Quality of transfers of critically ill patients within the hospital

Introduction

Transferring critically ill patients between clinical areas is recognised to be potentially hazardous [1] and associated with poor outcome [2]. This study addresses the standard of intrahospital transfer of sick patients within our Trust including monitoring, equipment availability, personnel and training.

Methods

We surveyed senior ward staff on how they would conduct the theoretical transfer of a deteriorating, hypoxic, shocked patient to the ITU. Monitoring and equipment deemed necessary and its perceived availability were recorded, as was transfer personnel. We then prospectively reviewed actual transfers of patients with Early Warning Scores (EWS) of 3 or greater.

Results

Theoretical transfer data were collected from 19 wards. Most (74%) requested oxygen saturation (SpO₂) monitoring, while less than one-third wanted either non-invasive blood pressure or ECG monitoring. Some wards expressed a need to borrow equipment, while others felt this would lead to delay. Three wards considered any monitoring unnecessary. Of 13 wards declining a defibrillator/cardiac monitor, two did so due to lack of familiarity. Prospective data were gathered from 32 transfers between September and November 2009. EWS ranged from 3 to 9. The actual transfer monitoring mirrored the initial survey, but for SpO₂ monitoring (44% vs 74%, respectively). A doctor was included by 10% for the theoretical transfer and in 16% of actual transfers. Less than one-half of actual transfers had a trained member of the transfer team. These patients were better monitored but the standard of transfers did not correspond to EWS. Patients with higher EWS were neither better monitored nor accompanied. Out of hours activity comprised 21% of actual transfers. The bulk of patients were from the admission units and the majority went to critical care or radiology.

Conclusions

There is considerable movement of sick patients around the hospital. Many transfers are performed by untrained staff, without adequate monitoring, and many are out of hours. There is poor understanding of risks of transfer and of appropriate monitoring. The data suggest that deficits are due partly to equipment unavailability - we are conducting a further audit to determine this. We propose additional investment and training and are compiling intrahospital transfer guidelines according to EWS.