Safety Risks in Intrahospital Transport of Critically Ill Patients

Abstract: What factors contribute to adverse events during the intrahospital transport of critically ill patients?

The Intensive Care Unit (ICU) delivers concentrated care to critically ill patients, who often have unstable conditions, rapid clinical changes, and a high risk of adverse events. Up to 44% of these patients require transport to diagnostic departments, specialty wards, or operating rooms for targeted care¹. Sudden environmental changes, limited on-transport resources, and inadequate transfer equipment frequently lead to clinical deterioration or other adverse events.

Studies report that adverse events during intrahospital transport occur in 46.2% to 79.8% of cases². In 2015, The Joint Commission (TJC) identified patient transport as one of the top 10 patient safety concerns in the U.S.

Based on clinical research and detailed transport data⁴, adverse events are primarily driven by five factors:

1. Patient Clinical Instability

The leading cause of emergency responses during transport is cardiovascular deterioration (41%), primarily new arrhythmias (0.7%–2.4%) and cardiac arrest. Respiratory compromise accounts for 29% of incidents, including hypoxia (SpO₂ < 90% for more than 5 minutes) and airway obstruction. Other contributors include neurological changes (14%), altered mental status (9%), gastrointestinal disturbances, hyperglycemia, and hypoglycemia³.

During transport-related cardiac arrest, immediate activation of cardiopulmonary resuscitation (CPR) is mandatory. Rapid initiation of high-quality CPR, defibrillation, and advanced life support (ALS) is essential.

2. Catheter and Tubing Complications

Catheter dislodgment, obstruction, accidental removal, and IV line issues—including disconnection, occlusion, or kinking—occur in up to 46% of transports³.

Effective management includes:

· Pre-transport: Verify all lines and secure loose devices.

· During transport: Secure equipment to prevent traction; use restraints for agitated patients.

· Post-transport: Recheck all lines and document in the handoff report.

3. Inadequate Fluids or Medications

Infusion interruptions caused by insufficient fluids or delayed medication administration (including emergency drugs) contribute to adverse events, though with a lower incidence of **0.2%–3.9%**³.

4. Equipment Failure, Battery Depletion, or Insufficient Oxygen

Equipment-related issues account for 64.5% of transport adverse events³, including:

· Ventilators: Malfunction, dead battery, disconnected circuits, inadvertent power-off

· Monitors: Failure, low battery, ECG lead detachment, lost NIBP/SpO₂ signals

· Infusion pumps: Malfunction, battery depletion, alarm failure

· Oxygen supply: Low reserve, closed valve, detached tubing or mask

· Transport beds: Malfunction or unraised side rails leading to falls

Comprehensive equipment checks are crucial:

· Pre-transport: Test function and battery, log inspections, verify oxygen delivery

· During transport: Secure devices and continuously monitor function

· Post-transport: Label low-battery devices and assign maintenance responsibility

5. Organizational and Process Deficiencies

Common process-related issues include:

· Wrong patient identification

· Missing signed informed consent

· Missing belongings, records, or medications

· Transport delays, interruptions, or incorrect destination

· Refusal at receiving unit, long wait times, elevator delays

Pre-transport steps to prevent these errors:

· Confirm patient identity

· Explain purpose and obtain informed consent

· Communicate with receiving departments

· Coordinate dedicated routes and access

Patient safety during transport relies on thorough pre-transport assessment, careful preparation, continuous monitoring, timely interventions, and reliable equipment.

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References

1. Voigt LP, Pastores SM, Raoof ND, Thaler HT, Halper NA. Review of a large clinical series: intrahospital transport of critically ill patients: outcomes, timing, and patterns. J Intensive Care Med. 2009;24(2):108–115.

2. Quality, Safety and Standards of Critical Care Medicine [M]. Yunnan University Press; 2014.

3. Zhang WY, Xiao SM, Zhou RN, Peng YQ. Research progress on adverse events in intrahospital transport of critically ill patients. Chinese Journal of Nursing. 2019;36(1):51–54.

4. Ott LK, Hofman LA, Hrawak M. Intrahospital transport to radiology: adverse event risk, nursing surveillance, and practice implications. J Radiol Nurs. 2011;30(2):49–52.