) showed that determinants reflecting severity of illness were of relative minor importance. The most important factors are the escorting personnel and transport facilities according to the ICU physicians in determining transportability of critically ill patients.

A study was done by a London hospital (Bellingan et al 2000) comparing a specialist retrieval team with current United Kingdom practice for the transport of critically ill patients. The inter hospital transfer in the UK is commonly undertaken by the use of standard ambulance with a junior doctor escort. The study evaluates the effect of transfer method on acute physiology and early mortality. Patients were divided into 2 groups, Group A is the specialist retrieval team using the mobile ICU and Group B uses the standard emergency ambulance with a medical escort provided by the referring hospital. There was no selection policy determining which mode of transfer was used. The specialist team consists of an ICU trained doctor (consultant or senior SPR) transfer competent nurse, driver, and medical physics technician, all trained in ICU transfer. The mobile ICU is equipped is equipped to ICU standards with all round stretcher access, mechanical ventilation, suction, piped oxygen and air, nitric oxide, 220 V power supply and multi-channel monitoring. The specialist team spent a mean of 70 minutes stabilising patients before the transfer. The criteria recorded is in (Appendix 2).

Results of the study showed no difference in the demographic characteristics, severity of illness, diagnoses and overall ICU mortality. Despite the similarity between the 2 groups, however there were significantly more patients in Group B who were severely acidotic and hypotensive upon arrival than in Group A. In addition, Group B had more deaths within 6 hours of admission, there were fewer early deaths in Group A. The results of the study clearly demonstrated that a fully trained and equipped team results in improved patient resuscitation post transfer.

There is a 50% reduction in the number of patients arriving in a dangerously hypotensive condition and a 70% reduction in those with serious metabolic acidosis.

This study thus confirms from previous reports that critically ill patients can be safely transferred if those involved are appropriately equipped and have the proper up to date training (Britto,1995).

An observational study was conducted in the Netherlands in 2009 comparing adverse incidents and patient stability during Mobile Intensive Care Unit (MICU) transfer and transport with standard ambulance. The result of the study revealed that MICU transfers showed no major deterioration in vital signs despite a high severity of the disease. Adverse events were related to technical failure and have little influence on patient’s status. Improvement on respiratory status before and during transfer compared to transfer by standard ambulance (Wiegersma,2011).

However, a review published in 2006 argued that there were insufficient data existed to determine whether the use of specialist transport team improves patient outcome.

Out of 39 publications, 33 were excluded because there was either no control group or unsuitable control group (Droogh,2015).

According to Beckmann’s study the most prominent issues are in relation to common equipment issues, as well as patient/ staff management issues where problems occurred from “Patient elevators, battery/power supply, drug delivery systems, intubation equipment, transport ventilators, oxygen supply and monitors. Communication/liaison, airway management (securing, accidental extubation, unplanned reintubation), vascular line use (dislodgment, disconnection, inadequate securing), patient monitoring and positioning and set-up of equipment.” (Beckmann, 2007) The study identified that there was almost an even rate of an incident occurring between doctors, nursing and other healthcare professional involved with transportation. The detection of these incidents was mainly identified by nurses statistically 82% of reports. Reports had found that 39% of incidents were caused by other staff other than the ICU team. The majority of which came from the operating room or recovery room, followed by the emergency department and radiology, suggesting that majority of the transfers for diagnostic testing results in either an equipment or management related adverse event. The reports had made available multiple selections to identify factors that contributed to the incident, split as technical issues to human errors. An important number of factors were identified which help reduce the frequency and severity of an incident, that being rechecking equipment in 62 reports, rechecking patients in 60 reports, prior experience in 51 reports, use of correct protocol in 40 and skilled assistance in 39 reports. (Beckmann, 2007). What the study saw was that a number of reports were a result of supervision by the transport team and the lack of training that lead towards it. From the data, 44% of incidents are during an on-going ICU care, need to discuss and outweigh the risk that is associated with transportation. There were more than a third reports that showed the outcome resulted in serious adverse outcomes from Beckmann’s study, the problem with this study is the fact that while it highlights and focuses on risk factors is limited towards being equipment adverse events and staff management related adverse events of all intra-hospital transportation that occurred during the period data was collected. So while it shows where the majority of transport related incidents occurred and what caused the incident, we are unable to see how beneficially transferring a patient is entirely, without having detailed information from all transportation that occurred and their underlying conditions. It was also highlighted in the study that duration of the incidents was not recorded, but the finding’s suggested the importance of portable equipment and the fact equipment failure was one of the most prevalent causes of an incident during transfer. It also raised that there were factors that would reduce the chance and severity of an incident, suggesting that having someone who is experienced and trained under the standard protocol leads to better practice overall to overcome an incident. This leads onto the fact that in their data of airway and ventilation management that endotracheal tube malpositioning and accidental extubation were frequent. Taking this into account there are multiple factors during transportation related adverse events, as well as the fact that the portable equipment plays a huge role in their transportation as we would take them outside of an ICU environment where everything is controlled poses a risk.

Lahner’s study represents a cohort study where there is an example of pre-transport stabilization of patients, careful preparation of the equipment and proper training of personnel. From 452 intra-hospital transfers 47 (10.4%) were equipment related complications, no difference was found from the emergency department which deemed that adequate preparation was done in both areas. The significance of these results show that the risks presented from intra-hospital transfers are still fairly common preformed under the standards recommended by the Society of Critical Care Medicine. (Lahner, 2007) What this means outside of an ICU environment even under those standards these complications still remain a problem. Results gathered from Lahner (2007) also differentiated between minor adverse events where a there is a physiological decline in the patient or caused by an equipment problem, as well as serious adverse events that require emergency therapeutic intervention as patient’s life is in danger. A point raised in Lahner’s study was the fact that the number of escorts did not contribute to the risk of an adverse event. They also found that within their investigation that the transfer destination did not play a factor towards an increase in an adverse event which covers offers difference in conclusion towards what had been found by Beckmann’s study. But on the other hand, Lahner’s study showed there was no difference between the experience of junior and senior doctors in terms of adverse event incidences. This reinforces the point from Beckmann’s study in relation to having lacking training leads towards more adverse events which shows that junior doctors have sufficient training.

Noted before Beckmann (2007) had stated that battery/ failure was a main equipment issue in infusion pumps and monitors, hypotension resulting from a lack of inotrope delivery, as well as insufficient upper airway management and insufficient oxygen is backed up by a study conducted by Papson. The study identified that a majority of minor adverse events were brought on due equipment problems caused by cases related to tubes, drainage and monitoring, including that half of the incidents that were caused by ventilation. (Papson, 2007) Evaluating this information, what can be gathered is that the risk factors that lead towards equipment related adverse events are the mechanical ventilator management of settings, sedation and stabilisation of patient.

Critical Evaluation

The Department of Health (2000) Comprehensive Critical Care strongly recommended the adherence to Intensive Care Society guidelines on transportation of critically ill patients. There are local ICU guidelines on safe transfer done in 2011. In addition to that, local ICU quality improvement project was done in 2016 on patient safe transfer. The Trust Patient Escort Policy 2013 is committed to improving patient safety and reducing any potential risk of harm or injury during transfer of patients until they reach their safe destination.

Jude’s intra hospital transport to CT scan department had numerous adverse events, patient was not managed well and did not adhere to the guidelines on safe transfer. The reasons as follows:

Ineffective communication between CT scan department and ICU. There was insufficient time to stabilise Jude prior to transfer. Intensive Care Guidelines (3

^rd

Edition,2011) strongly recommended that patients should be appropriately stabilised and resuscitated prior to transfer to reduce physiological disturbance associated with movement and reduce the risk of deterioration during transfer. Poor preparation leads to poor performance.

Not enough time to prepare equipment and medications to be used e.g transfer monitor, suction machine, portable ventilator, transfer equipment bags and emergency medications.

Shortage of transfer equipment specifically suction machine and transfer monitor. Medical physics staff is trying to locate around the trust the equipment that has gone missing and fix the broken ones. Management was made aware and evaluating if purchasing a new transfer equipment is essential.

A transfer competent nurse needs to accompany the patient; the bedside nurse has not completed competency assessment tool for safe transfer of critically ill patients.  Local ICU policy on safe transfer needed to undertake 3 achieved transfer competency assessment. There is no local ICU transfer training offered to the staff as it is done externally, however transfer update is incorporated in staff line study day. Comprehensive Critical Care emphasize the need to improve training in all aspects of critical care, medical and as well as nursing staff involved in the transfer should receive appropriate training and have the opportunity for supernumerary capacity.

Unavailability of airway trained doctor at the time of the transfer. Specialist retrieval teams are advocated by the Department of Health as there are evidences from the UK (Bellingan et al 2000 and Reeve et al 1990) and other countries that quality of care improved if a specialist retrieval is used. The hospital that Jude was admitted had a specialist retrieval team until 2005, however problems encountered were staffing and financial issues hence the service has come to an end.

There was no transfer checklist used for the transfer and no observations recorded during the transfer. A new local ICU transfer form will be launched for use on January 2017, it will undergo trial for 2 months then subject for review by the Education Team. ICS guidelines (2011) emphasized the importance of transfer checklist to ensure that all necessary checks have been completed. According to Handy et al (2007) a transfer checklist is a helpful tool but sadly these are not being used, unavailable, poorly completed and unfamiliar to the transferring team.

There was an equipment malfunction depleted battery of infusion pump causing haemodynamic instability. Daily checks should be carried out and recorded including the battery status. ICS recommends that ideally all equipment within a critical care network is standardised to enable a seamless patient transfer.

There was a high adverse incidence risk transferring the patient to CT with all these circumstances. Careful planning should be done and risks should be weighed against its potential benefit for each individual critically ill patient (Flavouris et al,2006). Jude still managed to be transferred back from CT scan department to ICU in a stable condition.

Conclusion

The principles of safe transfer between ICUs are no different to those of any of patient transfer, even transport of patients between two departments in one hospital can be risky. However, critical care patients have the most difficult challenges and require detailed planning, preparation, knowledge, skills and team work to achieve success (Martin,2012).

The critical analyses showed a lot of literature reviews on specialised retrieval teams with improved patient resuscitation post transfer, however it has been argued that definitive evidence is still lacking.

In addition to, important factors in determining transport in determining transportability of clinically ill patients are escorting personnel and transport facilities, the severity of illness is of minor importance.

Most important issues on transfer are equipment, either unavailable or malfunctioning. Furthermore, a study showed that there was no difference between the experience of junior and senior doctors in relation to adverse incidences. This was disputed by another study stating that lack of training leads towards more adverse incidents.

This was a case study of Jude, who was admitted in ICU for ventilatory support due to aspiration pneumonia. Adverse incidents happened before and during intra hospital transport due to a number of mishaps. Jude’s transfer was not managed well based on the Intensive Care Guidelines on safe patient transfer for the following reasons: communication failure between ICU and CT scan department leading to insufficient time to prepare and stabilise the patient, equipment malfunction causing haemodynamic instability, level of competency of transferring personnel, lack of transfer checklist and documentation.

Future recommendations are local ICU transfer training programme should be developed, reinstating the specialist retrieval team, adherence on using the transfer checklist, sufficient working transfer equipment, proper documentation and audit.