Development and Validation of a Standardized Intrahospital Patient Transfer Checklist for Intensive Care Unit Nurses: A Methodological Study

Abstract

Background

Intrahospital transport of critically ill patients is high risk. This study aimed to develop and validate a standardized transport checklist for intensive care unit (ICU) nurses in a tertiary care hospital.

Methods

A four-phase methodological design was used: Phase I (item pooling), phase II (modified Delphi validation with 17 experts), phase III (reliability testing via 40 observed transfers), and phase IV (usability testing with 10 nurses).

Results

The final 42-item checklist covered pre-, intra-, and post-transport phases. Content validity [Scale Content Validity Index/Universal Agreement (S-CVI)/UA] reached 1.0. Inter-rater reliability showed substantial agreement (Cohen's κ = 0.75). All nurses reported positive perceptions regarding the clarity and usability of the checklist among ICU nurses.

Conclusion

The checklist is a valid, reliable, and feasible tool with high perceived usability among ICU nurses.

Highlights

A 42-item intrahospital transport checklist was developed using a modified Delphi technique. The tool demonstrated excellent content validity and substantial inter-rater reliability. Intensive care unit (ICU) nurses reported high usability and feasibility in clinical settings.

Introduction

Intrahospital transport of critically ill patients is a necessary but high-risk event, often termed a “vulnerable phase” in patient care.^1,2 Despite being moved within the same facility, these patients are susceptible to a wide range of life-threatening complications, including cardiac arrest, hypoxia, and accidental extubation.³ Research indicates that transport-related incidents increase patient mortality, morbidity, and the overall cost of health care.^3,4

Nurses play a frontline role in mitigating these risks.⁵ The critical condition of ICU patients requires advanced equipment and continuous physiological monitoring during any movement. Professional bodies, such as the Indian Society of Critical Care Medicine (ISCCM), have established transportation safety guidelines to standardize this process.² However, global evidence suggests that without a structured tool, compliance with these safety protocols remains inconsistently applied.^5,6

In many clinical settings, including the tertiary care hospital where this study was conducted, there is a lack of formalized documentation and practical checklists for intrahospital transfers.¹ Clinical observations revealed that while transport is planned, it often lacks structured personnel roles, equipment rechecks, and adequate documentation of care. This gap in clinical practice can lead to “critical incidents” evolving from simple errors, such as oxygen supply failure or inotrope disconnection, into complex medical emergencies.⁷

Despite established safety guidelines, the lack of a structured, evidence-based tool for intrahospital transport in many critical care settings represents a significant gap in clinical practice. This methodological study aimed to develop and validate a standardized intrahospital patient transfer checklist for ICU nurses using a structured methodological approach.

Methods

A methodological research design with a quantitative approach was adopted to develop and validate an intrahospital patient transfer checklist.⁸ The study was conducted at Dayanand Medical College and Hospital, a tertiary care hospital in Ludhiana, Punjab, India. Ethical clearance was obtained from the Institutional Ethics Committee (IEC) (Ref no.: DMCH/R&D/2021/39).

The initial phase involved an extensive literature review and analysis of existing guidelines from the ISCCM and the Society of Critical Care Medicine (SCCM).^1,2 A total of 47 items were initially identified. These items were grouped into three domains based on clinical workflow: Pre-, intra-, and post-transport phases. Overlapping or redundant items were reviewed by the research team and merged or refined to ensure clarity and avoid duplication before proceeding to content validation.

The draft tool was subjected to content validation using a modified Delphi technique.⁸ A total of 17 experts from critical care medicine, nursing, and related specialties were purposively selected based on their clinical experience (≥5 years) and expertise in ICU care. A core research team coordinated the Delphi process, including the distribution of questionnaires, collection of responses, and analysis of feedback. Experts were asked to rate each checklist item for relevance using a 4-point Likert scale. Seventeen experts were invited to participate, of whom 15 responded in both Delphi rounds, yielding a response rate of 88.2% for each round. The content validity ratio (CVR) was calculated for each item using Lawshe's method, with a minimum acceptable CVR value of 0.51 for 17 experts. Items not meeting this threshold were removed or modified based on expert feedback. The Scale Content Validity Index/Universal Agreement (S-CVI/UA) was calculated to assess overall content validity. Details of the Delphi questionnaires and item modifications have been provided as supplementary material.

Two trained ICU nurses independently observed 40 intrahospital transfers using the checklist. Inter-rater reliability was assessed using Cohen's κ.¹ The checklist demonstrated substantial agreement (κ = 0.75), with overall agreement of 90%.

The final draft of the checklist was tested for practical application by 10 staff nurses working in the ICU. Usability was measured using a structured 15-item feedback questionnaire (Likert scale) covering aspects such as clarity, time consumption, and perceived impact on patient safety. Summary statistics (percentage agreement across domains) were calculated to describe usability responses.

The sample size for reliability testing (n = 40 transfers) and usability assessment (n = 10 nurses) was based on feasibility and is consistent with similar methodological validation studies.

The study methodology was aligned with consensus-based standards for the selection of health measurement instruments (COSMIN) recommendations for tool validation.

Results

The initial item pool of 47 items was refined through two Delphi rounds. In round 1, items were evaluated for relevance and clarity. After applying Lawshe's criteria, items with a CVR < 0.51 were revised or removed. By the end of round 2, the S-CVI/UA reached 1.0, indicating 100% agreement among the 17 experts on the final 42 items included in the checklist. These statistical indices are presented in Tables 1 and 2.

Table 1.

Professional profile of the validation experts (N = 17)

Variable	Categories	n
Designation	Nursing experts	12
	Medical intensivists	5
Educational status	Postgraduate (MSc/MD)	16
	PhD	1
Experience (years)	Mean ± SD	17.58 ± 9.01
Area of work	ICU/critical care	17

ICU, intensive care unit; SD, standard deviation

Table 2.

Content validity and reliability summary

Checklist phase	No. of items	S-CVI/UA	Cohen's κ	Agreement (%)
Pre-transport	17	1.0	0.75	90
During transport	11	1.0	0.75	90
Post-transport	14	1.0	0.75	90
Overall tool	42	1.0	0.75	90

κ, Cohen's κ coefficient; S-CVI/UA, Scale Content Validity Index/Universal Agreement; Agreement (%) represents the overall percentage agreement between observers

The inter-rater reliability was assessed by two observers monitoring 40 patient transfers. The statistical analysis yielded a Cohen's κ coefficient of 0.75 with overall agreement of 90%. According to standard interpretation scales, this represents a “very good” to “excellent” strength of agreement, confirming the tool's stability across different users.^9,10 The comparative reliability scores are highlighted in Table 2.

The feedback from 10 staff nurses regarding the clinical application of the checklist was overwhelmingly positive. Their feedback regarding the checklist's clarity, safety impact, and feasibility is summarized in Table 3. Key findings included the following: First, clarity and safety, for which 100% of the participants agreed that the checklist provided clear instructions and would help reduce communication errors and improve patient safety; second, format: The “Portrait A4” single-page design received 100% approval for its layout and readability, and third, workload concerns: While the tool was observed as highly beneficial, 40% of nurses noted it might increase their documentation workload, and 30% felt it could be time-consuming during emergencies (Fig. 1).

Table 3.

Usability and feasibility feedback from ICU staff nurses (N = 10)

Parameter	Agree (%)	Disagree (%)
Provides clear and concise information	100	0
Reduces communication errors during handover	100	0
Enhance perceived patient safety during transport	100	0
Easy to understand and follow	100	0
Format (A4 portrait) is convenient	100	0
Increases documentation workload	40	60
Time-consuming during emergencies	30	70

ICU, intensive care unit

Fig. 1.

Final validated intrahospital patient transfer checklist

Discussion

This study aimed to develop and validate a standardized intrahospital patient transfer checklist for ICU nurses using a structured methodological approach. The final checklist demonstrated excellent content validity, substantial inter-rater reliability, and high perceived usability among ICU nurses, indicating that it is a robust and practical tool for clinical use.

The content validation process, conducted through a modified Delphi technique involving multidisciplinary experts, resulted in an S-CVI/UA of 1.0. This reflects complete agreement among experts regarding the relevance and clarity of the checklist items. The systematic refinement of items across Delphi rounds ensured that the final checklist was both comprehensive and clinically relevant. The grouping of items into pre-, intra-, and post-transport phases further enhances its applicability in real-world settings by aligning with the natural workflow of patient transfer.

The inter-rater reliability analysis demonstrated substantial agreement (Cohen's κ = 0.75), indicating that the checklist yields consistent results when used by different observers. This level of agreement is comparable to other checklist-based validation studies in clinical settings, where structured tools have been shown to reduce variability in practice and improve standardization of care processes. The observed agreement of 90% further supports the stability and reproducibility of the tool in clinical environments.

The usability assessment revealed that ICU nurses perceived the checklist as clear, easy to use, and beneficial for guiding intrahospital transfers. All participants reported that the checklist improved clarity of procedures and could help reduce communication gaps during patient transfer. However, a proportion of nurses indicated that the checklist may increase documentation workload and could be time-consuming during emergencies. These findings highlight the importance of integrating the checklist into routine workflows, potentially through electronic health record systems, to enhance adoption without adding to workload burden.

When compared with existing literature, previous studies have emphasized the role of structured protocols and checklists in improving the safety of intrahospital transport of critically ill patients. For instance, studies by Jia et al. and Shields et al. have reported that standardized approaches can reduce transport-related adverse events and improve adherence to safety practices.^3,5 However, unlike these outcome-focused studies, this research was limited to tool development and validation. Therefore, while the checklist demonstrated strong validity, reliability, and usability, its direct impact on clinical outcomes, such as reduction in adverse events, was not assessed.

The checklist developed in this study translates existing guidelines from organizations, such as the ISCCM and the SCCM, into a practical bedside tool. By incorporating essential elements, such as equipment checks, patient stabilization, monitoring, and communication, it provides a structured framework to support ICU nurses during the high-risk process of intrahospital transfer.

Strengths and Limitations

This study has several limitations. It was conducted in a single tertiary care center, which may limit the generalizability of the findings. The sample size for reliability and usability testing was relatively small. Additionally, the study did not evaluate the effect of the checklist on clinical outcomes, such as adverse events, morbidity, or mortality. Future research should focus on multicenter validation and assess the effectiveness of the checklist in improving patient safety outcomes during intrahospital transport.

Despite these limitations, the study provides a systematically developed and validated tool with strong methodological rigor. The checklist has the potential to standardize intrahospital transfer practices and support ICU nurses in delivering safe and consistent care during patient transitions.

The developed checklist is a valid, reliable, and feasible tool for standardizing intrahospital patient transfer processes, with high perceived usability among ICU nurses.

Declarations

Availability of Data and Materials

The datasets used and analyzed during this study are available from the corresponding author on reasonable request.

Ethical Approval

The study was approved by the Institutional Ethics Committee of Dayanand Medical College and Hospital (Approval No: DMCH/R&D/2021/39).

Authors’ Contributions

AD: Conceptualization, study design, data collection and analysis, manuscript preparation. BK: Conceptualization, study design, and supervision. JS: Co-supervisor for the study; provided critical oversight throughout the methodological development and manuscript review. All authors reviewed and approved the final manuscript.

Orcid

Arshdeep K Dhanoa https://orcid.org/0009-0004-9648-0148

Bindu K https://orcid.org/0009-0004-7238-5234

Jyoti Sharma https://orcid.org/0009-0005-8721-0573