1. Intra-Hospital Transport of Intubated Closed Head Injury and Stroke Patients

2. Introduction
Efficient intra-hospital transport of severe closed head injury and stroke patients requires maintenance of consistent ventilation and oxygenation
minimize hyperventilation, hypoventilation, hypoxemia, and adverse stimulation
decrease in fluctuation in ventilator parameters which can result in adverse changes
low or high carbon dioxide levels
increased intra-cranial pressure
poor oxygenation levels
decreased cerebral blood flow 
Intra-hospital transport is associated with an adverse event rate of 70% with cardiopulmonary changes representing a large number of the events reported (Day, 2010; Zuchelo, 2009).

3. Methods
Prior to August 2009, intubated patients with closed head injury transported by staff using manual ventilation.
Various staff members were at times responsible for manual ventilation and airway stability.
No standard of care or consistency among team members when ventilating transport patients.
Our Goal: Performance Improvement
to determine if standard transport policy leads to improved care, faster transports, safer environment and fewer adverse events

4. Methods Team collaboration Target population: To assess process:
Process/guideline development
Target population:
all intubated patients with:
suspected or confirmed increased intracranial pressure such as severe head injury/head bleed
intracranial pressure monitored or ventriculostomy in place (monitored or unmonitored)
patients receiving Mannitol or hypertonic saline for cerebral edema, and
any other suspected issue where elevated intracranial pressure is a problem.
To assess process:
Retrospective data query
Transports occurring between April 2011 and March 2012.
The Respiratory team designed standardized guidelines for ventilator transport of severe head injury and stroke patients.
The guidelines are an attempt to provide a consistency of care for ventilated patients.

5. Results
Guideline
The guideline requires the use of a mechanical ventilator to maintain ventilation and oxygenation settings (tidal volume, FiO2, PEEP, respiratory rate) throughout the entire transport period.
Now a P/P throughout the Seton Network

6. General Guidelines for Ventilator Transport of Head Injury Patients
(Effective Monday 08/17/2009)
All intubated patients with suspected/confirmed increased ICP must be transported via the transport ventilator. This includes the following circumstances:
Severe Head Injury
Head Bleed
ICP Monitor or Ventriculostomy in place (monitored or unmonitored)
Patients receiving Mannitol or Hypertonic saline for cerebral edema
Any other suspected issue where elevated ICP is a problem.
The ER, ICU or RT Charge therapist will transport the patient to any area of the hospital required (CT scan, Special Procedure, Cath Lab, OR, etc...) and mechanical ventilation will be maintained throughout the transport, procedure and return to the Emergency Department or ICU.
Special Guidelines for OR Transports:
The ER, ICU or Charge Respiratory Therapist will transport the patient to the Operating Room and upon arrival to the OR care will be transferred to the Anesthesia team. Mechanical ventilation will continue during the surgical procedure.
The transport ventilator will remain plugged in outside of the OR suite until the completion of the case and RT contact information will be posted on the ventilator.
Upon completion of the case the OR transport team will notify the designated RT (extension indicated on contact information attached to transport ventilator) that patient is ready for transport back to the ICU.
RT will return to the OR to assume responsibility of mechanical ventilation via transport ventilator and return to ICU (or other specified area) with OR team.

7. Conclusion The Respiratory Therapist
is a key member of a multidisciplinary team responsible for the intra-hospital transport of intubated closed head injury and stroke patients.
available to assess any airway issues or concerns, monitor ventilation and sedation levels to achieve adequate and ideal ventilation during intra-hospital transport.
Guidelines lead to quicker, easier, and safer patient transports.
Continued data collection efforts will seek to determine whether we are able to decrease transportation time and decrease adverse events that may occur during the move.
We are using our data to help track time and movement of the RT, as well as destinations, and the necessity of additional personnel or a resource position that would take over the duty of transport from the charge staff and act as primary transport personnel in addition to other assigned duties. This would provide an increased level of safety for the patient to have specific team members available for the transports. We are also using workflow to help with the design of a new facility to make patient transport quick, easy, and safe. The guidelines strive to maintain a high level of safety and consistency of care.
The Respiratory Therapist managing the mechanical ventilator is now a key member of a multidisciplinary team responsible for the intra-hospital transport of intubated closed head injury and stroke patients.
All transports now take place on a transport ventilator to maintain current settings ( tidal volume, FiO2, PEEP, respiratory rate).
The Respiratory Therapist is also available to assess any airway issues or concerns, monitor ventilation and sedation levels to achieve adequate and ideal ventilation during intra-hospital transport.

8. Additional Observations
Transport destinations and time are being used to define workflow and help with facility design.
Data gathering through a new addition in the Electronic Medical Record that will track more specific patient outcomes.
Adverse event information is critical to the transport providers and the providers assuming care of the patient following transport.
Documentation of adverse events in a standard location allows providers to track the patient experience and ensure a paper trail exists for future inquiries.
Documentation of events is paramount when healthcare and QI personnel need to vet the safety of intra-hospital transport policies and procedures.
The respiratory therapist is uniquely trained to identify and document a range of events associated with the cardiopulmonary system.
Critically ill patients require complimentary tests to assess condition severity and/or justify additional treatment options. These complimentary services are not located in the intensive care unit thus requiring transport within the hospital. Intrahospital transport is associated with an adverse event rate of 70% with cardiopulmonary changes representing a large number of the events reported (Day, 2010; Zuchelo, 2009).