Brunsveld-Reinders et al.

Critical Care (2015) 19:214

DOI 10.1186/s13054-015-0938-1

RESEARCH Open Access

A comprehensive method to develop a checklist

to increase safety of intra-hospital transport of
critically ill patients
Anja H Brunsveld-Reinders*, M Sesmu Arbous, Sander G Kuiper and Evert de Jonge

Abstract
Introduction: Transport of critically ill patients from the Intensive Care Unit (ICU) to other departments for
diagnostic or therapeutic procedures is often a necessary part of the critical care process. Transport of critically ill
patients is potentially dangerous with up to 70% adverse events occurring. The aim of this study was to develop a
checklist to increase safety of intra-hospital transport (IHT) in critically ill patients.
Method: A three-step approach was used to develop an IHT checklist. First, various databases were searched for
published IHT guidelines and checklists. Secondly, prospectively collected IHT incidents in the LUMC ICU were
analyzed. Thirdly, interviews were held with physicians and nurses over their experiences of IHT incidents. Following
this approach a checklist was developed and discussed with experts in the field. Finally, feasibility and usability of
the checklist was tested.
Results: Eleven existing guidelines and five checklists were found. Only one checklist covered all three phases:
pre-, during- and post-transport. Recommendations and checklist items mostly focused on the pre-transport phase.
Documented incidents most frequently related to patient physiology and equipment malfunction and occurred
most often during transport. Discussing the incidents with ICU physicians and ICU nurses resulted in important
recommendations such as the introduction of a standard checklist and improved communication with the other
departments. This approach resulted in a generally applicable checklist, adaptable for local circumstances. Feedback
from nurses using the checklist were positive, the fill in time was 4.5 minutes per phase.
Conclusion: A comprehensive way to develop an intra-hospital checklist for safe transport of ICU patients to
another department is described. This resulted in a checklist which is a framework to guide physicians and nurses
through intra-hospital transports and provides a continuity of care to enhance patient safety. Other hospitals can
customize this checklist to their own situation using the methods proposed in this paper.

Introduction related to equipment failure (39 to 45%) [6-8], physiological

Critically ill patients are frequently transported between deterioration of the patient including hypotension in up to
the ICU and other sections of the hospital for diagnostic 47% and hypoxia (20 to 29%) [3]. Specific knowledge on
and/or therapeutic interventions [1-3]. Unfortunately the risk of particular incidents during IHT can contribute
there is an increased risk of an adverse event during to improved safety but so far little is known about what
intra-hospital transport (IHT) [4]. The first documentation kind of incidents occur during intra-hospital transport of
that IHT is potentially dangerous was published in 1970: critically ill patients.
during transport, arrhythmia occurred in 84% of patients Measures to reduce incidents include better pre-transport
at high risk of cardiovascular events [5]. Subsequent planning, the introduction of standardised procedures
studies reported incidents in 4.2 to 70.0% of critically ill related to personnel, organisation and equipment during
patients during IHT [1-3,6-8]. Incidents were mostly transport and the use of checklists during the preparation
phase [3,6-10]. Indeed, some guidelines on optimal IHT
* Correspondence: [email protected] [11,12] are available but they are not easily translated into
Department of Intensive Care, Leiden University Medical Center, Albinusdreef 2,
PO Box 9600, 2300, RC Leiden, the Netherlands practical measures to reduce incidents. As an alternative,

© 2015 Brunsveld-Reinders et al.; licensee BioMed Central. This is an Open Access article distributed under the terms of the
Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use,
distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public
Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this
article, unless otherwise stated.
Brunsveld-Reinders et al. Critical Care (2015) 19:214 Page 2 of 10

checklists are practical and can provide tools to improve databases were searched for medical literature with the
safety [13]. The aim of our study was to develop a checklist following terms: ‘intensive care’, ‘critical care’, ‘critically ill’,
covering the pre-transport preparation phase, the actual ‘intra-hospital transport’, ‘in-hospital transport’, ‘radiology
transport phase and the ICU reinstallation (post-transport) department’, ‘guideline’ and ‘checklist’. Reference lists of
phase, to improve safety during intra-hospital transport of review articles and eligible primary studies were checked to
adult critically ill patients. identify cited articles not captured by electronic searches.

Methods Study selection

This study was conducted in a 29-bed, adult patient Two authors (AB and SK) scrutinised titles and abstracts
mixed tertiary ICU at the Leiden University Medical of all references for possible inclusion. Inclusion criteria
Center (LUMC), the Netherlands. Three complementary were: transport of adult ICU patients in the hospital,
methods were sequentially applied to develop the checklist. checklist and/or recommendations for IHT. Excluded were
These consisted of (1) a review of the available literature articles related to paediatric critical care, inter-hospital
on IHT guidelines and checklists, (2) an analysis of inci- transport, reviews and editorials. Full text articles were
dents related to IHT at the LUMC and (3) an inventory of examined and any disagreement was resolved by a third
what could go wrong during IHT and how to prevent its author (SA).
accumulation through structured interviews with ICU
doctors and ICU nurses. Based upon the study results, a Data abstraction
checklist was developed and the feasibility and usability of The following data were abstracted from the studies
the checklist were tested during a one-month period. with guidelines or checklists: author/research group,
year of publication, country and recommendations and
Definitions checklist items related to the pre-transport-, transport- and
For the purpose of this study we explicitly divided post-transport phase.
intra-hospital transport into three phases, and for the
literature search we determined whether these three Analysis of incidents related to transport
phases were addressed in the guidelines and checklists. We collected and analysed IHT incidents in our hospital
Furthermore, we specifically focussed on the separate to learn about the types and contributing factors of IHT
phases when analysing the reported incidents and in the incidents. In our ICU all incidents are submitted to an
interviews with doctors and nurses [14]. electronic incident reporting system. All routinely registered
The pre-transport phase is the phase in which the patient transport-related incidents were analysed and categorised
is prepared for transport. The focus is on the patient’s with respect to type, phase of occurrence and contributing
severity of illness and stability, on the kind of monitoring factors in the period from 2006 to 2009. Subsequently,
and therapy the patient currently requires and also on what over a 12-month period in 2012 we specifically asked
the patient is likely to need during the transport process. ICU physicians and ICU nurses to report all incidents
The transport phase comprises the transport from the ICU occurring during intra-hospital transport. A questionnaire
to another department and vice versa as well as the period was developed to collect these incidents. Incidents were
during the diagnostic or therapeutic procedure. The predefined and categorised as airway, breathing, circulation,
post-transport phase is the phase when the patient has disability, exposure and other. Also, a free-text field allowed
returned to the ICU, in which ICU monitoring and earlier the reporter to give a description of the situation during
ICU therapies have to be reinstalled, and the patient has to transport, perceived causes and actions that were taken.
be stabilised. This phase requires 0.5 to 1 h after transport Incidents were analysed with respect to type, circumstances
and must be considered as part of the transport process. and contributing factors.
An incident is defined as ‘any event or outcome which
could have reduced, or did reduce the safety margin for the Interviews with experts in the field of intensive care
patient. It may or may not have been preventable and may Structured interviews based on findings from the literature
or may not have involved an error on the part of the health and collected incidents were undertaken with ten ICU
care team’ [15]. physicians and fifteen ICU nurses. The interviews followed
a questionnaire containing 53 questions on what could go
Review of the literature wrong during the three phases of IHT and how to
Our review of the literature focused on guidelines and prevent it. Questions were related to equipment, patient
checklists on intra-hospital transport of critically ill physiology, monitoring, medication and fluid management;
patients. We searched in PubMed, Embase, Web of Science, and covered all three transport phases. Additionally,
COCHRANE, CINAHL, Academic Search Premier and for the transport phase questions focused on logistics
ScienceDirect; from inception until 12 January 2014. The and communication with the other department, and
Brunsveld-Reinders et al. Critical Care (2015) 19:214 Page 3 of 10

registration of vital signs. For the post-transport phase the physiology, a careful evaluation of the risk-benefit ratio
focus was on the reinstallation of ICU therapies and should be made by the physician [11,16-24] and special
monitoring and on the stabilization of the patient. A attention should be paid to the indication for transport
detailed overview of the questions used for the structured [11,12,17,18,23,24]. Other recommendations included
interview can be found in Additional file 1. planning of personnel with the suggestion that a mini-
mum of two qualified staff members, an ICU nurse and
Development of the checklist ICU physician, should accompany the patient [11,12,16-24]
The information gathered from the review of the literature, and the need for clear communication to ensure that
the analysis of transport-related incidents and the interviews the patient is expected at the destination department
with experts in the field were combined to develop the [16,20,22-24] and to confirm that the receiving party
checklist. Checklist items were structured according to the is ready [11,12,20,23,24].
different phases of transport. The checklist was introduced In the transport phase an important goal should be to
to ICU physicians and ICU nurses and was implemented in continue monitoring during the transport as well as during
the Patient Data Management System of our ICU to be the diagnostic or therapeutic procedure [11,17,18] and to
used in daily practice. check and record the patient’s vital signs on a regular basis,
at least every 15 minutes [16,24]. Furthermore, medication
Feasibility and usability and fluid management and maintenance of physiologic
The checklist was used by the ICU for one month, where- stability should be of key importance.
upon we collected data to investigate the feasibility and Back in the ICU, after installation and stabilization of the
usability of the checklist. Nurses were asked to fill in a patient, it is essential to check monitoring and medication
questionnaire after each transport documenting their and to document the course of the transport in the medical
experiences using this checklist. The following data were chart. With respect to the latter, attention should be paid to
collected: overall rating of the checklist, the time it took to the status of the patient during and after transport
fill in the checklist, relevance of the questions, logistics of [11,12,16-18,23,24] and also to the events and interventions
the filling in of the checklist, and questions that were felt to that occurred during transport [12,16-18,20,24]. All the
be lacking. The questionnaire is listed in Additional file 2. transport equipment should be cleaned and plugged back
in the main power supply to ensure that the equipment is
Ethical approval available for another transport to the receiving department
The Medical Ethics Committee of the LUMC waived for a diagnostic or therapeutic intervention.
the need for ethical evaluation of the study due to In the literature, five checklists for intra-hospital trans-
the observational nature of the study. Consequently, port of critically ill patients were found [25-29], of which
the need for informed consent was not applicable. one was specifically developed for obese patients [29]. The
main focus of the checklists was on the pre-transport
Results phase. Only the checklist developed by Jarden [27] also
Review of the literature described items for the transport and post-transport phase.
In total eleven guidelines [11,12,16-24] and five checklists Checklist items in the pre-transport phase related to the
on IHT [25-29] were identified in the literature. The patient, monitoring equipment, communication and quality
guidelines were developed in USA, Europe, India, of the team. Before transport, the clinical stability of the
Australia and New Zealand and described recommenda- patient [26-28] and the necessity of the transport should be
tions for intra-hospital transport as well as for inter-hospital assessed [28]. Medication, fluids and the equipment should
transport. In the guidelines some basic principles regarding be checked including transport trolley, monitoring devices,
transport were defined for example, that a hospital and additional equipment [25-29]. Items related to planning
transport protocol should be present [11,16-18,21,22,24] and organization should also receive attention [26,28,29].
and that the patient should receive the same level of basis For example, in order to guarantee a safe transport, items
physiologic monitoring during IHT as they received in were formulated with respect to the composition of the
the ICU [12,17-19,23]. Three phases of transport were transport team, namely the presence of a physician [27]
recognized. For each phase recommendations could be and a minimum number of ICU nurses [26].
subdivided into categories namely (i) use of (monitoring) During transport, when the patient has arrived at the
equipment, (ii) patient physiology, (iii) medication and destination department, various items should be checked
fluids, (iv) organization and planning. The pre-transport and ensured. First, the continuity of the oxygen supply and
phase was most extensively described. In this phase, the electronic supply for transport trolley and medication
recommendations were related to the use of a transport pumps should be checked [27]. Furthermore, vital signs
trolley, equipment to secure an airway, and preparation of and administration of medication should be registered
monitoring, medication and fluids. With respect to patient frequently.
Brunsveld-Reinders et al. Critical Care (2015) 19:214 Page 4 of 10

Upon return in the ICU, it is essential to reinstall 118 incidents (2.0%) were IHT related. Of the 118 IHT
respiratory support devices, medication and monitoring, incidents 38% occurred in the pre-transport phase, 47%
and to describe in the medical chart the complications in the transport phase and 15% in the post-transport
that have occurred during transport and to recheck the phase. In the pre-transport phase most reported incidents
used equipment [27]. An overview of the content of the were related to equipment and organizational issues.
published checklists is shown in Table 1. Examples of equipment-related incidents were: low
battery of the ventilator and/or medication pumps, use of
Analysis of incidents related to IHT a mechanical ventilator not suitable for the MRI and an
Over a 36-month period, a total of 5,937 incidents were empty oxygen tank. Examples of organization-related
reported in our incident registration system, of which incidents were inappropriate preparation of the patient
Table 1 An overview of the content of published intra-hospital (IHT) checklists
Author Pope [28] Fanara [26] Jarden [27] Roland [29] Choi [25] Current
checklista
Year of publication 2003 2010 2010 2010 2011 LUMC
Pre-transport
Necessity of transport is confirmed +
Patient assessment pre-transport + +
Wrist band patient or consent form + + + +
Transport team is notified + + +
Equipment and materials are gathered + + + + + +
Check sufficient oxygen level + + +
Extra intravenous fluid and medication + + + + +
Check sufficient intravenous medication + + + + +
Stop enteral feeding and enteral insulin +
Check tubes and lines + + + + +
Check and set monitor alarms + + +
Check and set transport ventilator alarms + +
Insert intravenous cannula in case of computed +
tomography with contrast
Preparation and equipment adapted to procedure + +
(magnetic resonance imaging)
Fill in magnetic resonance imaging safety questionnaire +
Register baseline vital signs +/− + +
Receiving department is notified + +
Transport route is clear +
During transport
Check and plug in equipment at destination + +
Registration of administered fluids/medication + +
Registration vital signs every 20 minutes + +
Post-transport
Start enteral feeding and enteral insulin +
Turn on humidifier +
Change HME filter +
Change suction bag if used + +
Complement transport bag +
Report occurred incidents/events + +
Re-check equipment and materials + +
a
Current checklist Leiden University Medical Center (LUMC) refers to the final checklist that was based on reviewing the available literature on IHT checklists and
guidelines, an analysis of transport related incidents and a structured interview with ICU physicians and ICU nurses. HME, heat and moisture exchanger.
Brunsveld-Reinders et al. Critical Care (2015) 19:214 Page 5 of 10

leading to delay of transport or inadequate communica- 305 minutes). In 77% the reason for the IHT was to perform
tion with the receiving department. computed tomography (CT) and in 10% angiography.
Also in the transport phase most reported incidents In 133 of the 503 transports (26%), one or more incidents
were related to equipment and organisation. Examples of occurred, and in total, 358 incidents were reported.
equipment incidents during this phase included failure of Incidents occurred in the transport phase (215/358,
the transport trolley and its monitor. Examples of the 60%), in the pre-transport phase (80/358, 22%) and in
organisational incidents were in availability of CT or MRI the post-transport phase (63/358, 18%). The ten most
equipment. Post-transport, most reported incidents were frequently reported incidents during transport are shown in
related to airway and respiratory management, such as Table 2. In the transport phase the incidents were related to
failure to install adequate oxygen level or to reconnect the hemodynamic instability, respiratory instability, equipment
humidifier of the ventilator. An overview of the most dysfunction and increased need of medication. In the pre-
common incidents is shown in Table 2. transport and post-transport phase incidents were related
In 2012, we prospectively collected transport-related to hemodynamic instability. The lack of communication
incidents. In this period, 503 transports to the radiology with the radiology department before and during transport
department were undertaken. In 334/503 (66%) of IHTs also occurred regularly.
an ICU physician and ICU nurse accompanied the
patients to the radiology department. In 133/503 (27%) Interviews with experts in the field of intensive care
of IHTs three ICU staff members, an ICU physician and Ten physicians and fifteen nurses were interviewed to
two ICU nurses and in 16/503 (3%) four ICU staff discuss the findings from the literature and the collected
members, two ICU physicians and two ICU nurses incidents. A transport protocol existed in our hospital
accompanied the patient. When the patient was not but 90% of the physicians and 73% of the nurses were not
intubated the nurses sometimes accomplished the familiar with the protocol. The protocol described the
transport without a physician 20/503 (4%). The median composition of the accompanying team, the monitoring
duration of the transport was 55 minutes (range 10 to and respiratory equipment to be used, and the medication

Table 2 Top ten most commonly reported intra-hospital transport (IHT)-related incidents
Top 10 routinely registered IHT related incidentsa Pre-transport During transport Post-transport Total
Equipment malfunction 9 24 1 34
Preparation before transport 30 0 0 30
Lack of communication with radiology department 1 5 0 6
Dislocation of intravenous lines and tubing 0 12 1 13
Oxygen tank empty 4 4 0 8
Increase need vasopressor or inotropics 0 3 0 3
Equipment not available at radiology department 0 5 0 5
Lack of documentation in medical chart 0 0 2 2
Failure reconnect humidifier on ventilator 0 0 11 11
Hypoglycemia 0 0 1 1
Top ten prospectively collected IHT-related incidentsb
Equipment malfunction 7 24 2 33
Preparation before transport 6 5 0 11
Lack of communication with radiology department 5 5 0 10
Dislocation intravenous line 0 7 2 9
Oxygen tank empty 4 2 0 6
Increase need vasopressor or inotropics 5 15 6 26
Low blood pressure§ 21 44 18 83
Hypoxia§/increased oxygen demand 5 18 12 35
Increased need sedatives or opiods due to agitation 2 17 2 21
Hypertension§ 2 9 3 14
a
Analysis of transport-related incidents that were identified from routinely collected incidents in an elecronic incident reporting system in Leiden University
Medical Center. bFor 12 months all incidents occurring during intra-hospital transport were prospectively collected. §No definitions were used to define
hypotension, hypertension and hypoxia. Physicians and nurses were able to judge whether it deviated.
Brunsveld-Reinders et al. Critical Care (2015) 19:214 Page 6 of 10

and additional equipment that should be available during Development of the checklist
transport. Based on the literature, we chose the checklist of Jarden
Incidents considered most important by physicians and [27] as a base to develop our own checklist. The other
nurses in the pre-transport phase were an empty oxygen four checklists were used to complement our new check-
tank, lack of sufficient intravenous access, missing equip- list. All the checklists had several items in common such
ment, trolley failure, inadequate length of intravenous tub- as check equipment/materials [25-29], medication [26-28]
ing and miscommunication with the radiology department. and intravenous access [25-29]. We included these items
In the transport phase, nurses and physicians mentioned in our checklist. One item, only found in the checklist by
potential incidents such as dislocation of an intravenous Pope was ‘whether the receiving department is notified’
cannula or endotracheal tube, low battery in the pumps, and we included this item also in our checklist [28].
impaired view of the patient in the radiology department An overview of the items of the published checklists
and patient instability. In the post-transport phase patient is shown in Table 1.
instability and incorrect reinstallation of respiratory The final checklist developed as described above is
support and medication were commonly reported. presented in Figures 1 and 2. The basic principle of this
To enhance a safer transport, several improvement checklist was to guide the physician and nurses through
measures were suggested by physicians and nurses, such the different phases. In the pre-transport phase the
as introduction of a checklist for the three phases of focus is on required equipment, preparation of extra
transport and standardisation of the transport procedure medication and intravenous fluids and checking of
and improved communication with the radiology depart- procedures such as the use of contrast fluid and kidney
ment. A list of recommendations can be found in Table 3. protection. In the transport phase the focus is on the
Furthermore, the physicians and nurses indicated that they destination department with attention for the following
would feel more confident if they received more education items: plugging in the oxygen, monitoring equipment and
and practical training. keeping sight of the monitor during the procedure and

Table 3 Recommendations from ICU physicians and ICU nurses

Recommendations
Team Ventilated patient at least one ICU physician and one ICU nurse
Not ventilated patient and:
o ≤ 1 inotropic, one ICU nurse
o ≤ 1 inotropic, respiratory insufficient and arrhythmia, one ICU physician and one ICU nurse
Education Focus on how to operate equipment of transport trolley
More education for ICU physicians and ICU nurses to execute transport of ICU patients
Equipment and materials Equipment on trolley is equal to equipment in the ICU
Check equipment and materials prior to transport
Check extra length of intravenous lines for magnetic resonance imaging prior to transport
Check and calculate oxygen level in oxygen tank
Defibrillator is standard equipment on transport trolley
Check all equipment on transport trolley
Batteries are fully charged prior to transport
Organization and procedure Introduction of an intra-hospital checklist
Formal training in transport procedure to MRI
Standard Operating Procedure
Standardization of IHT procedure
Communication Confirm appointment with the other department prior to transport
Improve communication with the other department to prevent incidents during transport
Debriefing with ICU physician and ICU nurse after transport
Medication Check and prepare intravenous medication prior to transport
Extra intravenous medication and intravenous fluids
Recommendations suggested by ICU physicians and ICU nurses when they were interviewed to discuss safety and hazards of IHT and the findings from the
literature and the collected incidents.
Brunsveld-Reinders et al. Critical Care (2015) 19:214 Page 7 of 10

Figure 1 Newly developed Leiden University Medical Center (LUMC), checklist side one. i.v., intravenous; MRI, magnetic resonance imaging;
EtCO2, end tidal CO2; HME, heat and moisture exchanger; ET/TT, endotracheal tube/tracheal tube; PDMS, Patient Data Management System.

registration of vital signs, and medication and intravenous stated that the user friendliness of the checklist was good,
fluids. In the post-transport phase it is important to it was comprehensive and complete, it reduced the chance
connect the patient to the equipment in the ICU with of forgetting things, and it was easy to apply because it
specific attention to switching on the humidifier, was implemented in the Patient Data Management
nutrition, insulin and checking the correct dose of System. A point of criticism was the documentation of
medication via the perfusor. Also, to assure that required vital signs every 20 minutes on the paper-based checklist
equipment is ready for use on the next trip, the transport that was used in the transport phase. This was considered
trolley and transport bag should be checked and time consuming. Digitally input documentation was
connected to the power supply. Finally, documentation preferred. Items that were missed in the checklist were
in medical charts including registration of incidents information on the completeness of the transport bag and
should be checked. patient assessment in the pre- and post-transport phase.
Information on the transport phase and post-transport
Feasibility and usability phase was filled in after the transport.
In order to investigate the feasibility and usability of the
checklist, data were collected over a one-month period Discussion
using the checklist. During this month, 41 transports We developed a checklist to improve safety of intra-
were made to the radiology department. In 29 of these hospital transport by using three complementary methods:
transports, the checklist was used and a questionnaire a review of the available guidelines and checklists in the
was later filled in by the nurses about their experiences literature, an analysis of transport-related incidents and an
using the checklist. Reasons for not using the checklist inventory of what could go wrong during IHT and
during transport were either due to forgetfulness of the how to prevent it by interviews with ICU doctors and
team to use it (5/29) or to the urgency of the transport nurses. Importantly our checklist includes three phases of
(7/29). The time it took to fill in the checklist was on intra-hospital transport. Furthermore, we propose that
average 4.5 minutes per phase (range 3 to 10). Nurses our methods of local modification of an existing checklist
Brunsveld-Reinders et al. Critical Care (2015) 19:214 Page 8 of 10

Figure 2 Newly developed Leiden University Medical Center (LUMC) checklist, side two. i.v., intravenous; HR, heartrate; BP, bloodpressure; MAP,
mean aterial pressure; CVP, central venous pressure; PAP, pulmonary artery pressure; Vent mode, ventilation mode; FIO2, fraction of inspired
oxygen; PEEP/PS, postive end-expiratory pressure/pressure support; RR, respiratory rate; SpO2, peripheral capillary oxygen saturation; EtCO2, end
tidal CO2; GCS, Glasgow coma scale; PDMS, Patient Data Management System; HME, heat and moisture exchanger.

on IHT may be a useful procedure for any hospital aiming check the patient and equipment before transport. If the
at improving safety of intra-hospital transport. patient is checked before transport it lowers the risks of
The basic principles for intra-hospital and inter- incidents during transport. However, patient transport is
hospital transport are the same, namely to ensure safety not limited to the pre-transport phase. It is essential that
during this potentially dangerous transport [18]. We the entire transport process of critically ill patients is
were specifically interested in intra-hospital transports covered from start to end.
because they occur frequently on the ICU and because We wanted to adapt the checklist of Jarden [27] to our
the number of incidents during these transports is still own situation. It is often necessary to customise a checklist
very high. Our checklist is based on an earlier checklist because aspects of the checklist may not be suitable to a
by Jarden [27]. This is the only checklist that discerns specific local situation. Also in our case, some of our
three different transport phases. In other checklists the hospital policies and procedures differed from the described
focus was only on the pre-transport phase namely to checklist items. Therefore, ICUs need to customize the
Brunsveld-Reinders et al. Critical Care (2015) 19:214 Page 9 of 10

available checklists to their own situation taking into number of IHT-related incidents and improves safety.
account the hospital procedures and circumstances in This will be the subject of future research. Furthermore,
which a transport will be conducted. the checklist is by definition most useful in our specific
A comprehensive method was used to develop the hospital because it is customized to the local hospital and
checklist. This included a review of the literature for ICU procedures and protocols. Third, while we imple-
available guidelines and checklists, an analysis of incidents mented the pre- and post-transport phase checklist into the
related to transport in our hospital and an inventory of Patient Data Management System, the checklist items in
ICU physicians’ and nurses’ expert opinion over IHT. Due the transport phase are still registered on paper (vital signs,
to this approach, we obtained different types of knowledge medication and fluids). This may result in a potentially
available on the subject and we were better able to build a lower adherence during this phase.
comprehensive and practical checklist. This approach is A strong point of our study was the comprehensive
supported by Hales et al. [30] who stated that peer- way we developed the checklist. Particularly our inven-
reviewed guidelines and evidence-based best practice tory of what could go wrong during IHT and how to
should be considered to form the body of a checklist and prevent it, which we achieved through interviews with
that checklists should also reflect the local hospital ICU doctors and nurses, will have contributed to a
and institution policies and procedures. clinically relevant checklist and to the applicability
There are some differences between the Jarden checklist and acceptance of the checklist in daily practice by
[27] and ours. We added some items that are specifically ICU doctors and nurses. We think that this checklist
related to our local situation and some that are a more can contribute to the safety of ICU patients that need
generic addition for checklists on IHT. For example, in the to be transported during their ICU stay. However, to
pre-transport phase checking the availability of sufficient confirm this, the next step to be taken is testing and
intravenous medication was added. While Jarden’s checklist evaluating the efficacy of the checklist: is patient
included a patient assessment and documentation section safety increased with the checklist and are ICU nurses
in the pre-transport phase, we eliminated many of these and ICU physicians satisfied using it in daily practice?
items because this information can be found in our Patient Our checklist, though specifically adapted for one
Data Management System. We added a few items to the hospital, can be used in other hospitals as well. Each
checklist that were specific for our IHT policy. Examples hospital should assess whether the items from the
of these are extending the length of intravenous tubing, checklist are applicable to their specific situation. If
hyper hydration for kidney protection and an MRI safety necessary, local modifications can be made.
questionnaire for transport to MRI. In the post-transport
phase the focus was on connecting the patient to the Conclusion
available equipment in the ICU and on checking the rate In conclusion, we applied a comprehensive approach to
of administration of intravenous pumps with the Patient develop an intra-hospital checklist for safe transport of
Data Management System. These items were important ICU patients to another department and back to the
for our ICU due to frequently reported incidents that ICU. This checklist is not only based on available guide-
decreased patient safety. lines and checklists in the literature but also on reported
General guidelines and checklists provide guidance in incidents and expert opinions of ICU physicians and
developing a local checklist. The concept of local adapta- nurses. This resulted in a checklist that is a framework to
tion of the transport checklist developed by Jarden [27] guide ICU physicians and nurses through intra-hospital
was not previously described. In our opinion, customising transport and provides continuity of care to enhance
a checklist according to local policies and procedures patient safety.
improves the commitment of nurses and physicians
to use this checklist. Key messages
A checklist can be seen as an important instrument to
avoid incidents. It is of added value if it is introduced  A comprehensive method was applied to develop a
accompanied with education and training. Barriers to checklist which can be used to increase the safety of
using checklists in healthcare are related to operational intra-hospital transport of critically ill patients.
and cultural aspects [13]. Filling in a checklist adds to the  The checklist covers the transport of critically ill
nurse’s workload. However, in our small feasibility study, patients from the start until the end of the process,
it only took 4.5 minutes (range 3 to 10) per phase and it including all three transport phases.
appeared that nurses were on the whole positive about  Customizing the checklist according to local policies
using a transport checklist. and procedures - using the comprehensive method
Our study has a few limitations. First, we have not yet suggested in this study - is important to improve the
investigated whether our checklist indeed decreases the commitment of nurses and physicians.
Brunsveld-Reinders et al. Critical Care (2015) 19:214 Page 10 of 10

Additional files 16. Australasian College for Emergency Medicine, Australian and New Zealand
College of Anaesthetistis; Joint Faculty of Intensive Care Medicine. Minimum
standards for intrahospital transport of critically ill patients. Emerg Med
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ICU physicians and ICU nurses.
17. Whiteley S, Macartney I, Mark J, Barratt H, Binks R. Guidelines for the
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usability of current checklist Leiden University Medical Center 18. Australasian College for Emergency Medicine (ACEM), Australian and New
(LUMC). Zealand College of Anaesthetists (ANZCA), College of Intensive Care
Medicine of Australia and New Zealand (CICM). Guidelines for Transport of
Critically Ill Patients. 2013. http://www.anzca.edu.au/resources/professional-
Abbreviations
documents/pdfs/ps52-2013-guidelines-for-transport-of-critically-ill-patients.pdf/
CT: computed tomography; IHT: intra-hospital transport; LUMC: Leiden
at_download/file.
University Medical Center; MRI: magnetic resonance imaging.
19. Chang DW. AARC Clinical Practice Guideline: in-hospital transport of the
mechanically ventilated patient–2002 revision & update. Respir Care.
Competing interests
2002;47:721–3.
The authors declare that they have no competing interests.
20. Gupta S, Bhagotra A, Gulati S, Sharma J. Guidelines for the Transport of
Critically Ill Patients. JK Sci. 2004;6:109–12.
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AB contributed to the development of the manuscript concept and design, NVIC monitor. 2001;5:22–5.
carried out the study and performed primary writing and editing of all drafts 22. Quenot JP, Milesi C, Cravoisy A, Capellier G, Mimoz O, Fourcade O, et al.
of the manuscript. SA contributed to the development of the manuscript Intrahospital transport of critically ill patients (excluding newborns)
concept and design and performed editing of all drafts of the manuscript. recommendations of the Societe de Reanimation de Langue Francaise
SG contributed to the development of the manuscript concepts and design, (SRLF), the Societe Francaise d’Anesthesie et de Reanimation (SFAR), and
performed the literature search, analysed incidents and interviewed ICU the Societe Francaise de Medecine d’Urgence (SFMU). Ann Intensive Care.
physicians and ICU nurses and performed editing of the manuscript. 2012;2:1.
EdJ contributed to the development of the manuscript concept and 23. Warren J, Fromm Jr RE, Orr RA, Rotello LC, Horst HM. Guidelines for the
design and performed editing of all drafts of the manuscript. All authors inter- and intrahospital transport of critically ill patients. Crit Care Med.
read and approved the final version of the manuscript. 2004;32:256–62.
24. SIAARTI Study Group for Safety in Anesthesia and Intensive Care.
Received: 19 December 2014 Accepted: 22 April 2015 Recommendations on the transport of critically ill patient. Minerva
Anestesiol. 2006;72:XXXVII–LVII.
25. Choi HK, Shin SD, Ro YS, Kim DK, Shin SH, Kwak YH. A before- and
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