MOVING PAINS

Dr 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
INTRAHOSPITAL – Within the same facility
INTERHOSPITAL – Within two different
facilities
FROM HOSPITAL TO HOME – Post Discharge/
After Referral to other type of Healthcare
delivery Setups

TYPES OF TRANSFERS
 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
FOR CRITICALLY ILL PATIENTS
FOR NON CRITICALLY ILL PATIENTS

INTRAHOSPITAL TRANSFERS
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
Adverse Events occur in upto 70% of Transport
62% of Transports Reported Complications
45% of these related to Equipments and Transport
Environment, 31% related to Patients and 15% to both
Increase in VAP rates as compared to Non Transported
Patients
Notable Risk to more sick patients and urgent Transfers
Experienced Transporters have fewer side effects
Longer stay in ICU for Transported Patients
24 % of Transported patients reported change in plan
of treatment

TO SUMMARIZE
 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 Issues
In 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