Sending a critically
ill patient off unit for diagnostic testing seems safe. A registered nurse is with them during transport, and clinicians fill the corridors and floors around them. But up to 9 percent of intrahospital transports end in a life-threatening event.1
After two intensive care unit patients sent for CT scans in the Calgary Health Region of Canada suffered cardiopulmonary arrest during transport, a team of respiratory therapists, nurses, and physicians created a decision scorecard to help determine when a patient is stable enough for transport. Five years later, they're revising the scorecard to bring greater attention to respiratory problems that can turn a typical transport into a critical emergency. The new form puts "showstopper" respiratory items first in a series of decision points that the RT and bedside nurse complete one hour before a scheduled transport.
"The power isn't in the positives, it's in the negatives," said Terry Hulme, MD, FRCPC, medical director of Rockyview General Hospital of the Calgary Health Region of Canada. "It is putting the brakes on transports where the risk to the patient has been under-recognized."
One of the new system's first steps is for the RT to assess whether the patient can remain properly oxygenated in the position required during transport and the entire diagnostic test. For intubated patients, RTs check for endotracheal tube positioning and conduct a trial. The patient is switched from the mechanical ventilator to a transport ventilator or manual bagging for the length of time that they will be outside the ICU. If the patient demonstrates high ventilatory requirements reflecting potential difficulty in oxygenating the patient adequately, the RT documents it on the scorecard, and then notifies the attending physician.
"The original concept with this scoring was to help level communication fields for RTs and nurses with physicians," Dr. Hulme said. "What we have tried to do is take away opinion and clinical judgment and make it black and white."
With that objective data in mind, RTs and physicians can work together to reconfigure ventilator settings to better ventilate the patient. Or they may decide to cancel the transport and use an alternative bedside test to gather the same information.
Non-intubated patients appear to be less acute or less likely to have complications, but "that's not always the case" said Greg Duchscherer, RRT, FCSRT, quality improvement and patient safety leader for the department of critical care. The new decision scorecard provides specific criteria to help RTs identify underlying respiratory or neurological issues and take action to prevent problems during transport.
For example, if the patient has a history of difficult intubation or anatomical features that put them at risk for a difficult airway, the RT must notify the attending physician and fellow to reconsider the transport. If they decide that the patient must be sent for diagnostic testing, as least one RT and physician accompany the nurse on the transport.
RTs also use the 10-point Richmond Agitation Sedation Scale to classify whether a patient is alert enough to protect his airway. Patients who are breathing fast on high-flow oxygen or have risk factors for aspiration may be electively intubated. "That still is a judgment call," Dr. Hulme said. "The argument here is that we're trying to prevent serious harm, prevent death."
No official studies of the revised patient decision scorecard are being done, but the committee will use staff feedback to continue improving the form. The ultimate goal is to be able to provide the same level of monitoring and care in transporting patients as inside the ICU.
Kristen Ziegler can be reached at firstname.lastname@example.org.
1. Papson JP, Russell KL, Taylor DM. Unexpected events during the intrahospital transport of critically ill patients. Acad Emerg Med. 2007 Jun; 14(6):574-7.