Improving care in ventilated inter‐hospital transfers: a trainee‐led quality improvement project
Published Date: 27th October 2020
Publication Authors: Furniss T
In Mersey, the location of tertiary centres on distinct sites necessitates frequent emergency inter‐hospital transfers of critically ill patients. Local audits found a median transfer time of 5 h for ventilated patients to our tertiary neurosurgical centre, and the recommended target time of 2 h for ‘door‐to‐balloon’ in primary percutaneous coronary intervention (PPCI) was rarely met. Variations in practice may contribute to significant delays. A recent Healthcare Safety Investigation Branch report noted a lack of national guidelines for time‐critical transfers of level 2 and 3 patients [1]. Checklists are known to be effective tools to reduce human error and adverse events [2]. We undertook a quality improvement project to standardise care and improve patient safety during specialist transfers.
Methods
An online survey assessed baseline confidence amongst trainees in transferring ventilated patients with ST elevation myocardial infarction, subarachnoid haemorrhage and traumatic brain injury. Standards for staff roles, monitoring, physiological targets, medications and interventions were agreed with consultants in tertiary centres. Visually attractive transfer checklists were created, one for neurosurgical patients and one for PPCI. After local approval, they were implemented in five non‐tertiary hospitals in Mersey. A repeat survey of trainee confidence assessed their impact.
Results
There was a statistically significant increase in reported overall confidence in transferring patients (p = 0.01) as well as in management of traumatic brain injury and STEMI (p = 0.01), avoiding critical incidents (p = 0.01) and ensuring appropriate equipment (p = 0.04). There were non‐significant increases in confidence for ensuring appropriate monitoring (p = 0.15) and patient handover (p = 0.28).
Discussion
The checklists act as memory recall tools, relieving some of the cognitive burden facing anaesthetists. They are easy to use and the standards reflect current evidence, endorsed by tertiary centres. They provide consensus in controversial areas, such as arterial line use, drugs of choice and physiological targets. Crucially, they have gained acceptance regionally, standardising a process that has previously had many contrasting approaches. They have been approved by our local Intensive Care Society (ICS) Transfer Network and are being published in the ‘Standards and Guidelines’ section of the ICS website. They are now used regularly by trainees and consultants.
Fadden, E; Jones, R; Furniss, T; Chambers, O. (2019). Improving care in ventilated inter‐hospital transfers: a trainee‐led quality improvement project. Anaesthesia. 74 (S4), 43.