Research paper
Improving quality and safety during intrahospital transport of critically ill patients: A critical incident study

https://doi.org/10.1016/j.aucc.2018.12.003Get rights and content

Abstract

Background

Intrahospital transport is a high-risk procedure for critically ill patients, yet there is little known about how the transport team manages critical incidents that occur.

Objectives

The aim of this study was to explore critical care nurses' and physicians’ experiences and practices associated with critical incidents during the transfer process in critically ill patients.

Methods

As a part of an ethnographic study, semistructured interviews were performed using the critical incident technique. Data were collected in two intensive care units at one university hospital in a Swedish metropolitan city. Critical care nurses (n = 15) and physicians (n = 5) were interviewed, together describing a total of 46 critical incidents. Data were analysed using qualitative content and thematic analysis approaches.

Results

Content analysis of nurses' and physicians' practices resulted in a description of requirements for safe transports, including organisational prerequisites, professional skills and attributes, as well as actions and behaviours of safely performing transfers. Exploring the experiences of nurses and physicians in transporting critically ill patients yielded three main themes. The first theme, a hazardous process, revealed how caring for critically ill patients during intrahospital transfers was perceived as an unsafe, demanding task that presents several threats to the patient's safety. However, despite worries and concerns, participants trusted their own abilities to handle unexpected events, resulting in the second theme, performing when it matters. The third theme, towards safe practice, captured suggestions for improvement and attitudes towards existing safety hazards.

Conclusions

To prevent and manage critical incidents during intrahospital transport, findings of this study suggest that nontechnical skills such as situational awareness and teamwork are essential. In addition, the team must possess the requisite technical skills and knowledge to undertake transports. Finally, organisations are required to provide a supportive and sustainable transport environment that includes fewer transport-related hazards.

Introduction

In recent years, patient safety has been recognised as a public health concern and a top priority in healthcare,1 including critical care.2 The environment of the intensive care unit (ICU) is complex and fast paced, thereby presenting several patient safety challenges. Moreover, critically ill patients may be more vulnerable to iatrogenic injuries because of the severity and instability of their illness, as well as frequent need of medications and other interventions.3 Intrahospital transport (IHT), when patients are transferred from one setting to another within the same hospital to undergo diagnostic and therapeutic procedures, is a complex, high-risk procedure for critically ill patients.4 Complications, mishaps, and adverse events, defined as injuries caused by healthcare management rather than by the patient's underlying disease,5 have been estimated to occur in up to 80% of all IHTs.[6], [7] However, little is known about how critical care nurses (CCNs) and physicians in the ICU manage critical incidents that might occur during IHT. In this study, the focus was on practices to prevent and manage critical incidents during IHT.

Internationally, CCNs constitute the basis of the IHT transport team.8 Together with physicians and other healthcare staff, nurses strive to deliver the same standard of care, including monitoring and interventions, that is available in the ICU.9 The primary responsibility of CCNs during IHTs is to constantly monitor the patient and prompt interventions9; thus, they are ideally positioned to identify, prevent, and correct hazards before harm is caused to the patient.10 However, to improve safety, healthcare delivery systems need to be designed to support the performance of healthcare professionals.11 Hence, collecting information about the performances of those working at the sharp end (i.e., close to patient care) will provide opportunities to redesign systems and may be one way to facilitate improvements in the IHT process. The aim of this study was therefore to explore CCNs' and physicians’ experiences and practices associated with critical incidents during the IHT process in critically ill patients.

Section snippets

Study design and setting

This research is based on a constructivist paradigm, acknowledging that knowledge is produced between individuals, and influenced by sociocultural contexts and structural conditions.12 As a part of a larger ethnographic study, in-depth qualitative interviews were conducted using the critical incident technique.13 The critical incident technique can be used to understand effective and ineffective performance, with the aim of providing solutions to practical problems.14 A critical incident is

Results

A total of 20 CCNs and physicians were interviewed (Table 1), who together described a total of 46 incidents. Each participant contributed between one and six critical incidents. Almost one in four of the critical incidents described was related to clinical deterioration of the transported patient (24%), followed by critical incidents related to miscommunication and/or problems with cooperation (17%), as well as smooth transport characterised by preparedness and good cooperation (17%) (Table 2).

Discussion

This study explored nurses' and physicians' experiences and practices associated with critical incidents that occur during the transport of critically ill patients within the hospital. Requirements for safe IHT were identified, including skills and actions important to the prevention and management of critical incidents. To the author's knowledge, the strategies used by nurses and physicians to maintain safety during IHTs have not been identified and described previously. However, complementary

Conclusions

The findings of the present study showed that a multifaceted approach is needed to perform IHTs safely. First, organisations need to provide a supportive and sustainable IHT environment, including adapted technology and equipment. Second, the transport team must possess the required technical skills and knowledge. Third, individual and collective nontechnical skills such as situational awareness and teamwork are essential to ensure that IHT safety hazards are anticipated and corrected before

Authors’ contributions

L.B. collected all data, analysed and interpreted the data, and drafted the manuscript. M.P., W.C., and M.R. contributed to conception and design of the study, data analysis and interpretation of results, and revision of the manuscript. E.C. contributed to conception and design of the study and revision of the manuscript. All authors read and approved the final manuscript.

Funding

L.B. received a PhD fellowship granted by the Institute of Health and Care Sciences, University of Gothenburg.

Acknowledgements

The authors would like to thank all healthcare professionals at the included ICUs for their participation, time, and support in this research. The authors also thank Edanz Group for editing a draft of this manuscript.

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