High mishap rate reported for moving patients

An observational study at Victoria’s Austin Hospital Emergency Department (ED) reveals that moving emergency care patients to other hospital departments by wheelchair or trolley is prone to a high rate of mishaps. Incidents such as limb entrapment, collisions, and intravenous line or catheter issues occurred in nearly four out of 10 patient transports in less than two months, prompting the study authors to call for improvements to transport training and pre-transport preparation.

Publishing results in the Emergency Medicine Journal, the study authors observed the transport of 738 adult patients by trolley or wheelchair from emergency care to other departments at Austin Hospital on weekdays between 30 January and 20 March 2020. The number and nature of incidents was logged, as were any predisposing factors and resulting patient harm.

Incidents were observed in 289 (39%) manoeuvres: a single mishap occurred in 169 (23%) transports while several incidents, ranging from two to nine, occurred in 120 (16%), bringing the total to 521.

Cause of transport mishaps

Around one in four of the incidents originated with the patient, the most common being acute agitation, coughing and limb displacement.

More than half (54%) involved equipment, the most common being collisions, and issues with infusion pumps and monitoring. Endotracheal tubes (used to assist breathing), ventilator hoses and arterial lines were also associated with high mishap rates, and 23% of all incidents were associated with intravenous lines or catheters, the most common being catching or tangling of lines.

Predisposing factors included the number of pieces of equipment in any one manoeuvre, transport to a general ward, and patients with high blood pressure, abnormally high or low temperature, or low Glasgow Coma Score, which is used to measure the level of consciousness in a person after a traumatic brain injury.

Thirty-four (6.5%) incidents adversely affected the patient, resulting in distress (13 patients); pain (9); needlessly wasted materials/resources (3); staff assault (2); and single cases of exposure to blood; near miss fall; treatment delay; sedation wearing off; cannula dislodging; patient gown falling off, so exposing their body; and laboured breathing (dyspnoea).

The authors noted that the findings may not be comparable with experience in other institutions because of variable layout, transport protocols, and the distance/duration of transports, but concluded, “This high incidence of [incidents] indicates a need for improved transport training and adequate pre-transport preparation.”

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