Creative transport program designed to mitigate nursing shortage

FigureHOSPITALS ARE FACED WITH a constant battle to maintain adequate staffing while serving an ailing population. During the past few years, the nation has seen an exacerbation in the ongoing nursing shortage, with over 100 000 nurses exiting the workforce in the US over a 2-year duration.1 The National Council of State Boards of Nursing projects that an additional 600 000 nurses will depart the workplace in the next 3 years.2 This personnel gap poses a critical challenge to the delivery of safe and effective healthcare. Inadequate staffing increases patient-to-nurse ratios, which further contributes to a higher risk of adverse events, nursing stress, and burnout.1,3 As such, it's prudent for hospitals to consider alternative approaches to bolster patient safety amid staffing shortages, with a principal focus on utilizing existing resources so as not to further exhaust the institution. Previously, our hospital had an established patient transport program, but this program only supported the lowest-acuity patients. For the purposes of this article, we define a transport as any patient transfer outside of the unit, whether to another unit, testing area, or procedural area. In the circumstance of intermediate-level patients on telemetry (referred to stepdown in our institution), direct care nurses were required to perform transports themselves while also maintaining responsibility for up to three other patients. The combination of a reduction in staff and the maintenance of patient acuity had potential patient safety implications. With a solution in mind, we proposed to reallocate our existing resources and develop a dedicated transport team that could be used to move patients within the hospital; for example, to and from radiology and dialysis. Many hospitals have implemented similar transport programs for lower-acuity patients, but the literature regarding their use for intermediate-level patients with more involved clinical requirements is limited. An algorithm implemented at UPMC describes similar issues with staffing; however, their solution involved a temporary change in level of care to allow for the basic transport team to perform the transfer, rather than supporting patients still requiring telemetry for transport.4 Transport safety was initially studied in critically ill patients to prevent lapses in monitoring and reduce adverse events.5 Standardized protocols have been developed to maintain safety during transport.6 However, there are limited reports within the literature that address the transport of non–critically ill patients despite reported benefits, including improved patient satisfaction and decreased waiting times for transport.7,8 Transport programs for stable patients represent a unique opportunity to keep nurses at the bedside while maintaining safe and effective patient care. Transport volume in our hospital has grown, with monthly transports increasing from 13 000 to 23 700 (82%) in 8 years. Historically, 18.5% of transports required nurse assistance, which translates to approximately 4300 nurse-assisted transports per month at the end of the 8-year baseline period. After a dramatic decline in patient volume during the first year of the COVID-19 pandemic, the hospital saw a 47% decrease in nursing personnel. Following this downswing, a resurgence of patients returned the hospital to normal operating capacity, without a subsequent increase in nursing staff. To help fill the gap, outpatient and ambulatory nurses were reassigned to temporary inpatient roles, followed by the use of agency nurses. However, this solution was short-lived, as the ambulatory nurses soon had to return to the clinics. After evaluation of these circumstances, we set a goal to decrease the number of nurse-assisted transports to alleviate nursing workload amid the shortage. Our objective was to design and implement a transport program specifically for stepdown-level patients by expanding the scope and clinical skills of our existing telemetry and video monitoring personnel, patient monitoring technicians (PMTs). We hypothesized that implementing a transport program such as this would decrease the number of nurse-performed transports by replacing the nurses with designated PMTs to improve overall operational efficiency without compromising patient safety. Our goal was to reduce nurse-assisted transports by 25% within 3 years of implementation. METHODS Ethics This project was reviewed by the WVU Institutional Review Board and was determined not to be human participant research. Setting We performed quality improvement methodology in a quaternary health system in which nurses routinely transported stepdown patients while maintaining responsibility for care of other patients. Our institution is an 881-bed, rural university hospital employing more than 2500 nurses. The facility is a Level 1 trauma center with 89 intensive care unit (ICU) beds, 5-time Magnet recognized, extracorporeal membrane oxygenation capable, and a comprehensive stroke center. The institution had an existing PMT program. The PMT's original role was overseeing patients on video and telemetry monitoring from a central location and alerting nurses of abnormalities via a phone call. The hospital also maintains a Central Transport program for nontelemetry patients, whose personnel transport stable patients from one area to another. Creation of the program and training process Our goal was to expand the role of the PMT from remote monitoring to include transporting patients throughout the hospital, maintaining patient safety, and improving care delivery. Key stakeholders, including inpatient nursing directors, managers of the Central Transport and Patient Monitoring departments, and an Epic analyst, were recruited to create, develop, and oversee the program. The team reviewed the processes of the existing transport team to develop the orientation checklist (see Table 1). Additional training included Basic Life Support (BLS), a self-defense course (AVADE: Awareness, Vigilance, Avoidance, Defense, Escape), safe patient transfers and mobility, use of personal protective equipment (PPE), patient communication, hospital bed and wheelchair usage, location of testing sites, and handoff processes with the nursing staff. Nursing and transport management originally provided program-specific training, which is now provided by senior PMT staff. The PMT department provided training as paid workshop time. TABLE 1: - Orientation checklist Original PMT training sheet Current PMT training sheet Week 1 Week 1 Works as a lead technician in patient monitoring Completes 6 months as a telemetry and video monitoring technician Completes BLS training Completes BLS training Completes Lateral Lift Training Completes Lateral Lift Training Completes 8 hours of shadowing with Central Transport Orients 8 hours with a PMT Transporter Completes Customer Service Course Completes AVADE Training (self-defense) Week 2 Week 2 Demonstrates how to properly add and/or switch patient from hard monitor/telemetry pack/portable monitor Demonstrates how to properly add and/or switch patient from hard monitor/telemetry pack/portable monitor Navigates Epic Rover app Navigates Epic Rover (Acknowledge, In Progress, Complete, Delay, Cancel, Postpone, Round Trip, Request Help) Completes 24 hours of orientation with PMT Transport Operates all patient beds, stretchers, and wheelchairs Completes 4 hours of shadowing with a direct care RN Dons and doffs PPE Verbalizes location of all testing sites and units Demonstrates how to verbalize and receive a patient report References the PMT Do Not Transport list Verbalizes how to initiate a Code and Rapid Response Demonstrates using two patient identifiers Verbalizes proper protocol for job cancelations Demonstrates how to read oxygen tank levels Demonstrates protocol for room changes Key: BLS, Basic Life Support; PMT, patient monitoring technician; PPE, personal protective equipment Eligibility criteria and staff orientation PMTs with greater than 6 months of experience were eligible to participate in the new transport program. Advancement to the PMT role is voluntary; therefore, prospective employees submitted applications to PMT management. Management also sought out staff who had seniority and demonstrated mastery of their current role. PMT management and a nursing educator led the initial training process, which occurred during a 12-week period. This training comprised telemetry workshops and a comprehensive final exam. The training also included on-the-job instruction on interpretation of heart rhythms and how to upload telemetry strips into the electronic health record (EHR). After completion of this training, PMTs shadowed the Central Transport team for 4 to 5 shifts, then underwent transport-specific orientation for 2 to 3 weeks (see Table 1). Training included group sessions and hands-on opportunities. Nursing units were trained on the PMT criteria, use of clinical nursing judgment, and appropriate handoff to the PMTs. Nurses could initiate a PMT transport without a physician's order. This streamlined the process, allowing for quicker patient transfers, enabling direct care nurses to advocate for the most appropriate mode of transportation based on each patient's clinical status. Electronic health record integration Appropriate PMT criteria were integrated into the EHR. The algorithm automatically selected a PMT-appropriate transport versus one requiring nurse assistance. A Best Practice Advisory (BPA) was automatically issued if a contraindication existed in the patient record. To prevent the system from falsely impeding a transport, hard stops weren't implemented; nursing judgment remained integral to the process. The request was submitted through the Epic system, then sent to the individual PMT assigned to that transport via the Epic Rover system. This application has been a facet of in-hospital communication for several years and uses hospital-owned mobile phones to communicate. The Epic Rovers utilize the hospital's network to submit, accept, or deny requests from any location within the hospital directly through the EHR. Implementation strategy and transport criteria Once the Epic build and PMT training had been completed, tip sheets and in-person presentations were provided to designated nursing units as the beginning of the implementation process. Three Heart and Vascular Institute (HVI) stepdown units were selected for a 2-month trial to ensure that the criteria met the needs of the nursing staff. Weekly meetings were held during the trial period to gather feedback from core transporters, direct care nurses, and staff in testing areas, adjusting the criteria as needed. A "Do Not Transport" list was developed to direct nursing and PMTs on maintaining safe transports (see Table 2). This list was emailed to all clinical staff, as well as printed and posted in communal inpatient areas for nurses to reference. In addition to standard telemetry patients with stable rhythms, PMTs could also perform transports on those with continuous, non-vasoactive infusions, and could transport up to 4 LPM of supplemental oxygen. Ultimately, nursing judgment is a vital component of deciding which patients are eligible for PMT transport. TABLE 2: - Do Not Transport lists (original and current) Original Do Not Transport criteria Current Do Not Transport criteria Vitally unstable Vitally unstable Patient requiring constant observation Patient requiring constant observation Restrained Restrained Active chest pain Active chest pain Patient-controlled analgesia (PCA) pump or epidural Newly placed PCA pumps External pacemaker External pacemaker Patients requiring high-flow oxygen Patients on greater than 4L of oxygen Arterial lines Arterial lines Continuous drips requiring close monitoring Continuous drips requiring close monitoring Pericardial or ventricular drains Continuous bladder irrigation Systolic blood pressure <90 Excessive secretions requiring frequent suctioning TR BAND (Terumo, Somerset, NJ) in place Patient in a second- or third-degree heart block Initial PMT transports were completed only by lead technicians who were hand-selected by nursing and transport management based on their overall performance in the role, reducing barriers to rollout. These staff had demonstrated knowledge of the hospital layout, comfort in clinical settings, and familiarity with electrocardiogram lead placement and interpretation of lethal arrhythmias. Following the trial period, the program was expanded throughout the hospital. (See Figure 1, which outlines the rollout process of all units.) The program was sequentially introduced to one clinical unit at a time, monitored for 2 to 4 weeks, and then expanded to additional units, including ancillary departments, preoperative and postoperative areas, testing areas, and transfer of stable stepdown patients from the ICU to other units.FIGURE 1:: Rollout processOngoing process improvement and metrics tracked Based on feedback from the units, the hours of availability were adjusted to meet demand, initially starting at 7:00 AM and ending at 3:00 PM, then expanding to 5:00 AM to 6:00 PM on weekdays. PMTs aren't available during nights or weekends, due to the low volume of transports and testing during these times. Metrics tracked were the number of transports completed, the amount of time spent transporting patients, and the number of nursing hours allocated back to the bedside. Data were shared at weekly Comprehensive Unit Safety Program (CUSP) meetings, nurse manager meetings, and nursing leadership forums. RESULTS Outcomes Within the course of 36 months, PMTs completed more than 58 000 transports. Nurses remained at the bedside for more than 21 000 hours during this period, which was calculated using the average transport time of 19 minutes per transport performed by PMTs (see Figures 2 and 3). Every month, PMTs completed an average of 1816 patient transports, reducing nurse-assisted transports by 45%, exceeding our goal of a 25% reduction.FIGURE 2:: Monthly PMT transportsFIGURE 3:: Monthly nursing hours savedImpact on nursing and PMTs The implementation of the updated PMT transport program increased the time nurses spent providing direct patient care. Additionally, PMTs benefited from career advancement opportunities, creating a career ladder within the department. Telemetry and video monitoring technicians received a 7.4% increase in hourly wages through additional training. DISCUSSION Our results show that greater than 58 000 patient transports have been completed since the program's inception. Over 21 000 nursing hours have been reallocated back to direct care nurses at a time when staffing was at its lowest, filling a critical gap in maintaining bedside nursing care. The program's cost-benefit analysis revealed that the hospital expended no additional funds in hiring new staff, and the program's only cost was the additional training provided to the PMTs. Comparison to other programs Transport programs exist at hospitals of various sizes and capabilities. A 250-bed acute-care community hospital implemented one such program. Washington and colleagues reported that similar programs eased the burden on direct care nurses and improved patient satisfaction by decreasing the time spent waiting for transport. One challenge that this program faced was the inability of the transporters to monitor the patient, therefore reducing the number of patients that could safely be transported.7 Our program has addressed this limitation by expanding the existing role of the PMTs, who already have monitor training, to include transporting patients. Penn Medicine, an urban quaternary care institution, has a program similar to our program. Their employees have telemetry training, which increases the number of patients that can be transported, enabling nurses to remain bedside.4 One main difference is that the transport team is also responsible for responding to clinical emergencies. Our PMTs don't respond to emergencies and focus only on stable transports. Additionally, the PMT department includes a nursing clinical preceptor and supervisor as resources to communicate and address concerns from nursing staff. Career advancement and recruitment The PMT program offers career advancement opportunities for both telemetry and video monitoring technicians. Training includes on-the-job instruction with the current transport team, learning the locations of the testing sites, hospital equipment usage, patient communication, and safe patient transfer techniques. After 6 months of training in these basic skills, the employees can seek promotional opportunities as a transport PMT. The program has become a valuable recruiting tool for nursing units and the PMT department, attracting staff interested in medical careers. In fact, 25% of PMTs in our department have since pursued other healthcare-related career paths. Limitations and challenges Although the program has shown success, limitations and challenges were encountered. One challenge was nurses' ability to alter facets of care to fit within the criteria, thereby "overriding" the warnings given by the EHR. One of the most common BPAs bypassed was the 4 LPM oxygen maximum; nurses would reduce their patient's oxygen so the patient would qualify for transport. Further education is required to prevent potential adverse events related to bypassing BPAs. The PMTs utilized the Epic Rover system to receive transport requests and communicate with other staff. The devices initially faced reception issues and were unpopular among staff. To address this challenge, leaders from Central Transport and the PMT department worked with the Information Technology department to improve device functionality and familiarize the employees with the devices. Requiring transport PMTs to have 6 months of experience was another challenge. This requirement takes time to organize orientation efforts, and the expectation of the role needs to be clearly communicated in the job description and throughout the hiring process. Additionally, the assurance of further training and a higher rate of pay upon completion of the orientation period should be emphasized. Another potential challenge is a lack of involvement if current employees don't want to advance their skill set into the PMT role, because participation is voluntary. Certain testing areas in our institution are more time intensive. These include magnetic resonance imaging, fluoroscopy, dentistry, ophthalmology, pulmonary function testing, and radiation oncology. With only 8 PMTs available per day, having 1 or 2 PMTs occupied in these testing sites often led to delays in patient transport. In case of such shortages, our workflow prioritizes discharges and patients in the Emergency Department to maximize operations. IMPLICATIONS FOR NURSE LEADERS Given the continued nursing shortage and high patient acuity, this program may prove to be useful to other institutions. Reallocating nurses' time back to the bedside allows for increased delivery of safe, high-quality care. Hospitals should assess whether their acuity and resources justify the creation of a transport program. One approach could be to expand the role of existing licensed practical nurses (LPNs) with additional training. Each institution must tailor the program to its specific needs and budget; this program can't be one-size-fits-all. Although initiating such a program is a significant undertaking, the results demonstrate substantial benefits for the clinical staff and the hospital overall. Throughout the development and implementation of the program, interdisciplinary cooperation was imperative. Nursing leaders, PMT management, and direct care nurses, among many others, were involved in the shared decision-making process. Collaboration among these groups was essential to development and allowed more efficient production and rollout. This joint effort not only eased the workload of our direct care nurses but also that of the nursing leaders who face staffing shortages. PROTECTING TIME FOR PATIENT CARE Through this initiative, we sought to keep nurses at the bedside, allowing more time for patient care by providing a dedicated team to transport patients in their place. By reallocating resources within an existing department, the program facilitated professional growth and provided new opportunities while simultaneously decreasing nurse-assisted transports by 45%. This program is unique because it focuses on transporting stable patients requiring telemetry, unlike studies that have evaluated the transport of critically ill or observatory patients. Additionally, we utilized existing hospital staff, mitigating the need to hire and train new employees, which is particularly challenging in a rural state. Nevertheless, the program preserved over 21 000 nursing hours, permitting nurses to continue to render care at the bedside despite the shortage.