Does the implementation of a standardized workflow and checklist affect safety, communication and efficiency during the intra-hospital transport of adult ICU patients?

By Julianna Schmidt, RN

Background

At unit level there were safety concerns from multiple clinicians surrounding IHT. In addition to this, there was no standardized workflow, up to date policy and procedure or sufficient education in place for the IHT of ICU patients. Following a review of current literature, evidence does suggest that IHT does in fact put patients at risk, and that the appropriate protocols that address screening, preparation and communication should be in place. Therefore, a new workflow and checklist was created to identify safety concerns and barriers to transport prior to departure. It included a suitability screening tool, a multi-disciplinary team huddle to promote communication and checklist of practical reminders.

PICO Question

Intra-hospital transport (IHT) of ICU patients occurs frequently due to need for diagnostic and interventional procedures. Adverse outcomes (airway, hemodynamic, metabolic, etc.) are associated with IHT of ICU patients. The aim of this project was to create a workflow and checklist to address some of the factors contributing to safety and evaluate its effectiveness by implementing a rapid cycle small test if change.

Methods

A standardized workflow and checklist was implemented on a 32 bed, medical/surgical ICU that addressed safety, communication and efficiency, by ensuring the patient was adequately screened and prepared for IHT. To evaluate its effect on current practice a ‘real time' evaluation of the IHT, in the format of questionnaire was completed by the Respiratory Care Providers (RCP) and Registered Nurses (RN) that participated in the transport. In addition to this, an electronic survey to evaluate the Radiology Departments perception of the performance and preparation of ICU staff was completed pre and post implementation. Both surveys included questions that asked specifically about safety, communication and efficiency/delays.

Results

Unfortunately the sample size was small and the adoption of the new workflow was poor. In the post-implementation group 40% of the respondents had used the new workflow and checklist. The largest amount of transports were to CT scan. In this group there was approximately a 10% reduction in delays reported. The top reasons for delays were waiting for transport personnel, staff coverage at unit level, followed by communication with destination department and medical team. There was a 5-10% decrease in events that compramised safety. Waiting for transport personnel and patient stability were the top reasons for safety compromise. Communication only improved in the MD group following the implementation of the huddle. There was no positive improvement the Radiology Department staff perception of the performance of 9/13 staff when conducting IHT to their department post implementation, in relation to patient preparation and communication.

Discussion

Reinforcement and education on the new workflow appears critical to it’s successful implementation. More time is required to disseminate information and overcome resistance to change. Education proved to be more effective when disseminated in a number of formats to accommodate all learning styles. The workflow/checklist details must be easily accessible to staff at all times to optimize compliance with the new practice. An update of corresponding medical center policy and procedure will be required to ensure standardization of practice and accountability of clinicians.

Conclusion

The checklist and workflow serves as a useful reference and general framework for practice. Ongoing evaluation and modification of the tool will be required to ensure it is up to date and meaningful to practice. We know the problem still exists, now we just need to find the right solution. Additional research is needed to further evaluate the safety barriers during IHT and identify system interventions to prevent harm during IHT of ICU patients.