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PSNet: Patient Safety Network

 Cases & Commentaries

Mitigating the Risk of Intrahospital Transport for Pediatric Patients at Risk of Physiologic Instability

Commentary By Karen Semkiw, RN-C, MPA, Dua Anderson, MD, MS, and JoAnne Natale, MD, PhD

The Case 

A 3-month-old twin male infant, born at 26 weeks’ gestation and with a history of bowel resection and anastomosis due to necrotizing enterocolitis, was re-admitted to a children’s hospital with abdominal distention and constipation three weeks after being discharged from the neonatal intensive care unit. Systemic inflammatory response syndrome developed with associated abdominal pain and worsening distention. The patient was transferred to the pediatric intensive care unit (PICU) for management of severe sepsis with fluid resuscitation and antibiotics. With an obstructive pathology highly suspected, an urgent exploratory laparotomy was scheduled.   

The pediatric anesthesiologist arrived in the PICU to assess the patient and assist with transport to the operating room (OR). A verbal report was received from the PICU intensivist via phone, which included a brief history, recent changes in respiratory status, discussion of resuscitation for sepsis, and mention of newly confirmed bacteremia and the antibiotic therapy to target it that had been initiated earlier in the day. On exam, the patient was alert, interactive, but uncomfortable with abdominal distention; his breathing was non-labored while receiving humidified high-flow nasal cannula respiratory support. Discussion by the care team included whether the patient would require intubation prior to transport to the OR, and all parties agreed that the patient’s clinical exam suggested he would be stable for brief transport from the PICU to the OR. Transport personnel included two PICU nurses and the pediatric anesthesiologist. During the intrahospital transport, the patient had a brief bradycardic episode without any changes to breathing or oxygen saturation, which self-resolved. At that time, a PICU nurse shared that similar and increasing numbers of bradycardic episodes had been occurring over the course of the day for this patient, sometimes associated with oxygen desaturation; these events had been brief and had resolved without specific intervention.   

Transport continued, but just prior to reaching the OR, bradycardia recurred, with accompanying loss of muscle tone and upward deviation of both eyes. Positive pressure ventilation with 100% FiO2 was started immediately, along with chest compressions and intravenous epinephrine. The infant was rapidly moved into an OR bed while continuing resuscitation and intubation. Return of spontaneous circulation occurred within five minutes, although the patient remained acidotic and required vasopressor infusions. Exploratory laparotomy revealed complete bowel obstruction at the ileo-transverse anastomosis site with severely dilated proximal bowel. The stricture was resected, the bowel was left in discontinuity with ileostomy drainage, and an abdominal wound vacuum was placed. The patient remained intubated, and was transported back to the PICU without incident, although still requiring vasoactive support. 

The Commentary 

By Karen Semkiw, RN-C, MPA, Dua Anderson, MD, MS, and JoAnne Natale, MD, PhD 


Transporting critically ill patients to and from the intensive care unit is a necessary part of hospitalized patient care. Despite the diagnostic or therapeutic benefits of such transport, the physical movement of critically ill patients is fraught with potential safety risks.1-4 These risks include both mechanical events such as accidental extubation or unplanned removal of lines as well as a range of physiologic deteriorations including hypoxia, hypercarbia, increased intracranial pressure, hemodynamic instability and temperature dysregulation.5  Transport of critically ill pediatric patients between hospitals is undertaken by specially trained teams, utilizes specialized equipment, operates under transport-specific protocols and employs standardized patient handoff procedures.6,7 On the other hand, intrahospital transport of similarly ill patients is typically undertaken by an ad hoc group of highly competent clinicians who may not have had the opportunity to train as a team on task performance or sequences of possible events.1

Recent evidence has emerged regarding the frequency of transport-associated adverse events for pediatric patients whose care involves anesthesiology.8 The Wake Up Safe Patient Safety Organization, a quality improvement collaborative that includes 35 institutional members, identified serious adverse events occurring before, during, or immediately after movement of a patient cared for by an anesthesiologist or in proximity to their care by an anesthesiologist.8 Locations of these events included the preoperative holding area, operating room, post-anesthesia care unit, and any preoperative or postoperative transfer to or from the ICU. Out of almost 3000 events in the database, 5% were identified as transport-associated. Of note, root cause analyses performed by the member organizations deemed nearly 60% of these events to have been potentially preventable.  

Although transport-associated, anesthesiology-related adverse events occur across all age groups, the youngest patients are at particularly high risk. Although infants under six months of age represented only 7% of patients in the Wake-Up Safe database, they accounted for 40% of all transport-associated adverse events.8 

Approaches to Improving Patient Safety and Quality of Patient Care 

Efforts to mitigate the risks associated with intrahospital transport of pediatric patients at risk for physiologic instability should incorporate the broad approaches described below. 

First, it is important to recognize that the team transporting a patient typically consists of an ad hoc (as available) collection of clinicians and transport personnel who have not worked together previously to care for that particular patient. Therefore, as it is in many clinical scenarios requiring handoffs, standardized communication is critically important in this situation.9-12 Using institutional guidelines for handoffs, the experiences and knowledge of the bedside clinicians and transport team should be shared. By drawing on existing frameworks for communication, the perspectives of all care providers should be welcomed and equally valued.13 In the Case considered here, it was only mid-transport (after an event) that the bedside nurse shared the fact that the patient had been experiencing increasingly frequent episodes of bradycardia. Had there been a standardized interprofessional handoff huddle pre-transport, this information might have been communicated then and influenced team decision-making, as discussed further below. This team communication should, for example, include specifically asking “What might go wrong and what would we do?” In this way, pre-transport team communication should closely resemble an interprofessional postoperative handoff to the critical care team.   

Second, structured decision-making regarding the need for and circumstances of intrahospital transport can also mitigate risks. Collaborating clinicians need to evaluate the probable benefits of the diagnostic or therapeutic intervention requiring intrahospital transport while also considering the probable risks. Patient age, clinical status and any unique vulnerabilities all require careful consideration. For example, simply knowing that a patient is intubated is not as important as knowing that they have an especially critical airway in that their endotracheal tube had been dislodged twice in the past week during bedside care.  

Third, the geography and duration of the required intrahospital transport should be carefully considered. How long will the transport take? How clinically isolated will the transport team be? What barriers might impede rapid communication if help is needed during the transport? What bedside alternatives, if any, are available to provide the diagnostic or therapeutic services that would be accessed via intrahospital transport? This thoughtful assessment of risks and benefits can both confirm the need for transport and highlight risks that can be mitigated prior to the transport of the patient. 

Fourth, preparation, including the careful development and application of intrahospital transport protocols, can mitigate risk. Standards for the number and type of transport team members, and for facilitating their movement as needed (e.g., by holding elevators), should be specified in guidelines. Transport teams should include personnel with expertise in preventing perturbations in physiological homeostasis. For example, in some hospitals, when transporting a patient on extracorporeal life support (ECLS), a perfusionist is an essential team member, along with a respiratory therapist, an ECLS physician, and an ECLS nurse. Recognizing the need to anticipate the rare adverse event, a plan for communicating urgent needs for additional clinical support throughout the transport should be developed and shared among team members; having such a plan in place would have been helpful in this Case because the resuscitation event experienced by the team occurred while in a hallway rather than in a clinical area such as the surgical suite. Having a well-known protocol for where to go when mid-transport events occur is also critical. Specifically, in an effort to promote competency of intrahospital transport teams in obtaining emergency assistance while in hallways and other areas lacking patient care facilities, the event in this Case prompted revision and clarification of Hospital Policy on Transportation of Patients to the Operating Room. 

Finally, a recent analysis of intrahospital transport-associated events in adult ICU patients demonstrated that both the safety climate (measured using the short form of the “Patient Safety Climate in Healthcare Organizations” survey) and team-level processes during transports (measured using the “Leiden Operating Theatre and Intensive Care Safety” Scale focusing on communication, situation awareness, and teamwork) were independently related to the frequency of these events.14 This finding demonstrates that institutional and team factors, such as the patient safety climate, also deserve careful attention. 

Take-Home Points 

  • Intrahospital transport of patients at risk for physiologic instability is both common and potentially hazardous, particularly for infants six months of age or younger. Problems must be anticipated and risks should be mitigated.  
  • Structured decision-making should be undertaken to evaluate the risks and benefits of therapeutic or diagnostic interventions that require intrahospital transport. This process should include consideration of any available bedside alternatives. 
  • The intrahospital transport team is typically formed ad hoc and therefore interprofessional communication and preparation are especially important. These activities should be supported by clear institutional guidelines and/or protocols that include careful consideration of the patient, any vulnerabilities unique to the patient or situation, and the circumstances of the transport itself. 
  • The intrahospital transport team should be prepared to rapidly summon additional clinical support at any point during the transport. 


Karen Semkiw, RN-C, MPA, NEA-BC, CPHQ  
Children’s Surgery Program Manager  
UC Davis Health 

Dua Anderson, MD, MS
Associate Professor, Department of Anesthesiology 
UC Davis Health 

JoAnne Natale, MD, PhD 
Director, UC Davis Children’s Hospital Quality and Safety 
Professor, Department of Pediatrics 
UC Davis Health 


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  3. 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(2):227-233. 

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  13. The Joint Commission. Inadequate hand-off communication. Sentinel Event Alert. 2017(55). Published September 12, 2017.
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    This project was funded under contract number 75Q80119C00004 from the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services. The authors are solely responsible for this report’s contents, findings, and conclusions, which do not necessarily represent the views of AHRQ. Readers should not interpret any statement in this report as an official position of AHRQ or of the U.S. Department of Health and Human Services. None of the authors has any affiliation or financial involvement that conflicts with the material presented in this report. View AHRQ Disclaimers