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06 May 2021

Adverse Events Can Happen Anywhere, Anytime, Including Patient Transport

By Halley Herndon and Cathleen Olguin

If you did not document it, it did not happen, or you didn’t do it. How many times have we all heard this, said this, thought this throughout a shift over our nursing careers? Whether it is a part of an assessment or even making sure vitals are transcribed from that napkin or sheet of paper in your pocket, all of this information is important to provide a complete picture of your patient’s condition.

These are the pieces of the story that show where the patient began during this admission and whether they are trending towards improvement. But how can data continuity be established when the patient has to be transferred to a higher level of care from the ER or the med-surg environment? How can we, as nurses, be sure that we have the most complete data? Historically, a common approach has been to take a set of vitals prior to hooking up your patient to the transport monitor and then taking a quick set of vitals when you arrive at your patient’s new destination. If it is not broke, why fix it?

Perhaps a consideration to “fixing it” is research that identified, “Of 184 transports observed (164 patients), 85 (46.2%) were associated with mishaps. Eighty-two mishaps were patient-related (44.5%). Oxygen desaturation (30 cases), agitation (24 cases) and hemodynamic instability (15 cases) were predominant. One case of cardiac arrest and 3 cases of accidental extubation occurred during intra-hospital transport (IHT). Seventy-three systems-based mishaps were noted (39.6%). Emergency transports, mechanical ventilation and positive end-expiratory pressure (PEEP) ≥ 6 cmH2O were independent risk factors for a higher rate of mishaps. Reported in a 2015 study, complications did not statistically increase ventilator-associated pneumonia.[1]

Have you ever found yourself in one of the above-mentioned scenarios with your patient while transporting them? If you have, the immediate priority is patient stabilization, and sometimes documentation can fall by the wayside. Thus, there persists a gap in the data. What happened to that patient’s vitals from the time you left for the transport and when they began to decompensate? Maybe in the back of your mind you are thinking, how can we learn from this? How can we feed this kind of data in real time to a research data base?  OK, let’s be honest, in that moment, you’re not thinking about the research database, but after the fact, it pops into your mind. As nurses, we always ask ourselves what we could have done differently, better. How can we take what was learned in this situation and apply it to other patients because we are our patients’ advocates? It’s who we are at our core.

Capsule’s medical device integration solution contributes to data completeness at the point of care, during transport and then, of course, when the patient reaches her next location. Capsule Integration, leveraging the capabilities of the Medical Device Integration Platform (MDIP) can simultaneously send any or all the data to downstream systems, which might include a research database. The data is timestamped for an accurate timeline for both real-time documentation in the EHR and research.

Clinicians have many priorities and demands placed on them, especially when transporting patients across the hospital. Utilizing the Capsule Integration and MDIP transport capabilities allows clinicians to focus on the most important aspect of their work – their patients – all while confidently knowing that all the device data is being documented to ensure there are no gaps in the data.

To learn more about the vendor-neutral interoperability solutions of the Capsule Medical Device Information Platform, please contact us.

About the authors

Halley Herndon, RN, is senior clinical consultant; Cathleen Olguin, MBA, BSN, RN, CNOR is senior clinical solutions executive; and Teresa Soman, MBA, PMP is director of product management at Capsule Technologies

Hajjej Z, Gharsallah H, Boussaidi I, Daiki M, Labbene I, Ferjani M. Risk of mishaps during intrahospital transport of critically ill patients. Tunis Med. 2015 Nov;93(11):708-13. PMID: 27126429.

Read the 2020 panel discussion about opportunities to improve workflow and patient care as a result of the COVID-19 pandemic.