Type:
Educational Exhibit
Keywords:
Not applicable, Acute, Complications, CT, Emergency, Emergency Imaging
Authors:
C. Shilagani, P. Gerard, P. Patel, C. Gwardschaladse, J. Meshekow; Valhalla, NY/US
DOI:
10.26044/ecr2020/C-13032
Background
A critically ill patient may be transferred several times during their admission in a hospital, whether it is intra-hospital transfer for diagnostic or therapeutic procedure, or inter-hospital transfer for tertiary care. Thus, it is imperative for the team caring for this patient to maintain continuity of care during such transfers, which includes continuation of medication, monitoring devices and lines or tubes that may be connected to the patient.
A transfer of a critically ill patient requires appropriate hand-off between departments by personnel that are closely invested in the immediate care of that particular patient. For this reason, the Joint Commission recommends use of standardized hand-off technique to ensure transfer of care at the highest standard possible. This allows appropriate hand-off of all medications received and those that are pending; all monitoring devices; and lastly any catheters or tubing to monitor appropriate drainage and function.
Every patient admitted to the hospital undergoes radiologic imaging, which requires transfer of patients from their room to the radiology department. As such, a radiology technician is often the first person a patient encounters in the radiology department. Thus, they play a pivotal role in transporting of several critically ill patients to and from the stretcher to the computed tomography table, or x-ray table. With several hundred encounters occurring on a daily basis, there is a high risk of complication in transfer of such critically ill patients.
It is imperative for the radiology technician to receive appropriate hand-off from the patient’s nurse of all monitoring devices and catheters attached to a patient. To highlight this point, we present a few cases of dislodged catheters that occurred during inter-departmental transport of critically ill patients and how they were recognized by our radiologist and radiology technicians.