In this article, Physical Therapist and Health Care Expert, Christian Mongrain discusses patient transport in the health care setting. He covers the risks associated with mobilizing patients, errors that may occur, and best demonstrated practices utilized by health care professionals to reduce the incidence and severity of patient transport incidents.
Within health care facilities, it is extremely rare for a patient to be permitted to walk to/from tests or treatments; instead, they are typically transported by a health care worker, often via wheelchair or stretcher. This is known as patient transport.
The American Hospital Association calculated that there were nearly 35 million registered admissions to registered hospitals in the United States in 2014. If each of these patients was transported only to their room on admission, to and from one test, and then from their room to the exit, there would be 140 million opportunities for incident during patient transport. Considering the sheer volume of patient transports performed annually, even a low prevalence of incidents during transport can equate to hundreds-of-thousands of injuries.
The Office of the Inspector General reported in 2012 that an estimated 86% of hospital incidents go unreported. Transport of a patient is a dynamic event requiring knowledge, skill, equipment, and communication. Breakdown in any category can result in minor injury (such as a cut from pinching a finger on an unprotected rail) or, in some cases, catastrophe (such as a traumatic brain injury or death from a fall from a stretcher). The health care industry has long recognized the volume of patient transports and the potential for serious outcomes; as a result, most health care providers commit considerable resources to training, equipment upgrades, and facility investments in an effort to prevent these incidents from occurring.
Risks Associated with Patient Transport:
Errors in patient transport can result in a wide range of injuries and injury types. While falls may be the most common, patients with reduced functional capacity are at increased risk of pressure sores, entrapments, and other incidents.
- Falls are the leading cause of hospital acquired injury [Article on Hospital Falls]. While data gathered on falls in health care facilities does not indicate if the fall occurred during transportation, moving patients who are weak, sick, confused, in pain, unsteady, or debilitated has inherent risks. Falls can occur while transferring patients between beds, stretchers, or wheelchairs. Patients can also fall from stretchers or wheelchairs during transport.
- Pressure Sores
- Patient transport exposes patients to risk of injuries to the skin. While sliding a patient from bed to stretcher, sheering forces can cause sores or lacerations to skin. If not performed properly, slide transfers cause deep tissue injuries, most commonly at the sacrum or heels if not adequately supported or protected. In addition, patient transport can lead to pressure sores if the stretcher or wheelchair is not adequately padded, or the patient is subjected to prolonged positioning without ability to relieve pressure [Article on Pressure Ulcers].
- Other Injury Types
- In addition to falls and pressure sores, many other unintended outcomes can occur when a patient is moved from one location to another. Seatbelts used on wheelchairs during transport can become a hazard if applied too loosely; enabling a patient’s torso to slide down and the belt to become a choking hazard. Transporting patients without proper application or engagement of safety features such as anti-tip bars, brakes, or side rails may lead to incidents involving patient ejection, collision, or entrapped limbs, to name a few.
Hospitals and health care providers take specific measures to minimize the risk of injury or harm to the patient and employees during patient transport. Safe transport depends on three main factors:
- Patient Assessment
- Selection of Appropriate Equipment
- Safe Technique by The Provider
- 1) Patient Assessment
- Patient condition can change at any moment, making a transfer technique or transport device that was previously used inappropriate. For instance, patients fatigue when sitting out of bed, and therefore require a higher degree of assistance to return to bed than they did to get out of bed. It is up to the provider to assess the patient’s strength, cognition, vitals, and even willingness/ability to assist in determining a plan for patient transport. Depending on the stability of the patient, the safest option may be to bring the test to the patient instead of the patient to the test (such as portable x-ray instead of transporting to the radiology department, or doing bedside therapy instead of transporting the patient to the gym).
- 2) Selection of Appropriate Equipment
- When it comes to patient transport, the two most common pieces of equipment utilized are wheelchairs and stretchers. Many additional devices are often used to assist a provider as they transfer a patient to or from stretchers and wheelchairs. Common transfer tools include: lifts, transfer boards, transfer sheets, hover mats, walkers, crutches, and canes. If direction is not provided regarding which equipment should be used to perform a transfer or transport, the provider may use clinical judgement combined with understanding of patient precautions, mobility, stability, comfort, duration of transport, and the surface being transferred-to in order to choose the most appropriate transfer and transport equipment.
- Equipment selection can range from simple to complex, as there are many types and brands of medical equipment. For example: choosing a single point walking cane is relatively simple and usually only requires knowledge of patient height and weight. Choosing a wheelchair, on the other hand, can be significantly more complex depending on specific patient needs. At a minimum, the seat width, weight capacity, and presence of leg rests must be considered. For prolonged use, custom features involving leg rests, seat back, cushion, tilt function, and other features should also be considered.
- In some instances, a wheelchair may not be appropriate for transporting a patient. Patient paralysis, weakness, presence of other medical devices, safety awareness, or patient instability may be reasons for a provider to choose to transfer a patient using a stretcher, or even the hospital bed.
- 3) Safe Technique by the Provider
- There are many techniques to safely move patients. For instance, transferring from bed to wheelchair may be accomplished via a stand-pivot-sit with the provider approaching from the front, supporting the patient under his arms, and blocking the patient’s knees with his knees. Another option is to use a lateral slide using a transfer board and a wheelchair with a removable arm rest. Still another would be for the provider to perform a dependent transfer with the use of a lift. The method chosen by a provider is dependent on each situation, but in every case safety is the highest priority. For the example above, the provider of services needs to consider several factors including precautions (such as weight-bearing on legs), patient ability and willingness to assist, patient comfort, the limits of the person(s) assisting, the availability of appropriate equipment, and time. Choosing the wrong technique can result in significant consequences, even death.
- One of the most essential components of safe technique during patient transport is communication. It is the responsibility of the person providing the services to notify the patient of his/her actions and intent prior to providing care. This includes obtaining verbal consent, when possible, for providing transport from one location to the next. In most cases, informing the patient can lower patient anxiety, allow them to brace for the transfer, express any needs or concerns, and enable them to assist if they are capable.
Hospitals and health care centers recognize the risks associated with patient transport, and provide training to staff on safe patient handling. Training often includes body mechanics, transfer techniques, patient communication, precautions, proper selection and use of equipment, and education on how to identify equipment that is unsafe or requires maintenance. Simple procedures, like proper positioning of equipment, or application of the brakes, can prevent a routine transfer from becoming a catastrophe. Employees typically participate in safe patient handling training annually. When a new piece of equipment is introduced, staff should be trained in its use prior to using it for patient care.
Investigating Patient Transport Mishaps
Patient transportation can be a risky endeavor; from a forensic standpoint, there are many variables to consider when investigating an incident. An experienced health care professional, such as a physical therapist, can evaluate the patient’s functional level, issues involving equipment selection and maintenance, the education provided to the staff in regard to patient transport, as well as the transport techniques utilized in the incident.
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Rehabilitation Therapist & Health Care Expert
Christian Mongrain is a physical therapist and health care expert who has been actively involved in fall prevention, environment of care, and quality improvement councils in several hospitals. Since graduating with his Masters degree in Physical Therapy in 1999, Christian has worked as a therapist and director of therapies in hospital, LTACH, inpatient rehab, skilled nursing, and outpatient therapy centers. He applies his experience as a member of multidisciplinary teams to investigate incidents involving falls, patient handling, and unanticipated rehab outcomes.