Adverse Events During Intrahospital Transport of Critically Ill Children: A Systematic Review.

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Abstrakt

Tytuł:: Adverse Events During Intrahospital Transport of Critically Ill Children: A Systematic Review.
Autorzy:: Haydar B; From the Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan.
Baetzel A; From the Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan.
Elliott A; From the Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan.
MacEachern M; Taubman Health Sciences Library, University of Michigan, Ann Arbor, Michigan.
Kamal A; School of Public Health, University of Michigan, Ann Arbor, Michigan.
Christensen R; From the Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan.
Źródło:: Anesthesia and analgesia [Anesth Analg] 2020 Oct; Vol. 131 (4), pp. 1135-1145.
Typ publikacji:: Journal Article; Systematic Review
Język:: English
Imprint Name(s):: Publication: 1998- : Baltimore, Md. : Lippincott Williams & Wilkins
Original Publication: Cleveland, International Anesthesia Research Society.
MeSH Terms:: Transportation of Patients*
Critical Illness/*therapy
Adolescent ; Child ; Child, Preschool ; Critical Care/methods ; Humans ; Infant ; Infant, Newborn ; Pediatrics
References:: Fanara B, Manzon C, Barbot O, Desmettre T, Capellier G. Recommendations for the intra-hospital transport of critically ill patients. Crit Care. 2010;14:R87.
Haydar B, Baetzel A, Stewart M, Voepel-Lewis T, Malviya S, Christensen R. Complications associated with the anesthesia transport of pediatric patients: an analysis of the wake up safe database. Anesth Analg. 2020;131:245–254.
Foronda C, VanGraafeiland B, Quon R, Davidson P. Handover and transport of critically ill children: an integrative review. Int J Nurs Stud. 2016;62:207–225.
Zorzela L, Loke YK, Ioannidis JP, et al.; PRISMAHarms Group. PRISMA harms checklist: improving harms reporting in systematic reviews. BMJ. 2016;352:i157.
Williams T, Szekendi M, Pavkovic S, Clevenger W, Cerese J. The reliability of AHRQ common format harm scales in rating patient safety events. J Patient Saf. 2015;11:52–59.
Sanderson S, Tatt ID, Higgins JP. Tools for assessing quality and susceptibility to bias in observational studies in epidemiology: a systematic review and annotated bibliography. Int J Epidemiol. 2007;36:666–676.
Loney PL, Chambers LW, Bennett KJ, Roberts JG, Stratford PW. Critical appraisal of the health research literature: prevalence or incidence of a health problem. Chronic Dis Can. 1998;19:170–176.
Weinger MB, Slagle J, Jain S, Ordonez N. Retrospective data collection and analytical techniques for patient safety studies. J Biomed Inform. 2003;36:106–119.
Neyeloff JL, Fuchs SC, Moreira LB. Meta-analyses and Forest plots using a Microsoft Excel spreadsheet: step-by-step guide focusing on descriptive data analysis. BMC Res Notes. 2012;5:52.
Agrawal S, Hulme SL, Hayward R, Brierley J. A Portable CT scanner in the pediatric intensive care unit decreases transfer-associated adverse events and staff disruption. Eur J Trauma Emerg Surg. 2010;36:346–352.
Bastug O, Gunes T, Korkmaz L, et al. An evaluation of intra-hospital transport outcomes from tertiary neonatal intensive care unit. J Matern Fetal Neonatal Med. 2016;29:1993–1998.
Benavente-Fernández I, Lubián-López PS, Zuazo-Ojeda MA, Jiménez-Gómez G, Lechuga-Sancho AM. Safety of magnetic resonance imaging in preterm infants. Acta Paediatr. 2010;99:850–853.
da Silva GE, de Souza NL, de Oliveira Saraiva COP, et al. Risk Assessment of Morbidity and Mortality in the Neonatal Transport. International Archives of Medicine. 2017. Available at: http://imedicalsociety.org/ojs/index.php/iam/article/view/2699. Accessed December 21, 2018.
Dockery WK, Futterman C, Keller SR, Sheridan MJ, Akl BF. A comparison of manual and mechanical ventilation during pediatric transport. Crit Care Med. 1999;27:802–806.
Don Paul JM, Perkins EJ, Pereira-Fantini PM, et al. Surgery and magnetic resonance imaging increase the risk of hypothermia in infants. J Paediatr Child Health. 2018;54:426–431.
Frawley G, Bayley G, Chondros P. Laparotomy for necrotizing enterocolitis: intensive care nursery compared with operating theatre. J Paediatr Child Health. 1999;35:291–295.
Harer MW, Vergales B, Cady T, Early A, Chisholm C, Swanson JR. Implementation of a multidisciplinary guideline improves preterm infant admission temperatures. J Perinatol. 2017;37:1242–1247.
Harish MM, Siddiqui SS, Prabu NR, Chaudhari HK, Divatia JV, Kulkarni AP. Benefits of and untoward events during intrahospital transport of pediatric intensive care unit patients. Indian J Crit Care Med. 2017;21:46–48.
Hu XJ, Wang L, Zheng RY, et al. Using polyethylene plastic bag to prevent moderate hypothermia during transport in very low birth weight infants: a randomized trial. J Perinatol. 2018;38:332–336.
Nakayama DK, Lester SS, Rich DR, Weidner BC, Glenn JB, Shaker IJ. Quality improvement and patient care checklists in intrahospital transfers involving pediatric surgery patients. J Pediatr Surg. 2012;47:112–118.
Nikhar SA, Gupta KK. Pneumothorax during transportation of patient on Ayres T-piece: A rare but lethal experience! Saudi J Anaesth. 2016;10:490–491.
Patel R, Norden J, Hannallah RS. Oxygen administration prevents hypoxemia during post-anesthetic transport in children. Anesthesiology. 1988;69:616–618.
Prodhan P, Fiser RT, Cenac S, et al. Intrahospital transport of children on extracorporeal membrane oxygenation: indications, process, interventions, and effectiveness. Pediatr Crit Care Med. 2010;11:227–233.
Pullerits J, Burrows FA, Roy WL. Arterial desaturation in healthy children during transfer to the recovery room. Can J Anaesth. 1987;34:470–473.
Ramirez R, Ong J, Peralta L. Assessment of intrahospital transport of critically ill pediatric patients at the University of Santo Tomas Hospital. J Med. 2004;52:43–47.
Tobias JD, Lynch A, Garrett J. Alterations of end-tidal carbon dioxide during the intrahospital transport of children. Pediatr Emerg Care. 1996;12:249–251.
Vieira AL, dos Santos AM, Okuyama MK, Miyoshi MH, de Almeida MF, Guinsburg R. Factors associated with clinical complications during intra-hospital transports in a neonatal unit in Brazil. J Trop Pediatr. 2011;57:368–374.
Vieira AL, Santos AM, Okuyama MK, Miyoshi MH, Almeida MF, Guinsburg R. Predictive score for clinical complications during intra-hospital transports of infants treated in a neonatal unit. Clinics (Sao Paulo). 2011;66:573–577.
Vieira ALP, Santos AMN, Okuyama MK, Miyoshi MH, Almeida MFB, Guinsburg R. Factors associated with hypothermia during intra-hospital transport in patients assisted in a neonatal intensive care unit. Rev Paul Pediatr. 2011;29:13–20.
Wallen E, Venkataraman ST, Grosso MJ, Kiene K, Orr RA. Intrahospital transport of critically ill pediatric patients. Crit Care Med. 1995;23:1588–1595.
Wilson C, Webber S. Oxygen saturation during transfer. Paediatr Anaesth. 2002;12:288.
Yeager SB, Horbar JD, Greco KM, Duff J, Thiagarajan RR, Laussen PC. Pretransport and posttransport characteristics and outcomes of neonates who were admitted to a cardiac intensive care unit. Pediatrics. 2006;118:1070–1077.
Zambricki C, Schmidt C, Vos K. Bilateral tension pneumothorax following equipment improvisation. AANA J. 2014;82:20–24.
Lahner D, Nikolic A, Marhofer P, et al. Incidence of complications in intrahospital transport of critically ill patients–experience in an Austrian university hospital. Wien Klin Wochenschr. 2007;119:412–416.
Gillman L, Leslie G, Williams T, Fawcett K, Bell R, McGibbon V. Adverse events experienced while transferring the critically ill patient from the emergency department to the intensive care unit. Emerg Med J. 2006;23:858–861.
Papson JP, Russell KL, Taylor DM. Unexpected events during the intrahospital transport of critically ill patients. Acad Emerg Med. 2007;14:574–577.
Waddell G. Movement of critically ill patients within hospital. Br Med J. 1975;2:417–419.
Lovell MA, Mudaliar MY, Klineberg PL. Intrahospital transport of critically ill patients: complications and difficulties. Anaesth Intensive Care. 2001;29:400–405.
Choi HK, Shin SD, Ro YS, Kim DK, Shin SH, Kwak YH. A before- and after-intervention trial for reducing unexpected events during the intrahospital transport of emergency patients. Am J Emerg Med. 2012;30:1433–1440.
Jiang XX, Wang J, Zhang W, Wang XJ, Meng XH. Safe transport combined with prospective nursing intervention in intra-hospital transport of emergency critically ill patients. Int J Clin Exp Med 2016;9:13166–13171.
Beckmann U, Gillies DM, Berenholtz SM, Wu AW, Pronovost P. Incidents relating to the intra-hospital transfer of critically ill patients. An analysis of the reports submitted to the Australian Incident Monitoring Study in Intensive Care. Intensive Care Med. 2004;30:1579–1585.
Durak VA, Armagan E, Ozdemir F, Kahriman N. Discharge of emergency patients to the clinical wards or intensive care units: an assessment of complications and possible shortcomings. Injury. 2015;46(Suppl 2):S53–S55.
Marx G, Vangerow B, Hecker H, et al. Predictors of respiratory function deterioration after transfer of critically ill patients. Intensive Care Med. 1998;24:1157–1162.
Kollef MH, Von Harz B, Prentice D, et al. Patient transport from intensive care increases the risk of developing ventilator-associated pneumonia. Chest. 1997;112:765–773.
Andrews PJ, Piper IR, Dearden NM, Miller JD. Secondary insults during intrahospital transport of head-injured patients. Lancet. 1990;335:327–330.
Stearley HE. Patients’ outcomes: intrahospital transportation and monitoring of critically ill patients by a specially trained ICU nursing staff. Am J Crit Care. 1998;7:282–287.
Indeck M, Peterson S, Smith J, Brotman S. Risk, cost, and benefit of transporting ICU patients for special studies. J Trauma. 1988;28:1020–1025.
Meiklejohn BH, Smith G, Elling AE, Hindocha N. Arterial oxygen desaturation during postoperative transportation: the influence of operation site. Anaesthesia. 1987;42:1313–1315.
McKinlay CJD, Alsweiler JM, Anstice NS, et al.; Children With Hypoglycemia and Their Later Development (CHYLD) Study Team. Association of neonatal glycemia with neurodevelopmental outcomes at 4.5 years. JAMA Pediatr. 2017;171:972–983.
Hanley JA, Lippman-Hand A. If nothing goes wrong, is everything all right? Interpreting zero numerators. JAMA. 1983;249:1743–1745.
Weg JG, Haas CF. Safe intrahospital transport of critically ill ventilator-dependent patients. Chest. 1989;96:631–635.
Larsen GY, Donaldson AE, Parker HB, Grant MJ. Preventable harm occurring to critically ill children. Pediatr Crit Care Med. 2007;8:331–336.
Bergman LM, Pettersson ME, Chaboyer WP, Carlström ED, Ringdal ML. Safety hazards during intrahospital transport: a prospective observational study. Crit Care Med. 2017;45:e1043–e1049.
Agarwal HS, Saville BR, Slayton JM, et al. Standardized postoperative handover process improves outcomes in the intensive care unit: a model for operational sustainability and improved team performance*. Crit Care Med. 2012;40:2109–2115.
Entry Date(s):: Date Created: 20200914 Date Completed: 20201112 Latest Revision: 20240229
Update Code:: 20240229
DOI:: 10.1213/ANE.0000000000004585
PMID:: 32925334
: Czasopismo naukowe

Intrahospital transport of a critically ill patient is often required to achieve a diagnostic and/or therapeutic objective. However, clinicians who recommend a procedure that requires transport are often not fully aware of the risks of transport. Clinicians involved in the care of critically ill children may therefore benefit from a clear enumeration of adverse events that have occurred during transport, risk factors for those events, and guidance for event prevention. The objective of this review was to collect all published harm and adverse events that occurred in critically ill children in the context of transport within a medical center, as well as the incidence of each type of event. A secondary objective was to identify what interventions have been previously studied that reduce events and to collect recommendations for harm prevention from study authors. Ovid MEDLINE, Cochrane Central Register of Controlled Trials, Embase, and CINAHL were searched in January 2018 and again in December 2018. Terms indicating pediatric patients, intrahospital transport, critical illness, and adverse events were used. Titles and abstracts were screened and full text was reviewed for any article meeting inclusion criteria. If articles included both children and adults, incidence data were collected only if the number of pediatric patients could be ascertained. Of 471 full-text articles reviewed, 40 met inclusion criteria, of which 24 included only children, totaling 4104 patient transports. Heterogeneity was high, owing to a wide range of populations, settings, data collection methods, and outcomes. The incidence of adverse events varied widely between studies. Examples of harm included emergent tracheostomy, pneumothorax, and cardiac arrest requiring chest compressions. Respiratory and airway events were the most common type of adverse event. Hypothermia was common in infants. One transport-associated death was reported. When causation was assessed, most events were judged to have been preventable or potentially mitigated by improved double-checks and usage of checklists. Prospective studies demonstrated the superiority of mechanical ventilation over manual ventilation for intubated patients. Risk of adverse events during critical care transport appears to relate to the patient's underlying illness and degree of respiratory support. Recommendations for reducing these adverse events have frequently included the use of checklists. Other recommendations include optimization of the patient's physiological status before transport, training with transport equipment, double-checking of equipment before transport, and having experienced clinicians accompany the patient. All available recommendations for reducing transport-associated adverse events in included articles were collated and included.

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