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According to this study:
* Equipment problems are the most common adverse events occurring during transfers from the ED to the ICU.
* Delays in transfer also can occur.
Because critically ill patients are often moved from the ED to the ICU, researchers assessed the incidence and types of adverse events that occur during such transfers.
Over a six-month period, prospective observational and retrospective chart analysis was conducted for 290 patients transferred from the ED to the ICU. The most common adverse events were equipment problems, which occurred in 9% of cases; hypothermia, which occurred in 7%; and cardiorespiratory events, which occurred in 6%. The transfer of 38% of the cases was delayed by more than 20 minutes, and 14% were delayed by more than an hour. One patient was found to be wearing an incorrect identification band before surgery.
The adverse events identified were similar to those noted in prior research, although some of them occurred less frequently, according to principal study author Lucia Gilman, RN, of the School of Nursing, Midwifery and Postgraduate Medicine at Edith Cowan University and Royal Perth Hospital in Australia. "It is likely that a multifaceted approach will be required to further reduce adverse events in our department--for example, educating staff, reviewing protocols, and upgrading equipment, such as monitors, to models that are better suited to transport given the pattern of use in our ED," she says.
After completing the audit, the hospital purchased a warming cupboard that, anecdotally, appears to be reducing the number of hypothermic events in patients, says Gilman. In addition, the application of the incorrect identification band prompted a review of practice.
In a recent Agency for Healthcare Research and Quality case commentary on issues and practices in the transfer of patients, critical care staff members are advised to focus on "standardized assessments, use of checklists, ensuring that the appropriate providers and technology accompany the patient, creating contingency plans for changes in patient condition, and enforcing the standards."-HL
Gillman L, et al. Emerg Med J 2006;23:858-61; Schell H and Wachter RM. Morbitity and Mortality Rounds on the Web: Case and Commentary. July 2006. http://webmm.ahrq.gov/case.aspx?caseID=128.
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