Efficient Transfer of Patients with Critical Illnesses from General Wards to Intensive Care Units ()
1. Introduction
Patient-centered care has been a central focus of health-care systems worldwide since the 1960s [1]-[8], and patient safety has become a key aspect of health care. The Joint Commission of Taiwan region established standard operating procedures for between-unit patient transfers. Patient safety guidelines are reviewed annually, highlighting the importance of addressing safety concerns during patient transfer. Robust safety measures must be implemented to mitigate risks during patient transfers [9]-[11].
Patient transfers comprise several steps [12] [13] and require coordination between multiple individuals, who must pay attention to detail. A crucial task in patient transfer is ensuring that all necessary equipment is available and fully operational. Staff involved in a patient transfer must be well-prepared and capable of handling unexpected situations. Focus must be maintained, and location-specific protocols must be developed. During a patient transfer, immediate medical needs must be addressed. Health-care providers must be able to anticipate and mitigate problems that may arise during the transfer process. Nurses are at the forefront of this process and are responsible for managing all transfer-related tasks [14]. An efficient protocol that enables seamless coordination between medical team members should be developed to prevent clinical catastrophes resulting from delay. Effective communication and team-work are essential for optimizing patient transfers, minimizing complication risks, and ensuring patient safety.
In large health-care facilities, such as hospitals, transferring patients between units can be challenging [15]. Transferring patients between different buildings can be particularly challenging. Before initiating a patient transfer, nurses must notify all staff involved in the transfer, coordinate with family members, and gather essential equipment and supplies. These pretransfer tasks are time-consuming, increasing the likelihood of delays or errors in care delivery. The complexity of managing patient transfers in complex environments underscores the need for efficient patient transfer protocols. Thus, concerted efforts have been made to streamline patient transfer protocols. Pathways have been optimized, and time spent on logistical tasks has been reduced. By eliminating unnecessary steps and improving communication protocols, hospitals can reduce burdens on nursing staff, enabling staff to focus on patient care. Enhancing the efficiency of patient transfer can alleviate stress among staff and can improve patient outcomes by reducing delays in care, preventing potential errors, and ensuring timely treatment. The drive for improvement in logistics reflects a growing recognition that nursing efficiency and quality of care are directly associated with the effectiveness of transfer process management.
In this study, we explored key factors that influence the efficiency of patient transfer from general wards to intensive care units (ICUs). In our hospital, specific measures were implemented in 2022 to reduce patient transfer time. We subsequently validated the effectiveness of the implemented measures. Our objective was to optimize the transfer of patients with critical illnesses from general wards to ICUs.
2. Methods
To effectively transfer patients with critical illnesses, a general standard operation protocol is required. This study developed a protocol by reviewing evidence-based medical literature, analyzing patient charts, and gathering feedback from health-care professionals.
2.1. Factors Influencing Transfer Efficiency
Our hospital has two buildings (Buildings A and B). The ICU is located in Building A. Patients are moved into the ICU via a sky bridge. When a patient needs to be moved to the ICU, nurses inform the patient’s family about the reason for the move and ask the patient’s family to sign some paperwork. For patients who require oxygen therapy, nurses prepare the necessary equipment. Respiratory therapists are responsible for setting up ventilators and oxygen cylinders. Nurses prepare equipment, notify relevant medical staff, and document the following in their nursing records: patient vital signs, awareness level, and current medication. These tasks can be stressful.
Table 1. Respondent demographic characteristics.
|
Number |
Percentage (%) |
Gender |
Male |
15 |
11 |
Female |
120 |
89 |
Education |
Vocational high school |
2 |
1.5 |
College |
58 |
43 |
Bachelor |
67 |
49.6 |
Master |
8 |
5.9 |
Doctorate |
0 |
0 |
Seniority |
0 - 1 |
19 |
14.1 |
1 - 3 |
27 |
20.0 |
3 - 5 |
38 |
28.1 |
5 - 10 |
31 |
23.0 |
10 - 15 |
15 |
11.1 |
15 - 20 |
5 |
3.7 |
Level of
Training |
N |
31 |
23.0 |
N1 |
45 |
33.3 |
N2 |
44 |
32.6 |
N3 |
8 |
5.9 |
N4 |
7 |
5.2 |
Between May 15 and 30, 2021, a survey was conducted in our hospital to gather feed-back from colleagues on the transfer process. A total of 140 survey questionnaires were distributed, and 135 completed questionnaires were returned (recovery rate: 96.4%). The survey questions are listed in Table A1 (Appendix), and the distribution of respondents is summarized in Table 1. On the basis of the survey results, factors that influence patient transfer were identified and divided into the following three categories:
1) Preparation time for bed transfer: Failure to prepare a list of required items resulted in incomplete preparation. Furthermore, staff unfamiliarity with the transfer process and slowness in bed preparation increased transfer times.
2) Time required for shift handover: The protocol for transfers varied across nursing units, extending the time required for procedure completion.
3) Time required for between-ward patient movement: Between-unit movement of patients required a long time because of the following reasons: the long distance between the ICU and other wards, the lack of a single transfer route, nurse unfamiliarity with transfer routes, and long elevator wait times.
Another survey on patient transfer time was conducted between June 1 and 30, 2021, on these three factors. Each transfer step was timed using a stopwatch. Transfer times are listed in Table 2. Total transfer times were 2810 s for Building A and 3512 s for Building B. Nurse seniority and training level affected transfer time. In general, senior nurses were better able to transfer patients than were inexperienced nurses. Nurses should follow the same procedure to maintain the proper transfer of patients. Respondents completed the questionnaire (Table A1) every month for further enhancement on the procedure.
Table 2. Time required for patient transfer to ICU.
Item |
Task |
Average time (s) |
Building A |
Building B |
1 |
Preparation time for bed transfer |
774 |
854 |
2 |
Time required for shift handover |
1067 |
1252 |
3 |
Time required for between-ward patient movement |
969 |
1406 |
Total time required for ICU transfer |
2810 |
3512 |
2.2. Development and Implementation of Transfer Strategies
The following factors extended transfer time: unfamiliarity with transfer processes, unpreparedness, variations in transfer protocols across wards, unfamiliarity with transfer routes, and prolonged elevator wait times. The following strategies were developed and implemented to optimize the patient transfer process:
1) A standard material checklist was developed for patient transfer (Appendix Figure A1). The checklist covered every step of the transfer process and contained information on relevant contacts, material preparation, bed confirmation, and patient lists in the computer system. All staff were required to use the checklist to avoid the use of incorrect materials and delays due to unpreparedness.
2) A reminder card was designed for bed-turning processes and attached to the shift schedule. On the basis of the actual bed-turning process and after discussions with colleagues, the entire process of bed transfer was described on a small card. This card improved familiarity among colleagues and described the process in an easy-to-follow way.
3) A standard ICU transfer protocol was established on the basis of insights from a meeting with a nursing supervisor (Appendix Figure A2). The protocol was introduced during a morning ward meeting and then implemented.
4) Optimal transfer routes were identified. Site visits were conducted to examine routes. Optimal routes between Buildings A and B were identified and communicated to staff members (Appendix Figure A3).
5) A practical training session on elevator operation was conducted by the general division of our hospital. Nurses were shown how to correctly operate an elevator and were given an opportunity to ask questions.
The checklist helped nurses ensure that all essential items had been prepared. The reminder card served as an accessible guide. The ICU transfer protocol was developed in discussions with relevant personnel. Consequently, the protocol was highly applicable and reduced disputes between units. Disputes between units were not reported between July 1 and September 30, 2021. After the identification of efficient transfer routes, the transfer time decreased considerably. A survey was conducted among 31 staff members, 29 of whom were fully familiar with the revised procedures.
To further optimize the procedure, we arranged a seasonal check of the procedure based on the following:
1) Doctors are responsible for determining how urgently a patient requires transfer to the ICU. Doctors consider the following information when determining urgency: patient status, case background (patient issues, whether a body check has been performed), case assessment (evaluation based on situation and background), surgery, and other notes.
2) Staff performing a transfer must be trained in both basic life support and advanced cardiac life support. Being qualified in this way ensures that staff can overcome critical issues that may arise during a transfer. Additional training regarding dealing with potential issues may also be necessary [16].
3) The ICU is required to check the completeness of data provided by the ward. A checklist is used for this purpose [17].
On the basis of the aforementioned core concepts and potential changes in the layout and resources of the hospital, further optimizations to the patient transfer process can be made in the future.
2.3. Strategy Implementation in Different Hospitals
The proposed strategies can be adopted in any hospital, regardless of layout. The strategies are as follows. First, the patient’s condition must be assessed to determine how urgently the patient requires transfer to the ICU. Second, a standard material checklist should be used to ensure essential materials and equipment have been prepared. Examples of items on the checklist are pump settings, medicine details, monitoring details, and life support details. Third, distance to the ICU should be considered. To minimize transfer time, elevators must be efficiently operated, and the hospital must be effectively controlled. Clinicians should keep the following in mind to ensure transfer efficiency.
1) Pretransfer evaluation of patient condition is essential.
2) Staff must be familiar with the patient transfer procedure.
3) Recording of the transfer procedure and handover mechanism are needed to ensure the robustness of general procedure. These are required to be kept in the form of hard-copy to ease the process.
4) Long-term monitoring indices need to be recorded and discussed regularly to enhance quality and effectiveness.
By following the procedure for building the transfer plan and checklist, the morbidity or mortality of the patients can be effectively reduced.
The major challenges of implementing the proposed strategy are proper training of the participants, arrangement of the standard route, and building the checklist of required materials. These can be solved by following the information discussed in this section.
3. Results
The effectiveness of the implemented strategies was evaluated between October 1 and October 31, 2021. For this, changes in the three identified factors were assessed: preparation time for bed transfer, time required for shift handover, and time required for between-ward patient movement. We recorded the time taken for patient transfer in each ward; the results are presented in Table 3. In Building A, the total time required for ICU transfer decreased from 2810 to 1686 s (40% reduction). In Building B, the total time required for ICU transfer decreased from 3512 to 1996 s (43% reduction). Overall, the total transfer time for each patient decreased from 3161 to 1832 s (42% reduction).
Table 3. Time required for bed transfer after the introduction of the checklist.
Item |
Task |
Before Usage |
After Usage |
Building A |
Building B |
Building A |
Building B |
1 |
Preparation time for bed transfer |
774 |
854 |
356 |
446 |
2 |
Time required for shift handover |
1067 |
1252 |
832 |
668 |
3 |
Time required for
between-ward
patient movement |
969 |
1406 |
498 |
882 |
Total time taken for ICU transfer |
2810 |
3512 |
1686 |
1996 |
Reduction |
|
40% |
43% |
We asked doctors and nurses involved in patient transfers to self-evaluate their knowledge about and ability to perform the following parts of the patient transfer process.
1) Evaluating the patient’s condition.
2) Informing the receiving unit to prepare medicine.
3) Checking if the level of transfer is properly set.
4) Verifying that monitoring and life-supporting facilities have been checked by a doctor and have been properly set up.
5) Checking that pumps are properly operating and that enough medicine has been prepared.
6) Being ready to deal with unforeseen emergencies.
The participating clinicians scored close to 100% (no less than 96%) in their knowledge on the aforementioned items at every month for 2 years (Figure 1). This grasp of the process has helped reduce morbidity and mortality during patient transfers to 0% compared to the past.
Figure 1. Passing rate of the survey information.
4. Conclusion
Our strategies can be implemented in any hospital to optimize patient transfers. This study may guide healthcare professionals in assessing current patient transfer protocols and evaluating the effectiveness of improvement measures. The proposed strategies can help reduce nurse workloads and minimize errors during patient transfers, such as missing of materials or deceleration of transfer due to the wrong arrangement of transfer route, thereby enabling nurses to focus on patient care and safety.
Appendix
Table A1. Questionnaire for the internal survey.
□ Male/□ Female Level: □ N/□ N1/□ N2/□ N3/□ N4 |
Item/Grading |
1 |
2 |
3 |
4 |
5 |
Determining patient
condition |
I can easily identify the level of illness of the patient to be transferred |
|
|
|
|
|
I find the regulations for patient transfer clear and easy to follow |
|
|
|
|
|
Transferring unit |
The checklist can help me to prepare all the materials efficiently prior to the transfer. |
|
|
|
|
|
I am capable of using the record sheet of transfer sheet properly. |
|
|
|
|
|
My colleagues can correctly coordinate a transfer. |
|
|
|
|
|
My colleagues are completing the handover sheet correctly after implementing the new procedure. |
|
|
|
|
|
Receiving
unit |
I can efficiently check the handover
information with the transferring unit. |
|
|
|
|
|
The checklist and notes are clear and help me to prepare materials before transferring the patient. |
|
|
|
|
|
Average grading |
|
Signature/Date |
|
Suggestions of improvement |
|
Figure A1. Standard material checklist.
Figure A2. Standard ICU transfer protocol.
Figure A3. Planned transfer routes.