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New policy will lessen risk in intrahospital transfers

Asante is standardizing transfer practices at all three hospitals.


Your patient is a 67-year-old female admitted for urinary retention and generalized weakness with a long history of other chronic medical conditions. During her stay, she decompensated and required intubation. She remained intubated for two days. Post-extubation, it was identified she had experienced a stroke, requiring an NG tube.

Over the following week, despite being transferred out of ICU, she continued to decline, rejecting physical therapy and requiring increasing clinical interventions. Approximately a week after admission, she was sent for an imaging procedure but was not accompanied by an RN (VS stable but unresponsive with shallow breathing preceding transfer). During the imaging procedure, the patient was observed having a significant event, likely beginning with aspiration, and a code blue was called. Due to a DNR status, compressions were stopped, and the patient expired.

Intrahospital transport can carry a high risk for patients. Patient misidentification; line, tube or drain disconnection; and personnel who lack the clinical qualifications or experience to safely monitor patients are reported in the literature as areas of risk during transport. We have seen these factors at play in risk events at Asante.

This story and others highlight safety concerns when the appropriate personnel, mode of transport and equipment are not considered. A review of Asante transfer and transport processes throughout our system showed variability between facilities, including when an RN should accompany a patient during transport.

To reduce variance in how patients are transported and to provide standard expectations, Asante has drafted a new system-level policy, “Intrahospital transfer or transport of patients (Asante),” 400-PCS-NURS-0953. The procedure was developed with comprehensive feedback from the Asante Nurse Practice Council and multidisciplinary stakeholders across the system. The goal is patient safety, as well as efficiency, during transport.

This policy and procedure applies to all patients at Asante hospitals, excluding NICU. It provides guidelines on which personnel are appropriate to transport patients based on their clinical condition. The sending nurse (and charge nurse, if needed) is responsible for ensuring patients are transferred with the appropriate personnel, mode of transport and equipment necessary for their clinical condition and situation.

Inpatient nurses are required to review the new policy through ALEC by July 31. The policy takes effect Aug. 1.

Questions, concerns and opportunities for clarification will be monitored every 30, 60 and 90 days, then as needed. If concerns are identified, please reach out to [email protected].

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1 Comment. Leave new

  • Mary Boucher
    July 6, 2021 6:28 am

    Anne, thanks for all you do in leading the effort for us all to make Asante safer for all!


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