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our critically ill patients at risk during transport and how could we ensure that these risks are mitigated so that finally the benefits are higher over the next 60 minutes we will try to get a couple of answers to those questions with our panel of experts so welcome to our critical care live TV show from Paris we are very proud to have a huge audience from all over the world my name is Godwits and it's my pleasure to moderate our scientific session today today's intra Hospital patient transport has become critical it has evolved into a major activity with significant resource implications for healthcare providers this frequent complex and sensitive process requires adherence to high quality and safety standards it is also a time-consuming task for healthcare professionals working in critical care areas typically where nurses have to execute various tasks with high fatigue ill and psychological requirements a study published in 2015 in nursing critical care indicates that increased workload in ICU often keeps nurses from taking necessary work breaks leading to higher levels of work stress patient transport often contributes to these higher stress levels for staff and may create operational in efficiencies seeking for ways to faster and safer patient transport is a major concern and our main topic for this session so let me introduce our panel of European experts starting with my right mona Rindell from sweden she's associated professor in nursing at the Institute of Healthcare Sciences Sally green sky Academy in Gothenburg University and she is critical care nurse and senior advisor in research at the department of anesthesiology and critical care kongou hospital in sweden her main topics research our patient safety and patients recovery from critical illness next to her is a one-layer from France he's associated professor and head of the medical intensive care unit at breadth University Hospital and he's head of the healthcare simulation center Brest University with more than 5,000 students per year furthermore he is a member of the National Health Care Research Institute and his specific fields are automation algorithms and biomedical devices development biomedical devices evaluation and respiratory care to my left is tossin Stein jet from Germany he is associated professor and chairman of the department of anesthesiology and intensive care medicine at the da Cunha hospital in Shropshire in Germany his team does about 12,500 anesthesia procedures per year his specialties are regional anesthesia patient safety anesthesia during elderly and post-operative delirium so now we are ready to get started and you are all invited to take part in this discussion so please write your anonymous questions using the chat tab on your screen and you and I will pass them to our speakers we have a time after each presentation to address some of your questions and we will start a panel discussion with our experts at the end of their lectures Mona you are director of the PhD nursing program in 2017 you published study in critical care medicine titled safety hazards during intra hospital transport we are keen to learn what was your motivation to initiate this study and of course what are the main learnings I think that we have to talk about the complications and all the hazards the risk factors during introspective transport so you can actually divide them into two two patient related so we know that the sick of the patient is a greater chance there is or problems during transport and you can also divide them into system related related to staff and organization and related to equipment this system related could actually be avoided and we know that the critic analysis internationally constitute the basic of the transport team so together with the physician and other healthcare professionals they try to do the same care of the patient like in the ICU although we we don't know that much over their experience during the inter hospital transports actually so we did this study we have this study that we published in 2015 and it's the questioner study to critical care nurses in to Swedish ICUs in Sweden and there were eight to six critical care nurses who answered and as you can see here there actually said that they received intra Hospital training but only 52% did that 65 percent said that they had guidelines for the intros bit of transport there can be improvement here and also it's important to say that more than half of the intra Hospital transport in Sweden is performed by the critical care nurse without the physician so when we know this we also ask the quickly kenosis of say some comments about the transport and we analyzed it in five categories and you can see the the one who say well functioning and there were very few of them who says was well functioning most of them said it makes demands and it's time consuming a lot of critic analysis also said it's a moment of stress and it's burden of work for staff remaining in the ICU and this is also taking care of the other patients it's come to a halt as well so this is what we see about the stress factors the next slide is about what's actually happened during the intra Hospital transport so we further along we did the this observational study where the doctoral student Mylena Bergman was the one who was performing this and she did three months of observational study in two ICUs in Sweden we have 51 transports and you can see that there are sort of the patients are very sick 80% of them were on mechanical ventilation 51% had was suppressor support and actually most of the transport were performed without a physician so going with them and if we go to this we can see that there is 365 hazards during this inter hospital transport so it's in average seven hazards in every transport and we have used patient safety model to analyze these hazards and you can see the five difference sort of hazards group here and the biggest group is with 1/3 is tools and technologies and tools and technologies is poor usability or function of transport equipment and it's equipment error and that's the big group the other group is tasks hazards and that is 83 of the hazards and here you can see interruptions and disturbance for example moving the patient from the bed to the examined table we have here and the third big group is team hazards and here you have unclear team rules and the lack of situation awareness and communications problem that's the big part you can see him so we we will analyze this 365 hazards and see how many of those were actually one adverse events and there was only one percent of them who was sort of the the patient who could sort of getting harmed it could be an extubation for example 1% and in 21% it was resulting in near misses like the disconnecting of the tubes could be but due to the rapid response from the staff it could actually nothing was happening you can also see that were a lot of hazards who was increasing the risk of harms in 57% actually so I we were thinking what could we do to minimize the hazards and one solution could be for a timeout so a timeout is something that you do in the theater before starting the surgery and we could think that this could be something we could do before the transport as well so we have make a movie and this is the small part of it who is showing the timeout before the intervals better transport yep Yohan and Lena let's go through the timeout and make sure that we're ready for transport this is mr. Schmitt born in 1945 mr. Smith will undergo a CT scan today to check his current condition we will be leaving the ICU taking the elevator to radiology to lab 1 on the first level of the hospital I'm Geetha the critical care nurse responsible for the patient and team leader of this transport I have a phone with me so we can call the intensivist if we have any questions or concern I'm Joe on the critical care nurse that will assist Keaton and in this trend transport and I will be responsible for the emergency bag and make sure that lines are functioning my name is Lena I'm the assistant nurse I will help out during the transport and I know the way to the CT let's go through the checklist any questions no then we're ready to go so this is one example of the the time out actually that you could see and maybe we could implement them in further research so but there are more things that we can do as you can see here now we can implement strategies to overcome stress during into hospital transport for all the stuff actually I think it's necessary and finally we want to develop transport equipment in collaboration with end-users it's important to have a really safe transport for our bowl of patients thank you so thank you very much Mona for this insights into the daily work of a critical nurse we saw this impressing film and there was mentioned a checklist so of what does this checklist consist what is the meaning of this so the checklist is consistent that what sort of equipment do you need what sort of things do you take with you other enough oxygen other enough battery do we have all the medication with us a phone for example to call somebody so there could be a different checklist for different hospitals but the timeout is sort of both saying where you are going with whom you are going and the patient and the checklist and then it's focus now we are going everything is okay our check that's already existing for example in your clinic yes of course for example of patients get in the operational theater there has always be always we use the checklist before the patient can enter the operation theater for example regarding or if everything is completed laboratory data and all these things and yes and there was a leader a team leader announced in that film so who should be the team leader in real-life situations in intra Hospital transport I think that there could be sort of different professionals it could be the team leader I think the critical care nurse is a really good team leader but because the nurses one was taking care of the whole transport so I prefer the the the quickly cameras as a team did it the important thing is that a team leader is is everybody know who is the team leader during the whole transport so that's it so every one of the others agree disagree because for example you have shown that in Sweden most transport are done by nurses without physicians and I think this is really different especially my hospital and I think in the majority of hospitals in Germany that mostly if patients are in stable or ventilated they have been always be accompanied by a physician as well so we have ones physician and one nurse and then we have to talk about the responsibility who is the leader of that just for team and you can be the team leader of the transport but you're not responsible for the medicine for example yes oh so it's me yes I think it should be one of those people but it could could be actually the physician but it could also be the noise of the transport physician probably the critical care nurse I think the experience we all have this may be that that nurses are more familiar with the technical things of the monitoring instead of the physicians especially young younger residents and physicians among that familiar that's right I think it's important to sort of clear out who is the team leader mmm for this transport yeah so your study classified five different categories of hazard and the poor usability of transport equipment is one of the main hazards and that leads us directly to our next topic Iran you are an intensivist but you are also a human factor and usability expert you will give us a valuable insight how human factor engineering can help to improve intra Hospital transport but the first question of all is what is a human factor Engineering so thanks a lot GERD so that may be a tricky question for a physician but I'm just waiting for the slide in fact I will try to convince you that human factor engineering is very important from a physician point of view from a clinician point of view and that it may impact on the usability of the different devices that we are using in our unit we can define human factor engineering also as our guard of X evaluation it clearly referred to the way that machines the devices are design and aiming always to improve either the safety for the patients from the patient's point of view but also for the comfort point of view of the clinician and I'm totally convinced that this aim produces an enhancement of the productiveness the the question is is it really important from an l-square point of view if you just look at the inside an airplane you are totally convinced that the right the good button must be at the right place that's quite very simple to understand that will lead to less error and that will increase the productive nests of the pilot but the question is is it exactly the same in the health care environment if you just look at these three different images either from a biomedical device point of view from an emergency department process of care but also for from the I see you environment you see a lot of different Maya medical-device I'm totally convinced that that's no more different than the the pilot in in an airplane so we should focus on human factor engineering in the healthcare also so that's a reason why we try to develop a model and we published it two years ago in annals of intensive care and considering that to evaluate the efficacy we should not only focus on the technical point of view but have a look on the four different dimensions which are the efficiency the efficiency of course if you get a biomedical device it needs to work well it needs to provide the physician what they want but that's not their sole purpose we should also evaluate their ease of use and from our point of view but the best way to evaluate the ease of use is to test a knife subject we should also evaluate the tolerance to error is there enough alarm something that will increase the ease of use for the subject and of course we should also focus on the engagement or the clinician that are using the biomedical devices confident to what they are doing and how they are using the device and just considering these four dimension we just perform an evaluation of for several different ICU ventilators on the the left part of the the slide you see Espada short of the NASA italics the NASA telex is a way to evaluate the mental workload which is the amount of mental effort that is required to perform a different task our reference was the orange shot the idea which was a nan tient ventilator that we were using for more than ten years it was supposed to to provide us a very small short as small area which was exactly what we observed and with the idea just because we are experience with that we have a huge task completion rate less error and a good completion rate if you just look at the global mental workload that was required to put to use the v60 680 which was a prototype ventilator the spider shot is quite huge so physician that we're using it required a huge amount of work just to understand what they were doing and in fact we also observe with this increased mental workload decreasing the task completion rate so they're quite there's quite a good correlation between the mental workload that is required to the user device and the way we will finally do the task and if you just have a look on the arm on the last powder shot er x6 e from GE you can see that the area was quite small just like the old experienced ventilator and this was also correlated to good task completion rate so we are totally convinced that the the way physicians think though the the amount of work that they need to perform there is quite correlated to this complexion rate so how are we doing that in inner-city simulation lab we are using our usability lab or the scenario that are tested are quite standardized we're recording everything the audio also the the video you can see a small picture from the control room everything on the video is tagged though we can clearly define and find that the determines of what we are looking at we just performed for GTL scare last year a study on two different transport monitor just trying to to compare the two devices and to clearly evaluate the determinants of Farah so you can see on the slide with the the way the scenario and the the environment was standardized and just the tagging of the video and the result of darrid once again using the NARS italics on the left part you can't eat the orange short represent the comparator you can see that the global mental workload that was required to use his device was quite huge and you can see that this increased mental workload was also related to some failure you can see on the movie on the right slide that the monitor suddenly for the nurses was trying to understand how it could fit on the docking system she did not perform well and thus the monitor fold and it break so we are totally convinced once again that an increased mental workload as compared to to the kursk upon which is in blue is related to some part of error with the the blue devices will observe nine errors on the global testings while with the orange devices were observed more than twenty three error so that was a statistically significant difference so once again a good correlation between the amount of work required to perform the task and the real error and finally and it could also be related to some part of predicting predictiveness and if we just we're looking at the global time for a transport scenario in fact we observed with the devices that had the lowest mental that required the lowest montauk workload we observed decrease of approximately 25 percent of the global total time I'm not sure that this has any clinical significance but at least from an operating room point of view we are able to run it much more rapidly so this may be of some importance in terms of the hospital administration so just some three four three four simple take-home messages from my point of view human factor engineering may clearly improve improve care it may help us to decrease the error of the failure rate and and so on it may also be a very significant determinants of improved productiveness thank you very much for this impressing insight into engineering and human factor engineering I received already again questions from the audience and one is these subjects which are recorded during your evaluations they know that they are observed so what about the Hawthorne effect in this case that's what clear and that's known for for for more than 50 years that when subjects are looked at they do perform better so that's a reason why in our usability lab when we are doing some usability evaluation we are always trying to test a system or knife subject just because the knife subjects are coming from no experience at all so they can only improve nothing more than that and we are looking then backwards and and see if the their improvement is still the same while we've experienced user it's much difficult to see their improvement and to see if this improvement stays upon time and can you explain how human factors improve the productiveness just if we go back on the airplane point of view if the button is up at the right time it takes less time to perform it if in the ICU you need to to understand where I should plug it on or should plug my device off that takes time and times plus time plus time that may increase the global time of care had the other two speakers have you felt human engineering in your daily life already yes a thing off more often I think with products that and that the machine is not really well designed for our for our requirements I have one question to air one when a clean explained more specifically how did they decrease the transport time with more than about twenty percent that's really a huge there are different timings during a process of course plug in it um just plugging the cable docking and docking through time plus time plus time you gain time at each time to add the final recording that may be significant the connection of this connection plus error each error will increase the global time and sometimes our ganna mix some industrial just provide us a very fancy very fancy biomedical device you can just switch from a screen to the other and sometimes it's too fancy and too complicated that increased time also okay these many hazards which were shown in your study they are going back to sometimes to back of a lack of human factor engineering I can see that yes and I can also see that for example you have different alarms you have to know which alarms this is sort of alarming me at the moment and you have to be multitasking doing a lot of things at the same time and you have to have focused on the patient and something's happened and people are talking to you so it's very important that it is simple merely and um sort of if I could decide I think we should have everything on a screen actually so you can see what's happening which alarm is alarming for example yeah thank you very much so I think now we have a better understanding of human factor engineering and usability evaluation and now let's switch to daily practice Torsten you are recognized expert about anesthesiology and you to execute patient transport in your daily work maintaining a high level of safety and a high level of quality care so what are your thoughts about monitoring patients during transport after surgery and for after all which solutions did you implement in your eelain's unit Thank You ver for that nice presentation yes we were talking about intensive care medicine and now we have to talk about the operation theater and what happens there was patient transport and of course all patients have to be transported in the operation theater first in the operation area and then after induction from the induction may be in the operation room itself and after the operation the way from the operation room to the PACU or recovery room and sometimes even from the recovery room to the intensive care unit so there are many crucial points where something could happen where transport is absolutely required and so we heard of everyone that the very important aspect is connecting cables disconnecting cables and so you need a lot of technique and so this is really resource intensive and time consuming and the other thing is that we have a lot of risk what could happen after induction of anesthesia the patient is not able to breathe itself and so everything has to work how we ventilate and of course we have to know more about the monitoring what happens in the patient and so there are some key things they have to be considered so what's about the staff the working process the technology surrounding the staff and the working process the mobility how can we how can we provide mobility of monitoring and mobility of the patient and at the end of the day we have to ask want to talk about innovation and so I want to say some things about the staff and the processes all processes have to be absolutely reliable so that everybody knows what he has to do in the work flow and who is who plays which role and is responsible with during the processes and all these processes have to be written down like a standard operating procedure this is very important that everybody knows what to do during the process and so we have to talk about the technology this is really mandatory so the technology has to be very stable and functional because everything we're doing movement transporting patients in the operation area that needs robustness of the whole system robustness of the technology and this technology has to be well adapted to our workflow and if it's good adapt it you will have a nice acceptance by the staff because maybe it's very easy to use and so the other thing is these devices are really mobile and this is this is a problem because our our former monitoring systems had not been directly mobilized so you disconnect after induction after induction you disconnect the patient and you go in the operation room or after the operation you have to move to the recovery room that's a problem so at the end of the day you need a standardized equipment so if you change the location in the operation room it is important that everywhere we have the same technology and everywhere we use the same cables this is very important so mobility this is a very important aspect we have two crucial phases one phase is after the induction and the next phase is after the operation on the way to the recovery room and the way from the operation room to the recovery room I think it's the longest and it takes something about five to 15 minutes and in this time period a lot of things can happen and so we have to moba mobilize the patient from the operation table in the bed and these things and in normal hospitals the patient get always disconnected and during this connect this in this in this moment of disconnection there could be adverse events we know that all because of for example problems with relaxed ends with opioids with with our hypnotic drugs and of course volatile gases and so we have to know is there an adverse event and for example in my former Department static group wanted to know are we able to estimate the oxygen saturation and so they asked in in 1,000 cases M physicians and nurses what do they think how high is the oxygen saturation and in 20% they overestimated the situation they they estimated something like 95 to 98% but for real the situation was something under 90% and that is really an adverse event that patient our hypoxia m-- there there the hypoxic and nobody is recognizing this and so after that study we changed our our behavior that we used more oxygen for the transport from the operation theater to the recovery room and that we use pulse oximetry this is a very easy solution so for looking in the future what is important regarding innovation I think it is very important that we have one connection to the patient at the beginning and then the patient gets connected to the monitoring system until he's at the end of the recovery room so even in the recovery room it's always the same connection we do not disconnect the patient and then it is important that the economical situation where the monitoring is okay so that we have more or less a comfortable small monitor but with all parameters not only pulse oximetry maybe ECG and hammer dynamic parameters like blood pressure and respiratory parameters and this should be integrated in the whole system in the environment and maybe for the future the system should be open for new parameters we which are important for transportation so the best practice example is that we connected during the induction that we move to the or all are always with the same system to the recovery room always during the transport we are able to look and on all parameters which have to be visible so what is the outcome the outcome if we have really a continuous monitoring should be an increased staff satisfaction I'm sure because all the processes are easier you do not have to disconnect the patient and have to connect the patients you have always visibility of adverse events and maybe we can avoid hypoxemia and we identify a proxy Mia very very early and of course we apply oxygen yes it is mandatory important and required for the patient so my take home message is phases between the induction and you are and ORN recover room are critical and these critical incidences which could happen in that phases are underestimated and so continuous monitoring is mandatory important and for looking in the future we need monitoring which is connected directly at the beginning of the whole procedure of operation to the patient and M so will be connected during the entire process until the patient is finished with a recovery phase thank you very much docile I've got a question directly from from the audience concerning the process how was it to implement this continuous monitoring in health care unit like yours I think the first step is very easy if you just start with continuous pulse oximetry they are cheap they are small the patient can wear it the whole time that this would really help and if you have an adverse event like hypoxemia you will identify it directly you can apply oxygen this is the first step but the next step should be that we additionally additionally monitor for example ECG because ECG is of course the gold standard for monitoring it's even implemented in a as a recommendations and so we should always always monitor ECG and blood pressure as well and respiratory data mm-hmm so there's a step for a future that yes our monitoring companies adapt to that requirement but the first step is partic symmetry and oxygen what are you experiences with implementing of these continuous monitoring in clinics I think that if you have good devices actually and if you have good guidelines what to do it's it's easy actually to implement it because from a nursing point of view you want to have safe devices and you want to have good when you look at your patient you want to see all these figures and see the patient's it's okay so I think that if you have the good thing actually you can do it very well so it's not not a problem actually we applied some years ago in where we all were surprised that 20% of the patient were underestimated regarding oxygenation and afterwards everybody was thinking more about this topic of oxygenation and the people were not long thinking if they take the oxygen of the the oxygen bottle or not they took it was the right decision and very easy you really want your patient to have good care yeah you don't want anything to happen you're not transported did you recognize something significant with respect to patient safety in your department I think the avoidance of hypoxemia is always patient safety effector is the key safety factor so thank you to everybody of you for this bug of information we got from your lectures and now we have time left for a panel discussions and we have plenty of questions from the audience outside and let's try to answer some of these questions before our time is running away Mona there was a lot of questions around the daily life of nurses they have to execute a lot of very difficult tasks and and there are they are used to stress but why is patient transport so transport so extraordinary stressful for nurses so I think that it's stressful for nurses because you are out of your comfort zone because you're out of ICU in ICU you have a lot of colleagues that could actually help you if you sort of need help and then you have to go out for a transport and there is not that many people there who could help you and all the devices not working in the right way and also all when you are transporting a patient in a bed you you actually have to find your way and you also have to have all these bumps everywhere so things can actually happen it's a lot of nurses I've talked to and their studies all started saying now and I think it's really a risk taking but at the same time they also think that they can manage it they can manage the what the risks but they can do things that sort of nothing actually happens to the patients so hmm so toss them in your clinic how do you handle these stress of nurses are there techniques to lower them to give them more security to make them feel more comfortable I think it is very important what Mona says you're out of your comfort zone if you leave the intensive care unit for example if you need some drugs or whatever else you do not know where to search for your drugs and so it is very important to be well prepared we have the right drugs with you and yes and the other thing is we heard so much about problems with technical problems with monitoring and if this would work this would definitely decrease stress I'm sure and if this would be very comfortable it would be a a nice factor on the other thing there are so many things we cannot guide in that aspect for example if you're an elevator whatever it's and something happens you are alone you are alone and you have to to manage that problem why simulation lab could be of interest just doing lucky like in your peritreme doing some quizzes versus management during transport training and training the nurses to face situation that are outside that comfort zone and in the simulation lab we can do that without any arm for the patients and just doing something that are unusual that may ought to make the team more confident with the different authors that they may face events with intensive care medicine patients are much more more difficult compared to patient a 2 to adverse events in the operation theater during the transport from the operation to the recovery room because there are so many people so if there's something somebody would call emergency and in 15 persons will come and will a lot of innocence colleges and and I qualified nurses and on the way to the CT scan or MRI you're really a known one more thing you were talking about the elevator for example so in Saugus Co hospitals they have rebuilt the elevator there so it's they made them bigger and if the elevator stops or anything like that it's it taking you can you have oxygen there you have a phone there and you have suctioning and everything and that's also a good example of the environment what you can do for having more safe transports yeah so this standards are different all over Europe for example in that hospitals I know from Germany I have never seen that yet I feel the possibility of applying F of application of oxygen or but if you have a look at them you have the overview of a lot of many biomedical devices which are on the market what do you think most of them taking an account the human factor engineering and the usability I'm not sure that manufacturers and industrial I quite aware that they should focus on the user experience but by for years they have been mainly focusing on from an engineering point of view doing the most fancy things the most fancy biomedical device that we could provide just making some there are some ventilators that just look like an iPhone you can switch from screen to another screen so that was very fancy they just try to improve the user experience but in some time they increase the difficulty to use these devices some industrial I'm totally convinced are focused on the most important things and we have tested some ventilators we have tested some transport manager that are clearly dedicated to to the real factor that may improve the care but some need to make some progress certainly something I think for example regarding technology intensive care medicine regarding respirators there is very hard work I think because there are so many different kinds of ventilation and newer ventilators they have all that modern body inside in the program and it is very very difficult at the beginning for the nurses to cope with it because you do not have that overview you need and I think one way of working more effectively with with that new and technology could be that you reduce everything to that requirements in that specific department two years we have to buy more than 40 ICU ventilators for for our hospital we just tested all the technological problems but all the ventures were were quite equal in terms of technology some few many differences and ventilatory mood but the real differential criteria was organ omics and the devices that we both was only based the our chose were only based on a ergonomics I want to make a comment about this because we could also see that in our observational study that a lot of sort of you know the course there was too short so when you move the patient from the bed to the examination table the cords there was to sort of stretch out all the time so they're done for the patient in the ICU and not to move the patients for distance and that's what I think so so I was really shocked hearing about your study that during a patient transport in average seven hazards a core and most of them are related to tools and technology do you do you have any explanation for that no I I think more that the tools and technologies is actually the devices that we use so much and I should I say they are they are not we don't use them normally to go to transport it is sort of I think that you have to do very much improvement into new tools and technologies for a transport because patients are more transported today as well and the sick patients are more transported so I just think that the tools and technologies every research actually say that those are the the key thing when things happen hazards and that sort of things yeah what about innovation on is do we have a quick development of innovation from the technical point of view or is it slow at the moment the problem of innovation is always certification there are different ways to do too sick to think this point of course certifications lowers the process of implementing innovation and the other part of the problem is that innovation sometimes is not mandatory as you say we already know what is really important oxygenation ECG tracing blood pressure at least only three very simple problems why while transporting a patient we also need a good ventilator though I'm not sure we need very fancy ventilatory mode we just may focus on these very simple point probably but I have a huge conflict of interest just because I'm working on innovation automation automation of the oxygen processes may be important from my father you what is from your point of view the most convincing advantage of content you as monitoring yes the convincing advantage would be that you would really save time by just connecting once at the beginning and disconnecting really at the end and so that would times would be time saving it would be nice for all the staff which are working with it and it could be relatively easy because you just take one mobile monitoring and the cables and you connect them to the patient then this system accompanies the patient in answer to the recovery room until the anesthesiologist give the patient to the recovery room and then it gets a new monitor with them and cables for the next patient and so you have a circling of monitoring systems and cables and it would work it's easy but we're in 2019 and yes most hospitals we are always working with connecting and disconnecting so if this is standardized what do you think is a physician needed on every patient transport I think you you talked about this topic yeah so if I begin with that I would say that if you have a trained critic a nurse who is experienced and if you have two critical care nurse actually or three on a transport I can see that is safe enough actually you you need to have telephone with you so you can actually talk with a physician but if you if you say that you are in in a room with the critic a patient the physician is not in the room the whole time because you you phone him or her and and ask for advice or ordination and that sort of things and you can actually do that and only transport as well I can see then and ever critique a nurses can actually keep the patient in life until the physician is there but you of course the physician must be aware of that there is a transport ongoing yeah yes I agree and I believe that the nurses in in in Sweden are very very highly qualified but I do not know how is the forensic situation because for example and in Germany and in my department if a patient is in stable or if a patient is connected to a ventilator it's mandatory that a physician is to accompany the patient for a transport that's that's something like a rule and yes maybe we have different requirements in our country as to patient ratio is quite different at least in France from Sweden we only have one ICU nurse for four patients even if they are ventilated and they're real not renal replacement though it's quite difficult to get two nurses for transport though we get a junior resident but I will be much more confident with to critical care experience critical care nurse yes we have the ratio one to two patients and sometimes one to one depends on but it's also that could be a nurse critical care nurse who is sort of free out in the corridor and could go with the other nurse so and it depends on the patient if the patient in stable actually of course the physicians should go with but not or never transport I don't think so really to define in stable patient so this is a topic for further discussions I think we have time for one other question and I got an interesting one from the audience and that is related to your study again we had this high amount of hazards on the one hand and on the other hand a very low rate of adverse of serious adverse events so how did that come so hazards is something it's like a risk factor so we were actually looking for risk factors that something very bad could happen but it didn't happen because of the the staff were on their toes all the time and you are so focused when you are on the transport and and you are looking at everything you have one patient not four for example you have one patient and because of that I think that there are just a few adverse events and more of the risk factors so does that make sense were you actually so they act before anything's happens yeah it's a role evaluation of this problem which is considered that the reason model which is also a used in the airplane industry an adverse event is rarely due to one other is a succession multiple events that will go and make the adverse events finally and not one single auto yes time is running so fast and we are coming to the end of a very fruitful scientific sessions there are a lot of questions which we couldn't answer during our discussion now and I have the promise of all the speakers that we put together a document with all answered questions and we will share that with you and so let me follow in your lectures and the panel discussions I did extract some take-home messages of all these lectures and I would like to share these take-home messages with you and with our audience and it's to ensure a safer and a more efficient patient transport we need several things first of all we need continuous staff education and training and continuous monitoring during transport as a gold standard and implementing and following standards and guidelines and timeout is a very good example for that thank you very much we hope that our today's scientific show will have to drive changes in health care organization to improve patient outcomes you are very welcome to share today's key insights and I would like to thank our experts Mona Rinda from Sweden a one-layer from France and toasting Steinfeld from Germany for their time and for their inspiring lectures and of course the audience all over the world for their interest and the contribution to our panel discussion last not least let me also thank GE healthcare as the sponsor who made this educational session possible so we wish you a very nice evening from Paris and we hope to see you soon again with another live TV show so take care good bye you