Intensive Care Medicine

, Volume 30, Issue 8, pp 1579–1585 | Cite as

Incidents relating to the intra-hospital transfer of critically ill patients

An analysis of the reports submitted to the Australian Incident Monitoring Study in Intensive Care
  • Ursula BeckmannEmail author
  • Donna M. Gillies
  • Sean M. Berenholtz
  • Albert W. Wu
  • Peter Pronovost



Transportation of critically ill patients within the hospital poses important risks. We sought to identify causes, outcomes and contributing factors associated with intra-hospital transport.


Cross-sectional case review.


Incident reports submitted to the Australian Incident Monitoring Study in Intensive Care (AIMS-ICU).

Measurement and main results

Between 1993 and 1999, 176 reports were submitted describing 191 incidents. Seventy-five reports (39%) identified equipment problems, relating prominently to battery/power supply, transport ventilator and monitor function, access to patient elevators and intubation equipment. Hundred sixteen reports (61%) identified patient/staff management issues including poor communication, inadequate monitoring, incorrect set-up of equipment, artificial airway malpositioning and incorrect positioning of patients. Serious adverse outcomes occurred in 55 reports (31%) including major physiological derangement (15%), patient/relative dissatisfaction (7%), prolonged hospital stay (4%), physical/psychological injury (3%) and death (2%). Of 900 contributing factors identified, 46% were system-based and 54% human-based. Communication problems, inadequate protocols, in-servicing/training and equipment were prominent equipment-related incidents. Errors of problem recognition and judgement, failure to follow protocols, inadequate patient preparation, haste and inattention were common management-related incidents. Rechecking the patient and equipment, skilled assistance and prior experience were important factors limiting harm.


Intra-hospital transport poses an important risk to ICU patients. The adequate provision of highly qualified staff, specially designed and well maintained equipment, as well as continuous monitoring are essential to avoid/mitigate these incidents. Professional societies and local units should adopt guidelines/protocols for intra-hospital transportation. Monitoring of incidents should aid in the continuous improvement in patient safety.


Transportation of patients Critical care Incident monitoring Adverse effects Patient safety Quality assurance 

Supplementary material

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Supplementary Material (PDF 20 KB)


  1. 1.
    Abraham E, Lee G, Morgan MT (1986) Conjunctival oxygen tension monitoring during helicopter transport of critically ill patients. Ann Emerg Med 15:782–786PubMedGoogle Scholar
  2. 2.
    Barry PW, Ralston C (1994) Adverse events occurring during interhospital transfer of the critically ill. Arch Dis Child 71:8–11PubMedGoogle Scholar
  3. 3.
    Bion JF, Edlin SA, Ramsay G, McCabe S, Ledingham IM (1985) Validation of a prognostic score in critically ill patients undergoing transport. Br Med J Clin Res Ed 291:432–434PubMedGoogle Scholar
  4. 4.
    Burtnyk S (1992) Secondary transportation of critically ill people—implications for nurses and the need for specialist training. Intensive Crit Care Nurs 8:234–239PubMedGoogle Scholar
  5. 5.
    Duke GJ, Green JV (2001) Outcome of critically ill patients undergoing interhospital transfer. Med J Aust 174:122–125PubMedGoogle Scholar
  6. 6.
    Edge WE, Kanter RK, Weigle CG, Walsh RF (1994) Reduction of morbidity in interhospital transport by specialized pediatric staff. Crit Care Med 22:1186–1191PubMedGoogle Scholar
  7. 7.
    Ehrenwerth J, Sorbo S, Hackel A (1986) Transport of critically ill adults. Crit Care Med 14:543–547PubMedGoogle Scholar
  8. 8.
    Evans JS, Hotter A (1994) A novel equipment bridge for helicopter transport of critically ill patients. Anaesth Intensive Care 22:284–287PubMedGoogle Scholar
  9. 9.
    Fromm RE Jr, Dellinger RP (1992) Transport of critically ill patients. J Intensive Care Med 7:223–233PubMedGoogle Scholar
  10. 10.
    Gebremichael M, Borg U, Habashi NM, Cottingham C, Cunsolo L, McCunn M, Reynolds HN (2000) Interhospital transport of the extremely ill patient: the mobile intensive care unit. Crit Care Med 28:79–85PubMedGoogle Scholar
  11. 11.
    Girotti MJ, Pagliarello G (1988) Mead Johnson Critical Care Symposium for the Practising Surgeon. 1. Transport of critically ill adult patients. Can J Surg 31:319–322PubMedGoogle Scholar
  12. 12.
    Greco A (1990) Development of an interfacility transport program for critically ill cardiovascular patients. AACN Clin Issues Crit Care Nurs 1:3–12PubMedGoogle Scholar
  13. 13.
    Kanter RK, Tompkins JM (1989) Adverse events during interhospital transport: physiologic deterioration associated with pretransport severity of illness. Pediatrics 84:43–48PubMedGoogle Scholar
  14. 14.
    Kanter RK, Boeing NM, Hannan WP, Kanter DL (1992) Excess morbidity associated with interhospital transport. Pediatrics 90:893–898PubMedGoogle Scholar
  15. 15.
    Pristas LR, Rausch T (1997) Transport considerations for the critically ill child. Crit Care Nurs Q 20:72–80Google Scholar
  16. 16.
    Ridley S, Carter R (1989) The effects of secondary transport on critically ill patients. Anaesthesia 44:822–827PubMedGoogle Scholar
  17. 17.
    American College of Critical Care Medicine (1993) Guidelines for the transfer of critically ill patients. Am J Crit Care 2:189–195PubMedGoogle Scholar
  18. 18.
    Society of Critical Care Medicine (1993) Guidelines for the transfer of critically ill patients. Crit Care Med 21:931–937PubMedGoogle Scholar
  19. 19.
    Faculty of Intensive Care and Australasian College for Emergency Medicine (1996) Minimum standards for transport of the critically ill. Faculty of Intensive Care and Australasian College for Emergency Medicine. Report No.: IC-10Google Scholar
  20. 20.
    Beyer AJD, Land G, Zaritsky A (1992) Nonphysician transport of intubated pediatric patients: a system evaluation. Crit Care Med 20:961–966PubMedGoogle Scholar
  21. 21.
    Barton AC, Tuttle-Newhall JE, Szalados JE (1997) Portable power supply for continuous mechanical ventilation during intrahospital transport of critically ill patients with ARDS. Chest 112:560–563PubMedGoogle Scholar
  22. 22.
    Braman SS, Dunn SM, Amico CA, Millman RP (1987) Complications of intrahospital transport in critically ill patients. Ann Intern Med 107:469–473PubMedGoogle Scholar
  23. 23.
    Brokalaki HJ, Brokalakis JD, Digenis GE, Baltopoulos G, Anthopoulos L, Karvountzis G (1996) Intrahospital transportation: monitoring and risks. Intensive Crit Care Nurs 12:183–186PubMedGoogle Scholar
  24. 24.
    Carson KJ, Drew BJ (1994) Electrocardiographic changes in critically ill adults during intrahospital transport. Prog Cardiovasc Nurs 9:4–12Google Scholar
  25. 25.
    Caruana M, Culp K (1998) Intrahospital transport of the critically ill adult: a research review and implications. Dimens Crit Care Nurs 17:146–156PubMedGoogle Scholar
  26. 26.
    De Cosmo G, Primieri P, Mascia A, Gualtieri E, Bonomo V, Villani A (1993) Intra-hospital transport of the anaesthetized patient. Eur J Anaesthesiol 10:231–234PubMedGoogle Scholar
  27. 27.
    Evans A, Winslow EH (1995) Oxygen saturation and hemodynamic response in critically ill, mechanically ventilated adults during intrahospital transport. Am J Crit Care 4:106–111PubMedGoogle Scholar
  28. 28.
    Haupt MT, Rehm CG (2000) Bedside procedures. Solutions to the pitfalls of intrahospital transport. Crit Care Clin 16:1–6PubMedGoogle Scholar
  29. 29.
    Hurst JM, Davis K Jr, Johnson DJ, Branson RD, Campbell RS, Branson PS (1992) Cost and complications during in-hospital transport of critically ill patients: a prospective cohort study. J Trauma 33:582–585PubMedGoogle Scholar
  30. 30.
    Insel J, Weissman C, Kemper M, Askanazi J, Hyman AI (1986) Cardiovascular changes during transport of critically ill and postoperative patients. Crit Care Med 14:539–542PubMedGoogle Scholar
  31. 31.
    Kalisch BJ, Kalisch PA, Burns SM, Kocan MJ, Prendergast V (1995) Intrahospital transport of neuro ICU patients. J Neurosci Nurs 27:69–77PubMedGoogle Scholar
  32. 32.
    Link J, Krause H, Wagner W, Papadopoulos G (1990) Intrahospital transport of critically ill patients. Crit Care Med 18:1427–1429PubMedGoogle Scholar
  33. 33.
    Smith I, Fleming S, Cernaianu A (1990) Mishaps during transport from the intensive care unit. Crit Care Med 18:278–281PubMedGoogle Scholar
  34. 34.
    Stearley HE (1998) Patients’ outcomes: intrahospital transportation and monitoring of critically ill patients by a specially trained ICU nursing staff. Am J Crit Care 7:282–287PubMedGoogle Scholar
  35. 35.
    Szem JW, Hydo LJ, Fischer E, Kapur S, Klemperer J, Barie PS (1995) High-risk intrahospital transport of critically ill patients: safety and outcome of the necessary “road trip”. Crit Care Med 23:1660–1666PubMedGoogle Scholar
  36. 36.
    Tan TK (1997) Interhospital and intrahospital transfer of the critically ill patient. Singapore Med J 38:244–248PubMedGoogle Scholar
  37. 37.
    Tompkins JM (1990) Intrahospital transport of seriously ill or injured children. Pediatr Nurs 16:51–53PubMedGoogle Scholar
  38. 38.
    Venkataraman ST, Orr RA (1992) Intrahospital transport of critically ill patients. Crit Care Clin 8:525–531PubMedGoogle Scholar
  39. 39.
    Wallen E, Venkataraman ST, Grosso MJ, Kiene K, Orr RA (1995) Intrahospital transport of critically ill pediatric patients. Crit Care Med 23:1588–1595CrossRefPubMedGoogle Scholar
  40. 40.
    Waydhas C, Schneck G, Duswald KH (1995) Deterioration of respiratory function after intra-hospital transport of critically ill surgical patients. Intensive Care Med 21:784–789PubMedGoogle Scholar
  41. 41.
    Weg JG, Haas CF (1989) Safe intrahospital transport of critically ill ventilator-dependent patients. Chest 96:631–635PubMedGoogle Scholar
  42. 42.
    Beckmann U, West LF, Groombridge GJ, Baldwin I, Hart GK, Clayton DG, Webb RK, Runciman WB (1996) The Australian Incident Monitoring Study in Intensive Care: AIMS-ICU. The development and evaluation of an incident reporting system in intensive care. Anaesth Intensive Care 24:314–319PubMedGoogle Scholar
  43. 43.
    Beckmann U, Baldwin I, Hart GK, Runciman WB (1996) The Australian Incident Monitoring Study in Intensive Care: AIMS-ICU. An analysis of the first year of reporting. Anaesth Intensive Care 24:320–329PubMedGoogle Scholar
  44. 44.
    Australian and New Zealand College of Anaesthetists and Joint Faculty of Intensive Care Medicine (2003) Minimum standards for intensive care units. Report No.: IC-1Google Scholar
  45. 45.
    Beckmann U, Gillies DM (2001) Factors associated with reintubation in intensive care: an analysis of causes and outcomes. Chest 120:538–542CrossRefPubMedGoogle Scholar
  46. 46.
    Australian and New Zealand College of Anaesthetists and Faculty of Intensive Care (2000) Intrahospital transport of critically ill patients. Report No.:PS39Google Scholar

Copyright information

© Springer-Verlag 2004

Authors and Affiliations

  • Ursula Beckmann
    • 1
    Email author
  • Donna M. Gillies
    • 2
  • Sean M. Berenholtz
    • 3
  • Albert W. Wu
    • 4
  • Peter Pronovost
    • 3
  1. 1.Division of Anaesthesia, Intensive Care and Pain ManagementJohn Hunter HospitalNewcastleAustralia
  2. 2.Division of SurgeryJohn Hunter HospitalNewcastleAustralia
  3. 3.Department of Anesthesiology & Critical Care Medicine, School of MedicineJohns Hopkins UniversityBaltimoreUSA
  4. 4.Department of Health Policy & ManagementJohns Hopkins Bloomberg School of Public HealthBaltimoreUSA

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