Intrahospital Transfers of Adult Patients Requiring Intensive Treatment

- Review Paper

1 Vesna Konjevoda

2 Leonarda Lončar

2 Daniela Raguž

1 Croatian Catholic University, Zagreb, Croatia

2 Clinical Hospital Sveti Duh, Zagreb, Croatia 

https://doi.org/10.24141/2/9/2/11

Author for correspondence:

Vesna Konjevoda

Croatian Catholic University, Zagreb, Croatia E-mail: vesna.konjevoda@unicath.hr

Keywords: patient safety, intrahospital transfer, intrahos- pital transfer protocol, nurses, adverse events

Abstract

Introduction. The unstructured course of intrahos- pital transfer affects the quality of healthcare. In ad- dition to various clinically unfavorable incidents that prolong hospital stays and indirectly affect positive treatment outcomes, intrahospital transfers lead to

much more complex consequences for the health- care system. Particularly vulnerable and sensitive patients are placed in Intensive Care Units. Nurses have a key role in safe intrahospital transfers.

Aim. This study, based on the available literature, aims to provide a deeper and more comprehensive insight into the incidence of adverse events caused by intrahospital transfer, identify risk factors, deter- mine the need for more extensive surveillance and propose possible solutions for preventing incidents caused by inadequate IHT and improving the quality of healthcare services.

Methods. Review. Search of scientific studies pub- lished from 2019 - 2024 in scientific databases Med- Line and Cochrane.

Results. Research was conducted on 24 studies re- lated to patients and intrahospital transfer. Of the to- tal 24 studies included, 17 focused on adult patients, while the remaining 7 examined healthcare profes- sionals, primarily nurses involved in intrahospital transfer.

Conclusion. Many studies have emphasized the high-quality assessment of the potential benefits of the transfer in comparison with the consequences of adverse events. Special attention has been paid to vitally endangered patients as the most sensi- tive group whose transfers require a multidiscipli- nary approach and a clearly structured course. The implementation of protocols and procedures reduces the incidence of adverse events and deterioration of the patient’s condition during intrahospital transfers. Further studies and meta-analyses are needed.

Introduction

Numerous studies of different approaches are being conducted to reduce adverse events during intrahospi- tal transfers (IHT). Such studies have been conducted since the 1970s and an increasing number of studies correlate the impact of mistakes in intrahospital trans- fers with a number of factors that contribute to worse clinical outcomes (1). In addition to various clinically unfavorable incidents that prolong hospital stays and indirectly affect positive treatment outcomes, intrahos- pital transfers lead to much more complex consequenc- es for the healthcare system. Besides the individual approach, the impact of complications and deviations from intrahospital transfer guidelines on the hospital as an organizational structure should also be consid- ered. A reliable course of treatment and movement of patients is of great importance for the hospital system. The unstructured course of intrahospital transfers af- fects the patient, but also the health care quality in a wider context (2, 3). Therapeutic and diagnostic pro- cedures, especially for patients who require intensive treatment, are necessary to provide patients with time- ly and appropriate care. Nurses and technicians who supervise the patient during such procedures must possess a wide range of knowledge and competencies to recognize any acute event and react in a timely man- ner with the aim of preventing adverse events or com- plications (4). The studies published so far talk discuss the key role of nurses in ensuring the patient’s safety during IHT (5). Since it is required to have a high level of knowledge and skills that health professionals must master, some studies also suggest the introduction of specialized teams for IHT (6). In order to find an ideal solution, studies have highlighted not only technical challenges but also a significant prevalence of errors stemming from poor judgment, delayed recognition of acute conditions, deviation from established protocols, and gaps in knowledge and skills (7).

Also, as a relatively common cause of adverse events for the patient, studies single out poor communica- tion among health personnel, which results in con- flicts and disobeying the hierarchical structure when making medical decisions (8). The number of intra- hospital transfers during a stay in a healthcare facil- ity is ultimately reflected in psychological alterations in patients, as well as in lower satisfaction with the healthcare services (9).

Aim

This study, based on the available literature, aims to provide a deeper and more comprehensive insight into the incidence of adverse events caused by intra- hospital transfer, identify risk factors, determine the need for more extensive surveillance and propose possible solutions for the purpose of preventing in- cidents caused by inadequate IHT and improving the quality of healthcare services.

Methods

Available studies published in the last 5 years, from 2019 - 2024, in scientific databases MedLine and Cochrane were searched.

The search keywords were patient safety, intrahospi- tal transfer, nurses.

The search resulted in 674 papers published in the last 5 years. Adding additional keywords such as ‘adverse events’ and ‘intrahospital transfer protocol’, and narrowing the search to a specific goal, resulted in 24 papers, which were then further examined and analyzed according to the stated inclusion criteria.

The basis of the search was to gain insight into the incidence of adverse events caused by intrahospital transfer, identify risk factors, determine the need for more extensive surveillance and propose possi- ble solutions for the purpose of preventing incidents caused by inadequate IHT and improving the quality of healthcare services.

Phase 1 consisted of defining the inclusion and ex- clusion criteria for this review paper.

Phase 2: Reviews of the above scientific databases using the initial keywords resulted in 674 identified studies. Further filtering regarding specific objec- tives and keywords resulted in 17 studies concern- ing adult patient population and 7 studies concern- ing healthcare professionals.

Phase 3: Thorough analysis and reading of studies. Phase 4: Writing the review paper

Exclusion and inclusion criteria

Results

A total of 17 studies for adults and 7 studies regard- ing healthcare professionals’ perspective were iden- tified and analyzed. The majority of studies were cross-sectional or retrospective. Research was con- ducted on a sample of 56,840 adult patients, one meta-analysis that includes 12,313 within hospital transports and 1,898 patients from 24 studies. A total of 7 of the 24 included studies refer to a sam- ple of 1,395 healthcare professionals, mostly nurses participating in IHT.

Discussion

This review aims to provide insight into the course of IHT, describe the incidence and nature of the most frequent adverse events, bring closer the importance of attention to vitally endangered pa- tients, and demonstrate the importance of integrat- ing protocols and communication structures. The analysis includes studies that, prompted by a large number of incidents, address the flow, the biggest problems, and available tools for improved IHT be- tween various wards. Based on the inclusion and exclusion criteria, the discussion includes 24 stud- ies describing IHT from different perspectives. The study provides an in-depth analysis of the signifi- cance of the structured course to IHT, highlighting its impact on both the patients and the hospital as an organizational structure. Special attention is paid to the most vulnerable groups of patients - unstable and vitally endangered patients. Also, these studies provided an insight into the most common reasons for transfers of such patients within the institution, as well as the most frequent adverse events that occur during such transfers. IHT play a critical role when it comes to improving safety and achieving the best treatment outcomes. Numerous studies have demonstrated progress in this area using vari- ous protocol and communication tools that contrib- ute to the structured course of IHT.

Identification of studies via databases

Studies identified from: MedLine (n=676) Cochrane (n=7)

Studies removed before

screening:

Duplicate records removed (n=2)

Records marked as ineligible by automation tools (n=0) Records removed for other reasons (n=7)

Studies screened (n=674)

Studies excluded** (n=558)

Studies sought for retrieval (n=116)

Studies not retrieved (n=1)

Studies assessed for eligibility (n=115)

Studies excluded: 91 Studies addressing

exclusively transfers outside the hospital (n=44) Methodologically incorrect and inconsistent research (n=20)

Studies addressing the evaluation of 'checklists' (n=24)

Studies regarding pediatric and neonatal care (n=3)

Studies included in review

(n=9)

Included

Screening

Identification

Figure 1. PRISMA flow diagram

Based on interviews of healthcare personnel and retro- grade analyzes of IHT, studies have agreed on relative- ly low rates of safety and a structured course of IHT. They show the incidence of adverse events, including significant declines in vital functions. Hospitals strive to be maximally safe institutions; therefore, they must recognize risks and adopt measures to avoid adverse events when providing health care (5, 10). Also, when identifying risk factors, it is important to take into ac- count the patient’s health condition as a predisposing factor. Although adverse events during IHT transfer do not affect the mortality rate, they slow down the course of treatment and prolong the stay in the institution, es- pecially when it comes to patients requiring intensive treatment (11). Their characteristics as such represent risks for adverse events during the transfer, and before considering the other numerous components of the quality and structured course of IHT, according to one study, the incidence of adverse events stagnates with- out significant deviations regardless of the specialized team. In vitally endangered patients, the emphasis in risk identification and prevention is placed on patient evaluation (12). Taking that into account, another study emphasizes that stabilization of the patients before IHT takes place may reduce incidence of adverse events

(13). Also, the training of health professionals plays a

key role if adverse events for the patient occur (14).

IHTs are mostly required for diagnostic purposes and minor procedures. As diagnostic techniques become in- creasingly advanced and include a series of procedures aimed at the best possible clinical assessment, the clini- cian and the multidisciplinary team must always care- fully weigh the benefits of the test compared to the possible complications of the transfer and the procedure itself (15). During IHT, significant hemodynamic thresh- olds can be crossed, leading to an increased risk of vital instability, a series of potential complications and pro- longed hospital stays (16). This is supported by studies that specifically assess neurocritical patients and speak in favor of the need for analysis and improvement of the IHT procedure (17). Studying the metabolism of the brain before and after such migrations, changes are not- ed that are not exclusively related to damaged brain ar- eas (18). In addition, any atypical transfer results in pro- longed treatment (3). The assessment of brain injury is of great importance for the therapeutic approach; there- fore, the implementation of portable diagnostic devices is an important factor in the prevention of complications that may occur during IHT. Research has shown that portable MRI in the assessment of ischemic brain inju-

ry in the ICU did not interfere with the workflow (19). Also, the same research is carried out when it comes to portable CT. Although achieving such conditions repre- sents a financial challenge, research indicates the same effectiveness of the test without interfering with the interventions in the ICU. MSCT, as a frequent and im- portant diagnostic test, in a portable form represents a significant reduction in the need for IHT during inten- sive treatment. Although the number of adverse events did not decrease significantly, the research showed the need for additional analyzes (20). Timely transfers be- tween intensive care units represent an important mo- ment in the course of treatment. A timely transfer be- tween two ICUs reduces the risk of in-hospital mortality by 55.6%, therefore special attention must be paid to ensuring the orderly transfer (21). Also, the analysis of atypical transfers and the network of movement within the hospital are of great importance for identifying risks and ensuring quality (2). In addition to life-threatening events during IHT, pressure ulcers and pressure injuries, falls and errors in treatment and documentation are cit- ed as the dominant incidents. In addition to preventing vital collapses, hospitals strive to maintain the highest possible quality of life, therefore such incidents are en- tirely preventable and should not occur (22).

Clinicians must harmonize and clearly emphasize mu- tual expectations when exchanging information taking different protocols into consideration (23). The integrity of the handover is significantly affected by time pres- sure, interruptions, and inappropriate surroundings (24). Also, using the example of nursing handovers in emer- gency medicine compared with intensive care, we can notice different expectations of the handover content. High quality handover is essential for avoiding adverse effects. According to this study, nurses from different specialties should agree on a structured handover. Al- though this study was conducted in tertiary academic hospital and the results cannot be generalised, it speaks in favor of necessary structure when it comes to final part of IHT: handover (25). Quality improvement initia- tives can affect the reduction of adverse events. Health- care workers’ satisfaction with IHT is related with imple- mentation of formal protocols for IHT and the handover structure. More importantly, better patient outcomes were noted when using formally adapted tools (26). It is recommended to use pre-transport checklists in order to minimize adverse events. Also, minor surgical proce- dures and better bedside diagnostics are highly recom- mended to consider in future (15). Before implementing the protocol, it is necessary to evaluate the one created

by the health professionals. According to one study, the IHT protocol for Swedish hospitals was created in this way (27). And the very integration of the checklist and protocol proved to be effective in reducing adverse events (28, 29). In order to ensure better management of transfer processes, a network analysis has proven effective. Prior to protocol development, this approach involves a detailed examination of patient movements within the institution. However, the study’s small and specific sample remains a notable limitation (30).

Conclusion

An analysis of available literature reveals that ad- verse events during IHTs are a widespread challenge faced by many healthcare institutions. Although such events do not directly affect mortality, they contrib- ute to worse clinical outcomes and longer treatment. They affect hospitals as organizational structures and reduce the quality of healthcare. Research indi- cates the need for extensive analyzes on larger sam- ples. Regardless of the absence of a universally ap- plicable protocol, individual analyzes and guidelines have proved effective. Numerous studies have em- phasized the importance of thoroughly assessing the potential benefits of the transfer against the risks of adverse events. Special attention has been paid to vitally endangered patients as the most sensitive group whose transfers require a multidisciplinary ap- proach and a clearly structured course. Communica- tion and coordination of all team members, as well as the availability of the necessary resources proved to be vital in ensuring the safety of all patients during intrahospital transfers.

Author contributions

Author contributions: Conceptualization (KV, LL); Da- ta Curation (VK, RD); Data Analysis (KV, LL, RD); Writ- ing – Original Draft (KV, LL). All authors contributed to revising and editing the final manuscript

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial rela- tionships that could be construed as a potential con- flict of interest.

Acknowledgments

Not applicable.

Funding

The authors declare that no financial support was received for the research, authorship and/or publica- tion of this article

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