Cases & Commentaries

Moving Pains

Spotlight Case
Commentary By Hildy Schell, RN, MS, CCNS; Robert M. Wachter, MD

Case Objectives

  • Appreciate the risk posed by
    intrahospital transport
  • Identify key features of current
    transport practice and policies
  • Propose interventions that might improve
    safety of intrahospital transport

Case & Commentary: Part 1

A 90-year-old woman, whose son was a prominent
nonclinical member of the medical school faculty, was admitted to
the acute care ward of the school's teaching hospital with a
urinary tract infection and pneumonia. After developing hypoxemia,
on hospital day 2, she was placed on 2 L/min oxygen by nasal
cannula. On hospital day 3, her hypoxemia worsened, as did her
mental status. A head CT was ordered. She was placed on a
non-rebreather mask (NRM) at 15 L/min to maintain her oxygen
saturations. This change in respiratory status occurred while the
primary nurse was occupied by the critical needs of another
patient, so another nurse and the respiratory therapist placed the
patient on the NRM. The primary nurse completed the transport
stability scale (TSS—a local instrument used to assess a
patient's stability for transport and to determine the need for a
nurse or physician to travel with the patient) at the nurses'
station in preparing her patient for transport to the CT scanner.
Because the nurse was unaware of the change in her patient's
respiratory status, she recorded that the patient required only 2
L/min oxygen by nasal cannula. Accordingly, the TSS score did not
signal a need for a nurse or physician to accompany the patient.
Therefore, the patient was taken to the CT scanner by two transport
personnel/escorts and her son, the physician-faculty

The increased risk of morbidity and mortality
during intrahospital transport of critically ill patients is well
described in the literature and has led to the publication of
formal guidelines for such transports by the Society of Critical
Care Medicine and the American College of Critical Care
Despite the obvious risks (frequently due to sudden changes in
clinical condition) of intrahospital transport for patients in
acute medical wards, the issues surrounding patient safety for
transport for non-ICU patients have not been well described. In
fact, although we were able to find a few reports of "best
practices" in abstract form or shared via listserv communication,
we could not find any standardized, endorsed guidelines for safe
transport of this patient population, nor any peer-reviewed article
on the subject.

Even in the absence of formal guidelines, most
hospitals have recognized the risk of intrahospital transport and
have developed their own policies to help manage the process.
Unfortunately, our impression is that many of these policies lack
some essential elements. First, many policies lack clear standards
for patient assessment, including the elements of an assessment,
its timing, and the responsible party. Second, many are silent on
the levels of intervention required, nor do they outline
contingency plans should a patient's status change during the
course of transport. Many policies are vague as to who should
transport the patient under a variety of circumstances. Finally,
even hospitals with reasonably robust policies rarely have systems
in place to ensure that the policies are actually followed "in the

In this case, the hospital did have a system for
assessing and communicating the clinical stability of the patient,
but the assessment recorded on the transport stability sticker did
not reflect the patient's immediate pre-transport condition.
Enforcing an acceptable timeframe for the pre-transport assessment
is an essential element of a transport standard and policy. In part
because of the timing of the assessment (before her deterioration),
the patient was sent off the unit accompanied by two "transport
personnel/escorts." In general, such transport personnel are
unlicensed and have variable training and responsibilities.
Currently, there is no requirement for basic training or
certification for unlicensed staff who transport patients without a
nurse or physician, despite the fact that such personnel may need
to identify a patient's change in status or even serve as "first
responders" from time to time.

Case & Commentary: Part 2

As the transporters prepared to leave the
floor with the patient, one of them noticed that the patient had
labored breathing. He suspected that a nurse should travel with
them but did not question the nurse's assessment on the transport
stability form. During transport, the patient continued breathing
through her NRM, which was connected to an oxygen tank.

Once the patient arrived in radiology, the CT
technician noticed that NRM bag was deflated and the oxygen tank
had a regulator that limited oxygen delivery to 4 L/min. The
technician connected the NRM to the wall oxygen source at 15 L/min
for the study and located an appropriate tank (that would allow
higher-flow oxygen) for the trip back to the unit. After the study,
the patient was switched to this new tank at 15 L/min and awaited
transport. The tank was noted to have 1000 lbs of pressure by the
CT technician. The two transporters arrived, and the patient left
radiology to return to her room.

In the elevator, one of the transporters
realized that she no longer heard the flow of oxygen and that the
NRM bag was deflated. When they returned to the floor, she
immediately called for help. The patient was reconnected to the
wall oxygen source in her room at 15 L/min. However, by that time,
the patient was noted to be severely hypoxemic and markedly short
of breath. Over the next hour, her condition continued to worsen.
Because she did not wish to be intubated, she expired approximately
30 minutes after arrival to the floor. A root cause
analysis later attributed the death, at least in part, to
inadequate delivery of supplemental oxygen and insufficient
observation during the transport process.

Although it is tempting to ascribe this tragic
outcome to technical problems with oxygen delivery systems and
process problems with transport, it would be a mistake to ignore
some of the sociocultural and communication issues that were
undoubtedly at play. Try to picture the scene at the patient's
bedside before the patient was rolled out of her room to the
scanner. The two transporters see the dyspneic patient and wonder
whether a nurse should be present, but the transport scale says
that it isn't necessary. It would take a very strong culture of safety
to empower them to approach the nurse or a physician to question
what appeared to be a clear-cut assessment (of course, there was no
way they could know that the assessment had been done hours earlier
and was now irrelevant to the current situation). Moreover, they
were probably reassured by the presence of a physician, the
patient's son; there was no way they could know that this physician
worked in a nonclinical department.

The son, too, was placed in a terribly difficult
position. We don't know if he shared the transporter's concerns
about his mother's stability, but, as a nonclinician, he may have
been unsure. Moreover, his role was to be a family member, not a
health care provider—always a tricky balance, and one that
has become trickier since the patient safety movement has begun
encouraging patients to "speak up" when they see something
Finally, as a faculty member at the institution, he may well have
struggled with whether to assert himself as a "VIP," worried that
he would be branded as being overly demanding. In analyzing this
case, it is easy to shuffle all these issues to the bottom of the
deck (after all, creating a new transport protocol is far easier
than trying to dampen authority
gradients or think through the appropriate role of patients'
family members in ensuring safety), but it would be a mistake to
omit them from consideration and possible intervention.

Returning to more concrete matters, let's
consider the issue of delivering supplemental oxygen. One study of
intrahospital transport of non-ICU patients found that oxygen
therapy was frequently interrupted.(4) In
this study, the authors reported high levels of variability among
hospitals in the responsibilities of respiratory care practitioners
and nurses for oxygen therapy on acute care units. As we consider
the issues surrounding the delivery of oxygen to the patient in
this case, a number of questions arise: Who is adequately trained
to assess oxygen delivery devices for transport? What is the
required assessment of the oxygen system? When is it done? What are
the contingency plans if the patient's condition changes en route?
The critical care guidelines recommend that the oxygen source have
an adequate supply to provide for the patient's needs (flow rate
over time of transport to and from destination) plus a 30-minute
Respiratory therapists are best prepared to provide education and
be involved in improving care related to oxygen therapy and should
be brought into any discussions regarding how to make intrahospital
transport safer.

Recommendations for Improving the Safety of
Intrahospital Transport

To address this important—and we believe
underreported and understudied—patient safety issue,
hospitals should first assess their current practice and policies.
This assessment should include a review of the following elements:
which patients are being transported and to which locations,
pre-transport assessments, transport personnel competency and
responsibilities, handoff communication, necessary equipment and
supplies, and transport monitoring (Table).

Examples of Best Practices

Hospitals will have variable answers to the
questions posed in their review of practice and resources, and the
literature does not include scientific assessments of various
strategies and practices. Nonetheless, our review of the
literature, monitoring of listserv communiqués, and
discussion with various providers has pointed us to certain
practices worthy of consideration.

First, the use of a TSS or another tool that
standardizes the pre-transport assessment is an essential component
of safe intrahospital transport.(5)
However, this case clearly demonstrates that the tool itself will
not ensure safety. Developing a structure for how, when, and by
whom it is used and ensuring competency for its use is as important
as the instrument itself. One hospital uses a "Ticket to Ride"
system, in which the ticket serves as the communication form
between sending and receiving personnel. The ticket includes
patient identification, stability, and risk information. The
transport personnel are responsible for ensuring the nurse
completes the ticket and that the ticket is with the patient until
return to the home unit. Another best practice is a checklist
system used by the sending nurse. The checklist outlines the
essential steps of patient identification, pre-transport assessment
(including need for analgesia or sedatives), notification to
providers and accompanying personnel when necessary, and checking
supplies and equipment necessary for transport.

There are many implications for further study of
patient safety during intrahospital transport of acutely ill
patients. Identification of risk factors for negative outcomes
associated with intrahospital transport of acutely ill patients
would help inform the development of a useful pre-transport
assessment tool. Hospitals often retrospectively identify these
risk factors after sentinel events occur (eg, patients with
escalating oxygen therapy requirements, as in this case). Other
risk factors, such as altered mental status, morbid obesity, and
use of sedative agents and/or sleep apnea, may not be familiar to
care providers. Intervention studies are needed to evaluate system
improvements, such as transport teams or innovative communication

Partly because the issue of transport tends to
"fall between the cracks" of divisions, departments, and providers,
it has been the subject of too little research, too few innovative
quality improvement practices, and possibly too little regulation.
The time has come to rectify this, lest more patients fall victims
to the risk of moving around the hospital.

Take-Home Points

  • Intrahospital transport is probably
    quite risky but has been understudied.
  • In considering how to improve the safety
    of transport, the focus should be 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.
  • The issue of respiratory assessment and
    oxygen delivery is frequently poorly handled, and would benefit
    from the engagement of respiratory therapists in the planning
  • Some attention should also be paid to
    cultural issues that may get in the way of individuals raising
    appropriate concerns regarding the transfer process.

Hildy Schell, RN, MS, CCRN, CCNS
Associate Clinical Professor, University of California, San
Francisco School of Nursing
Clinical Nurse Specialist, Adult Critical Care, UCSF Medical

Robert M. Wachter, MD
Professor and Associate Chairman, Department of Medicine,
University of California, San Francisco
Chief of the Medical Service, UCSF Medical Center
Editor, AHRQ WebM&M and Patient Safety Network

Faculty Disclosure: Ms. Schell and Dr.
Wachter have declared that neither they, nor any immediate member
of their family, have a financial arrangement or other relationship
with the manufacturers of any commercial products discussed in this
continuing medical education activity. In addition, their
commentary does not include information regarding investigational
or off-label use of pharmaceutical products or medical


1. Warren J, Fromm RE Jr, Orr RA, Rotello LC,
Horst HM, the American College of Critical Care Medicine.
Guidelines for the inter- and intrahospital transport of critically
ill patients. Crit Care Med. 2004;32:256-262.
[go to PubMed]

2. Wachter RM, Shojania KG. Internal Bleeding:
The Truth Behind America's Terrifying Epidemic of Medical Mistakes.
New York, NY: Rugged Land; 2004.

3. Speak Up: Help Prevent Errors in Your
Care—Brochures and Poster. Joint Commission on Accreditation
of Healthcare Organizations Web site. Available at:
Accessed June 5, 2006.

4. Stubbs CR, Crogan KJ, Pierson DJ. Interruption
of oxygen therapy during intrahospital transport of non-ICU
patients: elimination of a common problem through caregiver
education. Respir Care. 1994;39:968-972.
[go to PubMed]

5. Ward M, Corcoran R, Mueller J, Ford-Weaver C.
Red light/green light: who transports the patient? Poster
presentation at: National Teaching Institute and Critical Care
Exposition; May 15-20, 2004; Orlando, FL. Abstract available at:


Table. Questions in Assessing Transport
Policies and Procedures

Which patients are being

  • Focus initial efforts on the most
    frequent source units and patient types (ages, clinical

To which locations are most patients

  • Are these destinations in the main
    hospital, adjacent buildings, across the street?
  • Are there special safety hazards in any
    of the units (eg, MRI magnets)?

Pre-transport patient

  • What criteria are used to determine
    patient stability, patient risk, and level of monitoring during
  • Who is responsible for this
  • What is the recommended timing for this
  • Do the assessment criteria include risk
    factor assessment based on the type of procedure/diagnostic,
    patient positioning during transport, and duration of transport
  • Does the assessment take into account
    the possibility of decline in clinical condition and the need for
    escalating support (eg, increase in oxygen flow rate and change to
    NRM with same oxygen saturations)?
  • How is this assessment communicated to
    the care team, the transport personnel, and the destination
  • Finally, how is compliance

Transport personnel

  • Who transports patients (unlicensed and
    licensed personnel)?
  • What are their specific responsibilities
    before and during transport?
  • What level of training and competency
    assessment is done related to patient safety during transport?
  • Are they required to have Basic Life
    Support (CPR) certification (in the case of an arrest, could they
    initiate the ABCs of CPR)?
  • What is the content of their training
    (does it cover how to get help during transport or how to receive
    and provide handoff communications)?

Handoff communication

  • How are the patient's condition,
    potential safety risks, and needs communicated?
  • Is a checklist used? Is patient
    identification included?
  • What is the responsibility of the
    sending and receiving providers and/or transporters?

Necessary supplies and equipment for

  • What equipment is required to accompany
    the acute care patient during transport (eg, mask with Ambu bag,
    ECG monitor)?
  • Who ensures that therapies (eg, oxygen,
    infusions, etc.) are maintained during transport?
  • Would the transport personnel know how
    to use or troubleshoot any accompanying equipment/supplies, if

Transport monitoring

  • What basic level of monitoring is
    expected during transport (eg, change in level of consciousness,
    color, respiratory effort, IV pump alarm, etc.)? And are the
    transporters qualified or adequately trained for this?
  • What is the expected level of
    intervention (eg, replace an oxygen mask if it falls off, silence
    an IV pump)?