Error Traps in the Intrahospital Transport of Critically Ill and Anesthetized Children

ABSTRACT

Intrahospital transport of anesthetized and critically ill children is a routine event that carries myriad risks. Patients with a vast array of conditions are transported between the intensive care unit, procedural and diagnostic imaging suites, emergency department, and other areas. Given this complexity, the range of potential adverse events is large. Improving safety during transport will require a broad and holistic approach. This review will inform pediatric anesthesiologists on the best approach to improve their care and patient safety during transport by identifying common error traps, with both individual‐ and system‐level countermeasures. The error traps include the failure to fully weigh all risks, costs, and benefits associated with transport for a procedure or test; secure appropriate resources for transport and at every destination; provide pertinent information during transfers of care; anticipate physical and physiological changes associated with transport; and execute the plan effectively as a team. Countermeasures include multidisciplinary discussion and resource optimization; use of systematic tools, standardized communication, and checklists to improve processes of care; encouraging the prioritization of a culture of safety around transport; and adapting the team composition and leadership style to suit the specific clinical scenario.

1. Introduction

Intrahospital transport is required for critically ill and anesthetized children to allow for invasive procedures, diagnostic testing, or transfer within the hospital. It is also undertaken to combine multiple procedures in different locations under a single anesthesia episode [1]. Transport has been described as inherently hazardous, unsafe, and demanding [2], with myriad risks [3]. Five percent of all pediatric anesthesia adverse events are associated with transport or patient repositioning, and it remains an understudied area [1]. Cardiac arrest and serious harm have resulted from routine events such as administering sedatives or neuromuscular blocking agents to an already‐intubated sedated patient or transitioning to a portable ventilator [1]. Most transport‐associated events during anesthesia care are preventable and are related to anesthesia care [1]. They occur at a disproportionately high rate in children with increasing comorbidity burden and younger age [1], consistent with all pediatric anesthesia adverse events [4, 5]. Numerous, wide‐ranging recommendations to prevent adverse events have previously been summarized [3], but many of these address only a single potential adverse event or issue. Given the wide range of preventable adverse events, a review of the broad categories of common error traps is warranted. Clinicians should recognize transport as a distinct phase of care with unique risks. This creates an opportunity to build expertise in risk assessment, transport care plan development, and execution using established techniques in clinical skill‐building [6]. For simplicity, this review will focus on patients in the intensive care unit (ICU) who require transport for procedures or diagnostic imaging. A summary of these error traps is provided in Figure 1.

FIGURE 1.

Summary of error traps.

2. Error Trap #1: Failure to Fully Weigh All Risks, Costs, and Benefits Associated With Transport for a Procedure or Test

Risk estimation of adverse events during transport is an essential first step and is best performed by the anesthesiologist in concert with the intensivist. Risk can be estimated by the degree and nature of physiological support as well as the number of nursing and physician bedside interventions required. These can include as‐needed sedative boluses, fluid boluses or blood product resuscitation, frequent adjustments of vasoactive infusions, endotracheal tube suctioning or manual re‐recruitment, frequent arterial blood gas sampling, extracorporeal membrane oxygenation (ECMO) or ventricular assist device (VAD) parameter adjustments, and/or ventriculostomy drainage. As a majority of transport‐associated events are respiratory in nature, increasing degrees of pre‐existing patient respiratory issues should alert clinicians to increasing risk. Intubated patients on high‐frequency ventilation or those with high ventilator settings are at risk of pulmonary derecruitment from even brief interruptions in their support. Transitioning to portable ventilators invariably causes some interruption, directly resulting in worsened patient respiratory function [7]. Patients on noninvasive ventilatory (NIV) require careful multidisciplinary assessment of the feasibility of maintaining NIV support during transport and the associated procedure [8]. If intubation will ultimately be required, identification of the optimal timing and location should be carefully considered. For example, induction of anesthesia and intubation in the intensive care unit may be preferable if NIV cannot be adequately maintained during transport. In patients with an anticipated difficult airway on inadequate NIV, a multidisciplinary discussion should occur to identify the safest location for intubation. In unintubated patients who require intubation for a surgical or diagnostic procedure, the multidisciplinary team should also discuss the most appropriate timing for extubation postprocedure, which is often in the ICU so that NIV can be immediately reinitiated.

Multidisciplinary discussion is a necessity before any high‐risk patient transport. Modern health care is complex and necessarily multidisciplinary [9]. Integration of the perspectives and priorities of care team members from varying medical specialties is needed to fully grasp the total risks, benefits, and costs of a procedure and associated intrahospital transport. This group must also consider alternative procedures that can be performed at the bedside. For any child receiving significant physiological support, a multidisciplinary discussion should therefore be held. This discussion should include the following: the surgeon or consulting physician recommending the procedure; the intensivist caring for this patient; the bedside nurse; the anesthesiologist who will care for this patient during the intrahospital transport and associated procedure; and any relevant consultants for comorbidities deemed to be high risk by the intensivist or anesthesiologist. The intensivist and bedside nurses' perspectives are especially important, as their immediate knowledge of the patient will reveal risks that can be subtle and idiosyncratic. If multiple procedures involving multiple anesthetizing locations are planned, the team should also weigh whether a simplified plan with fewer locations is more appropriate. It is appropriate to obtain informed consent after this discussion is complete. Afterwards, a standardized handoff should occur, ideally between the attending intensivist, attending anesthesiologist, any additional anesthesia providers, and the bedside nurse caring for the patient.

Consider two hypothetical patients. First, a critically ill child is failing conventional ventilation, and consultants recommended a CT scan of the chest. This patient requires high positive end‐expiratory pressure (PEEP), frequent endotracheal tube suction, and manual lung recruitment, but these interventions are not obvious in the electronic clinical documentation. As described previously, the transition to a portable ventilator may result in significant respiratory decompensation, and therefore, a portable CT scan may be more appropriate. In contrast, consider a moribund child on ECMO for cardiorespiratory failure who requires continual blood product administration due to bleeding. A consultant recommends cardiac catheterization. Though the risk is significant, this procedure and transport are worthwhile as they may be necessary for survival, and there are no equivalent bedside alternatives. In addition to considering the risks and benefits, the team must also consider the costs. This patient will require significant resources and extra personnel for safe transport, which may divert needed resources away from other patients [2]. The multidisciplinary discussion for this patient should optimize procedural timing, typically during normal business hours, to minimize the systems cost, consistent with the Safety‐3 Framework, which is intended to enhance safety for all patients in the system [10].

Transport can involve physical movement resulting in discomfort and alterations in venous return and other hemodynamic changes resulting in instability. Patient intolerance of these expected alterations relates to the presence of high‐risk conditions such as pulmonary hypertension or elevated intracranial pressure (ICP) and their pre‐existing degree of hemodynamic instability and frequency of bedside interventions. Patients at highest risk require careful preparation and handling prior to physical movement or discomfort, and some movements may be contraindicated. For example, at the conclusion of a Norwood Stage 1 operation, an OR nurse lifted the unstable neonatal patient's legs high above the head to facilitate the removal of an electrosurgery discharge pad. The patient suffered immediate cardiac arrest, ECMO cannulation, and ultimately death, though this is only partially attributable to the position change.

Most transport‐associated events occur during postprocedure transport [1]. At the conclusion of the procedure, if the patient's physiologic support requirements have increased significantly, the transport team should consider intensivist or consultant assistance with patient optimization prior to transport back to the ICU.

3. Error Trap #2: Failure to Secure Appropriate Resources for Transport and at Every Destination

Intrahospital transport of critically ill and anesthetized children requires maintenance of ongoing therapies and continuous monitoring, all while physically moving the patient. It is essential to determine the optimal personnel for transport and to secure appropriate equipment and supplies, as well as prepare the destination(s) prior to initiating care of the patient. Guidelines and standardization of personnel and equipment reduce planning workload and improve processes of care. Mnemonics and checklists can also be helpful [11, 12, 13]. Several examples can be found in the references [12, 13, 14]. Preparation for transport also includes preparing the patient, often by simplifying infusions and clustering care immediately prior to transport. The choice to simplify infusions should be individualized. The benefits should be weighed against the risk of creating pharmaceutical waste and the need to disconnect and reconnect infusions to the central venous catheters with resulting risk of catheter‐associated infections.

3.1. Personnel

The care team must include personnel who are adequately trained to manage all required equipment. For example, patients with VAD, on ECMO, high‐frequency ventilation, or with external ventricular drains [15] must have staff trained and able to operate that equipment during their time away from the intensive care unit. Patients may require changes in VAD, ventilatory, ECMO, or ventricular drain parameters as a necessary consequence of receiving anesthetics or undergoing surgical procedures. While the attending anesthesiologist leading the transport team may be comfortable operating these devices, this is not advisable during the transport of high‐risk patients. The anesthesiologist should be free to manage the team and direct overall care, akin to a resuscitation (code) team leader. Thus, for example, if the anesthesiologist is the only transport team member comfortable operating the portable ventilator, then another team member should be added to operate that ventilator, such as a respiratory therapist or member of the ICU team.

The transport team leader should count all tasks required during transport and have an appropriately skilled team member dedicated to each one. These can include pushing the bed and/or IV pole; operating a portable ventilator or manually ventilating; monitoring the patient; providing ongoing resuscitation including fluid, blood products, and/or medications; operating and adjusting infusion pumps and other equipment; clearing the path and obtaining an elevator (if needed); and directing overall care. It is essential to utilize anesthesia technicians and similar staff to perform simpler tasks, such as pushing the bed, to ensure that physician and nursing staff can focus on higher order tasks.

3.2. Medications, Supplies, Monitors, and Equipment

Standardization of emergency equipment and supplies will help ensure adequate equipment always accompanies the patient. Use of checklists [14] and premade kits reduces labor and product waste. Patients should be monitored continuously using American Society of Anesthesiologists standard monitors, including portable capnography for patients at risk for cardiac or respiratory decompensation during transport. Medications that should be brought along may include sedatives, neuromuscular blockers, vasopressors, anticholinergics, and hypertonic saline, depending on specific anticipated patient needs. Supplies may include a self‐inflating resuscitation bag, free‐flowing intravenous lines, crystalloid solution, blood products, and airway management equipment. Patients with existing tracheostomies require special attention to ensure appropriate supplies are always present. These include replacement tracheostomy tubes of varying sizes, suction catheters with appropriate depth markings, a self‐inflating resuscitation bag and Mapleson circuit, an oxygen cylinder, and a suction device. Patients with anticipated difficult airway management may require a supraglottic airway device to accompany them. Device dislodgement is a common adverse event, and care should be taken with the intravenous pole and all lines and tubes. Careful route planning, obtaining an elevator key (if needed) and hallway preparation, should be undertaken in advance of transport.

4. Error Trap #3: Failure to Provide Pertinent Information During Transfers of Care

Intrahospital transport often involves handovers between units, and occasionally between multiple units, such as a transport from the emergency department to the operating room to radiology and then to the ICU. Information loss during these handovers have resulted in double or missed doses of antibiotics and antiepileptic drugs and loss of critical information regarding patient status, resulting in serious errors and potential harm [1]. Structured handovers have been demonstrated to reduce information loss, improve provider satisfaction, and reduce costs without increasing handover time [11]. They have been associated with improved patient outcomes after cardiac surgery [16]. When possible, these tools should include prompts to help communicate clinician priorities and areas of concern for the patient. Our pediatric cardiothoracic ICU utilizes a structured handover between the ICU attending and the anesthesiologist, where the intensivist is asked to provide the “most likely mode of decompensation.” Figure 2 presents an example of a pre‐procedure clinician‐to‐clinician handover, while Figure 3 presents an example of a post‐procedure anesthesiology team to ICU team handover.

FIGURE 2.

Sample preoperative handoff tool.

FIGURE 3.

Sample postprocedure handoff tool.

5. Error Trap #4: Failure to Anticipate Physical and Physiological Changes Associated With Transport

Three important categories of changes occur when critically ill patients are transported for anesthesia care: changes in equipment, changes in patient position, and the physiological effects of medications administered to facilitate transport.

Changes in equipment are typically required for patients on conventional mechanical ventilation. Maintaining patients on their existing ICU ventilator is often best. However, these patients are often transitioned to portable units for transport and then possibly to anesthesia ventilators at the destination. There are important differences in the design and function of these units, which include the position of flow meters, circuit compliance, apparatus dead space, and the availability of heat and humidification within the circuit. ETCO2 sampling during transport may require the addition of a small circuit extension, increasing dead space [17]. In combination, these can have a cumulatively large effect on small infants with poor lung compliance and will be poorly tolerated by those with pre‐existing acidosis, increased ICP, or pulmonary hypertension. Anesthesiologists should be aware of these changes, ensure patient stability prior to transport, and adjust ventilator settings accordingly, correlating new settings with arterial blood gases when possible. The endotracheal tube should be suctioned prior to transport. Special attention must be paid to clamps on infusion lines, especially in infusions running slowly, most commonly in infants. Inadvertent clamping and accidental boluses from unclamping have resulted in serious adverse events [1]. Patients with VADs and on ECMO will require continued support using the same apparatus, with appropriate backup equipment. Patients on continuous renal replacement therapy typically require its interruption during transport.

Changes in position are common to facilitate surgical procedures or diagnostic imaging. Flexion or extension of the neck can result in malposition of the endotracheal tube, unplanned extubation, or endotracheal tube kinking. It is incumbent on anesthesiologists to confirm the position of all lines and tubes on recent radiographs or using point‐of‐care ultrasound, when indicated. Stabilizing the head and neck with a pillow and slight neck flexion will help prevent unplanned extubation in infants. If neck extension will be required, repositioning of the endotracheal tube may be necessary. Physical movement of the patient has resulted in dislodgement of critical airway and vascular access devices, as well as inadvertent kinking and disconnection.

Physical movement of an intubated patient and asynchronous manual ventilation can be uncomfortable. Sedatives and neuromuscular blocking agents are often given in preparation for transport, but their expected physiologic effects can be deleterious in critically ill infants. For example, leaks around uncuffed endotracheal tubes may be well‐tolerated in patients whose ventilation is assisted by ICU ventilators. Temporary ablation of the patient's ability to trigger ventilation may result in catastrophic leak and an inability to ventilate. CO₂ production can be reduced by those same agents, and inadvertent hypocapnia can ensue. Children who received sedative or neuromuscular blocking agents in preparation for transport have had sudden worsening of mucous plugging, of unclear etiology. This has resulted in cardiac arrest [1]. When medications are administered, clinicians should wait until they observe their expected effect. When transporting anesthetized patients back to the ICU, there may be unplanned emergence from anesthesia, with deleterious effects especially in patients with pulmonary hypertension or elevated ICP. Residual neuromuscular blockade is an additional risk.

There are also expected physiologic changes that occur independent of our medication effects. The effects of physical movements were previously discussed. Exposure to cold environments can result in severe hypothermia in neonates [18], while elimination of the ventilator circuit humidifier may increase IV fluid requirement.

6. Error Trap #5: Failure to Execute the Plan Effectively as a Team

Critically ill and anesthetized children undergoing intrahospital transport can have enormous inter‐individual variability in their disease and ongoing physiological support. A majority of transport‐associated adverse events are preventable [1], indicating a need for improved individual and team performance. There is a paucity of data on effective leadership and team training in pediatric intrahospital transport. Literature from analogous situations may be valuable, including trauma and resuscitation teams.

A review of leadership and teamwork in trauma and resuscitation teams by Ford et al. [19] demonstrated the complex interplay between leadership style, patient disease, and team composition. There is an inherent tension between the need for swift action in critically ill patients and the time required to discuss specific findings, likely etiologies, and indicated therapies. In situations where the team is inexperienced or patient disease and instability are high, Directive Leadership was shown to be most effective in one included study. Directive Leadership is akin to a military chain of command, where explicit instructions are given to subordinates from an authoritative leader. In situations where the team is more experienced, Empowering Leadership is more appropriate. With Empowering Leadership, the leader delegates responsibility to team members, allowing them to make and implement decisions. Empowering Leaders focus on communication and coordination [19]. This is especially important when the individual patient care tasks are complex. As experienced team members perform required tasks and communicate them to the team, other team members can adjust appropriately without requiring the Empowering Leader's prior approval. This reduces delay and improves overall team performance. In the previous example of a child on ECMO requiring ongoing resuscitation, an experienced team with Empowering Leader(s) would be appropriate. In this scenario, as transport team members resuscitate this patient with blood products, the ECMO specialists adjust ECMO flows appropriately to maintain normotension. This interaction would be monitored by the Empowering Leader(s) as they monitor and direct all tasks related to patient care and transport.

Some transport teams may require multiple simultaneous co‐leaders, similar to the trauma team model. In that model, patients are simultaneously comanaged by emergency medicine and trauma surgery. Each leader manages their specific domains independently, with ongoing communication between them [19]. This may be required during anesthesia transport for moribund trauma patients en route to the operating room, or for patients who require ongoing active care during transport that is beyond the scope of the anesthesiologist's practice.

Having a positive institutional and team safety climate and culture surrounding transport is essential. It was linked to lower adverse events in a multicenter study of adult intrahospital transport, with an apparently larger effect on event rate than patient disease or transport duration [20]. Team processes and training have an additional benefit in reducing adverse events but have a smaller impact than safety culture [19]. Individual and team training specific to transport in anesthesia is an understudied area. In the trauma literature, leadership training has been associated with improved processes of care and better task‐performance scores for chest compressions and manual ventilation [19].

7. Conclusions

Intrahospital transport of anesthetized and critically ill children should be considered a distinct phase of care with myriad risks. Improving the safety of patients during this period should include multidisciplinary discussion and resource optimization; use of systematic tools, standardized communication, and checklists to improve processes of care; encouraging the prioritization of a culture of safety around transport; and adapting the team composition and leadership style to suit the specific clinical scenario.

Ethics Statement

The author has nothing to report.

Consent

The author has nothing to report.

Conflicts of Interest

The author declares no conflicts of interest.

Data Availability Statement

The author has nothing to report.