The Case

A 47-year-old woman with history of primary pulmonary arterial hypertension (PAH) was admitted to the hospital for sepsis secondary to an infected intravenous (IV) line through which she was receiving IV treprostinil, a potent pulmonary vasodilator used for. Given its potential toxicity, it is categorized as a "high alert" medication. The patient's home pump was switched to another line that had been inserted in the intensive care unit (ICU). The bedside nurse received education about treprostinil, with special instructions not to flush the line as this would lead to a very large and dangerous dose. The ICU nurses were very familiar with using treprostinil in patients with pulmonary hypertension.

After the patient's infection improved and blood cultures cleared, the decision was made to have the interventional radiologistsplace a new permanent catheter. She was transferred to interventional radiology (IR) with a full treprostinil supply, and the sign-off between the ICU charge nurse and the IR department included instructions to not flush the treprostinil line.

During preparation in the IR suite for the new line placement, one of the infusion pumps started alarming. However, the charge nurse was outside the suite at that time. A radiology technician in the room attempted to identify the alarm, and in the process accidentally flushed the treprostinil line. Consequently, the patient received an excessive amount of the medication, which resulted in a near code situation. The patient experienced flash pulmonary edema and respiratory distress, which required emergent intubation.

The charge nurse entered the room while the patient was being resuscitated, recognized the error, and stopped the medication. Once the patient was stabilized, a pharmacist was consulted, and the patient was restarted on a lower dose of treprostinil to allow for elimination of the excess medication. She was extubated and eventually discharged home after a prolonged ICU stay.

After this incident, inservice training was given to all individuals involved in the use of this high-alert medication, including medical, pharmacy, and nursing staff. In addition, a new protocol was established that requires the charge nurse to escort patients during all transfers from the ICU.

The Commentary

by Nancy Staggers, PhD, RN

Intrahospital transfers occur frequently in acute care settings. In addition, transfers due to diagnostic necessity are nearly inevitable during the first 24 hours of admission to an intensive care unit (ICU).(1) The frequency of intrahospital transfers, especially to radiology, may create complacency regarding the high risk for adverse events. Risk during intrahospital transfers has been evaluated since the 1970s (2) with reported complication rates as high as 70% in the past.(3) Today, despite the creation and implementation of practice recommendations for safe intrahospital transfers, adverse events remain common.(4) For example, nearly half of ventilated critical care patients experience adverse events during transfers, with 15%–20% of the events considered serious.(5) Of 254 critical care patients transferred for diagnostic purposes, 64 patients (25%) experienced 139 unexpected events.(6)

The primary reasons for these adverse events include equipment problems (e.g., battery power or transport monitor function), which account for 39% of events, and staff/management issues (e.g., such as poor communication or incorrect positioning of patients), which account for 61% of events.(7) Adverse effects range from pulmonary events (e.g., pneumothorax or airway displacement), hemodynamic disturbances (including cardiac arrest), nosocomial infections, and injury exacerbations (especially for patients with neurological or orthopedic conditions).(8) Medication-related events, such as that described in this case, have not historically been identified as a significant risks in these transfers.

The need for a transport team and time nurses must spend away from other activities to oversee care makes intrahospital transfers extremely resource-intensive. A 2017 retrospective analysis of 34,715 transfers found that transfers consumed an average of 42 minutes of staff time per transfer, and 11.3 full-time equivalents in nursing time over the course of a year.(9)

Most adverse events during transfers are multifactorial (7), as in the case presented. On the surface, this case seems to be about a medication error. However, the medication issue could be a proxy for any number of patient safety issues that can arise during transport. This case thus highlights the need for improvement in at least three domains: interdisciplinary communication, procedures for intrahospital transfers, and support from health information technology (IT).

Interdisciplinary Communication

Interdisciplinary communication has received much attention in the last decade. For high-risk handoffs, tools (including I-PASS) are available to help structure clinical information during handoffs.(10,11) However, research to date has primarily concentrated on intradisciplinary sign-offs among physicians, shift report among nurses, and interdisciplinary communication among primary clinical team members. Interdisciplinary communication protocols seldom consider the need for transmitting clinical information to ancillary departments, such as radiology, despite the fact that such departments also require robust clinical handoffs that include patient safety information. For example, interdisciplinary communication to radiology might include critical medication issues, warnings about patient positioning, and required infection control measures. The current case highlights the importance of interdisciplinary communication during transfers. While the ICU nursing staff was very familiar with treprostinil's safety parameters, the radiology technician did not receive sufficient communication regarding safe management of the treprostinil infusion pump.

Standardizing Procedures for Intrahospital Transfers

Guidelines and toolkits for intrahospital transfers exist (12,13) but require tailoring and translation for specific settings.(4,14) As standardized procedures are developed or refined, clinicians may find it helpful to analyze internal transfer incidents to create site-specific improvements. Each hospital should have a formal intrahospital transfer plan (15) for each phase of a transfer: pretransfer, during transfer, and posttransfer.(4)

Pretransfer preparation should include an assessment of the risk–benefit for the proposed transfer. The clinical team, particularly the physician, should evaluate the patient's condition and the availability of alternative diagnostics.(8,14) Such alternatives have become more viable with the growing availability of modern portable and mobile health equipment. Pretransfer activities should also include both the transfer coordination and the testing and use of transport equipment by trained and qualified personnel.(15) This phase should anticipate untoward events in the assembly of needed equipment and medications.

Patient monitoring needs should also be assessed. A standardized procedure would specify which personnel are responsible, whether it is an interdisciplinary team or specially trained individual staff members.(16) Formal procedures would also indicate qualifications and required training for the transport personnel. Last, standard documentation elements can be specified as part of the posttransfer procedure, and creating a standardized procedure that includes management of high-risk medications during intrahospital transfer can reduce the number of adverse drug events such as the one presented in this case.

Enhance the Role of Health IT in Intrahospital Transfers

Current recommendations on intrahospital transfers concentrate on manual procedures and patient risk identification. Recommendations do not yet outline the role of health IT. However, interdisciplinary communication and standardized procedures may be supported by a site's electronic health record (EHR). Advanced EHRs can support the transfer process by providing specific templates that pull in key interdisciplinary information from the medical record and make it available to all departments, including radiology. Moreover, current technology allows smart IV pumps to be interoperable with the EHR, but improvements are needed to display patient safety information about specific medications or conditions. Relevant to this case, such information might include warnings on the pump display and in the EHR about not flushing the IV line for patients on powerful vasodilators.

Take-Home Points

• Intrahospital transfers have inherent risks, especially for critical care patients.
• Interdisciplinary communication should be expanded to include critical patient safety information. Intrahospital transfers to radiology should be treated as a formal handoff, with a summary of clinical and medication information as well as the typical diagnostic requirements.
• Every hospital should have standardized procedures for intrahospital transfers, especially for critical care patients, that outline three phases: pretransfer coordination and communication, monitoring and requirements during the transfer, and posttransfer evaluation and activities.
• Health information technology should be enhanced so that it supports communication about patient safety information during intrahospital transfers.

Nancy Staggers, PhD, RN President, Summit Health Informatics Adjunct Professor, University of Utah

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