Novel program underscores safety in moving patients
System cuts medical complication rates
Transporting patients from the ICU to another floor of the hospital for X-rays or diagnostic tests has always been a dangerous maneuver for patients, nurses say. Most RNs have serious reservations about seeing their patients leave the safety of the ICU.
In most cases, nurses have either chosen to go along with their patients or their unit’s policy requires them to do so.
In either case, the idea has never been well received by managers, says Harold E. Stearley, RN, CCRN, a former stat nurse in the critical care department at University Hospital and Clinics (UHC) in Columbia, MO.
National data show that in three out of four cases, transporting a patient out of the ICU leads to patient-related complications, including significant vital sign changes.
To address this problem, UHC nursing officials have resorted to a simple but novel idea for safely transporting critically ill patients throughout the institution.
The system, dubbed the Stat Nurse Program, allows a specially trained RN to accompany the patient to radiology or elsewhere in the hospital, and lets the patient’s primary nurse remain in the ICU caring for patients who remain behind.
| Criteria Used to Determine Patients' Change in Status During Intrahospital Transportation | |||
| Change in status* | |||
| Parameter | Minor | Moderate | Severe |
| Heart Rate | +10 bpm | +10-20 bpm | >+20 bpm |
| Blood Pressure | +10mm/Hg | +10-20 mm/Hg | >+20 mm/Hg |
Intracranial Pressure |
Changes greater than 7 mm/Hg in the absence of stimuli in which the pressure does not return to the baseline level are classified as severe. | ||
| Oxygen Saturation | Any decrease to less than 93% saturation is classified as severe. | ||
| *Determinations of each patient's status were based on the patient's baseline and overall clinical presentation. | |||
| Source: Data courtesy of University Hospital and Clinics, Columbia, MO. | |||
"The system," says Stearley, "benefits ICUs greatly where the patient-to-nurse ratio is greater than 2-to-1."
In the past, the bedside RN had to accompany the patient to X-ray, Stearley says. For a nurse to leave the ICU, even for an hour, meant placing the patients who were left behind in the hands of a floater or other staff nurse.
Often, those replacements, though only on duty temporarily, know relatively little about the patients in their care, Stearley says. Worse yet, many ICUs experience nurse shortages on several days and can’t afford to lose a staff nurse even for an hour.
"In the absence of a better system, most bedside RNs have been torn between the necessity of both going and staying," he says.
But by creating a specially trained transport team consisting of one RN, one or more orderlies, and a respiratory therapist, a patient can be moved throughout the facility and given any necessary care in route or at the new destination, Stearley says.
Any essential life-supporting equipment such as a portable ventilator, cardiac monitor, or IV devices can be sent along with the patient. Necessary medications can be taken along as well and administered by the nurse in the event the patient’s condition changes during the move, Stearley says.
"Essentially, you’re moving the whole ICU with the patient," he says.
To build a stat nurse program, provide for the following considerations:
• Staff training.
Key to the program is training the transport team, Stearley says.
The team has to be able to synchronize and perform the following routines quickly:
— Prepare the patient for transport via a specified route within the hospital (e.g., avoiding small or crowded elevators).
— Set up necessary ventilators, monitors, and catheters.
— Brief the stat RN on necessary medications and ordering those medications for the trip.
— Anticipate potential problems, such as arranging for traction for the patient at the destination. In those cases, a physician may have to be called.
"The transport procedure itself isn’t different from any other," says Laurel Despins, RN, CCRN, an advanced practice nurse at UHC. "But now there’s a trained team moving the patient, which makes a big difference."
• Hiring an extra nurse.
Your needs may vary, but be prepared to hire at least one transport nurse for the team. Hospital administration may balk or require that you assign an existing staff member for the job. You may have to defend the idea of hiring an additional FTE for the program, especially if your present staffing is running tight. "Defending the program won’t be difficult once you explain the cost vs. projected benefits on patient safety," Stearley says.
| Partial List of Medical Diagnoses, Procedures, or Interventions for Adult Patients Transported Within Hospital | |||
| Nonoperative | No. of patients | ||
| Cardiovascular or vascular | |||
| Cardiac arrest | 2 | ||
| Aortic aneurysm | 3 | ||
| Peripheral vascular disease | 37 | ||
| Acute myocardial infarction | 9 | ||
| Respiratory | |||
| Pulmonary edema (noncardiogenic) | 4 | ||
| Bacterial or viral pneumonia | 5 | ||
| Chronic obstructive pulmonary disease | 17 | ||
| Pulmonary embolism | 1 | ||
| Postoperative | |||
| Cardiovascular or vascular | |||
| Dissecting or ruptured aorta | 6 | ||
| Abdominal aneurysm repair | 5 | ||
| Peripheral artery bypass graft | 13 | ||
| Coronary artery bypass graft | 14 | ||
| Carotid endarterectomy | 4 | ||
| Respiratory | |||
| Lung neoplasm | 3 | ||
| Respiratory infection | 2 | ||
| Gastrointestinal | |||
| Gastrointestinal perforation or rupture | 2 | ||
| Gastrointestinal obstruction | 3 | ||
| Gastrointestinal bleeding | 5 | ||
| Cholecystitis | 4 | ||
| Total patients (some not listed) | 219 | ||
| Mechanical ventilation | 109 | ||
| Pulmonary artery catheter | 41 | ||
| Source: Data courtesy of University Hospital and Clinics, Columbia, MO. | |||
Study supports program benefits
• Needs evaluation.
Assess where and when demand for transporting patients becomes critical. Where does the system get into a crunch? How many patients are expected from the operating room and when? Is the number of staff nurses on duty capable of handling the increase census? Should you transport patients at that time to radiology?
The information can be gleaned from the daily OR patient logs and will be helpful in coordinating with other departments on scheduling X-rays or MRIs when the ICU is less chaotic, Stearley says. You don’t want to transport patients when you can’t adequately prepare the transport team.
• High-demand periods.
The evening shift will most likely be when you will need the system most. That’s when you may have the most flexibility in scheduling X-rays and some tests, so you will most likely have to hire the stat nurse for that nursing shift, Stearley says.
The UHC system isn’t new. It was implemented by the hospital in 1991 following a two-year pilot program. But Stearley says he is surprised by the number of hospitals that after nearly a decade still wrestle daily with safety concerns when transporting patients to other departments.
In 1998, Stearley published findings of a patient-outcome study of Stat Nurse Program.1
The research showed that the use of a specially trained ICU transport team "can substantially reduce the rate of adverse outcomes generated by the transportation of critically ill patients for specialized radiological procedures."
In the study, patients moved by the transport team had a 15.5% complication rate, and less than 1% — 0.8% — were in such difficult straits that the examination had to be aborted. (The charts on pp. 116-117 show other study findings.)
Complication rates nationwide, according to the study, ran as high as 75% with adverse events that included medication delays, significant vital-sign changes, and cardiopulmonary arrest.
At hospitals with small seven-to-10-bed ICUs, nurses may transport up to 15 or more patients per week. At larger facilities, the rate is much higher. UHC typically transports one to two patients per day, Despins reports.
The hospital, which actually is composed of two separate facilities, has nine ICUs of different sizes between the two physical plants.
Reference
1. Stearley HE. Patient outcomes: Intrahospital transportation and monitoring of critically ill patients by a specially trained ICU nursing staff. Am J Crit Care 1998; 7:282-287.
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