Proactive risk assessment of intrahospital transport of critically ill patients from emergency department to intensive care unit in a teaching hospital and its implications.

AIMS AND OBJECTIVES: To explore the effects of the health failure mode and effect analysis (HFMEA) used in intrahospital transport (IHT) of critically ill patients from emergency department (ED) to the intensive care unit (ICU). BACKGROUND: Patients who were transported from ED to ICU is highly critical. IHT of these patients is potentially risky, which may associate with adverse events (AEs). The concern of safe IHT can be addressed by performing proactive risk assessments using HFMEA and implementing the findings after the ED of our hospital being reconstructed. DESIGN: A qualitative action research study combined with a quantitative cross-sectional method. METHODS: According to the HFMEA method, the failure modes of IHT were identified and analysed, and the effect of alterations was verified. We built a project team, drawn up a IHT flow chart, defined steps of IHT, classified the failure modes, calculated risk priority number and analysed by the decision tree, then formulated an action plan and verified the effects of the alterations. Incidence of AEs of transport was compared before and after HFMEA.SQUIRE 2.0 checklist was chosen on reporting the study process. RESULTS: The HFMEA outlined a total of 5 major steps and 16 sub-steps in the IHT process. From this, 64 potential failure modes were identified, with 17 modes having a RPN score higher than 8. Determined by the decision tree, there were 20 priority control failure modes, of which 16 involved 8 IHT alterations. Notable work-flow alterations included use of a three-stage hierarchical transport strategy based on patients' condition assisted by the intelligent assessment system. Incidence of AEs was significantly decreased from 19.64% to 7.14% after the implementation of HFMEA (p < 0.05). CONCLUSION: Application of the HFMEA in optimising IHT process can improve the safety of transportation, which is worthy of promotion. Hierarchical transport scheme can reduce the incidence of AEs in IHT of critical emergency patients, which mainly includes the integration and construction of the transport team, equipment configuration and patient information system based on the classification of patients' condition. RELEVANCE TO CLINICAL PRACTICE: Nurses play a crucial role in the IHT process. HFMEA can be adopted for proactive risk assessment of critically ill patients' IHT from ED to ICU which involves multiple processes. The IHT hierarchical strategy based on the results of failure mode analysis should be more widely used to further verify its clinical effects.

T follicular regulatory cells infiltrate the human airways during the onset of acute respiratory distress syndrome and regulate the development of B regulatory cells.

T follicular regulatory (Tfr) cell is a CXCR5+Foxp3+ subset of T regulatory (Treg) cell with critical roles in regulating germinal center responses and modulating the immune environment in the lymph nodes. Studies have shown that the proportion of Tfr cells may increase during acute inflammation. In this study, we investigated the role of Tfr cells in acute respiratory distress syndrome (ARDS). We found that Tfr cells were significantly enriched in peripheral blood and in mini-bronchoalveolar lavage (BAL) during the onset of ARDS. Notably, Tfr cells represented the majority of Treg cells in the mini-BAL samples. Tfr cells also showed CTLA-4, IL-10, and TGF-ß expression, but compared to the non-Tfr Treg cells, the CTLA-4 and IL-10 expression by Tfr cells were slightly reduced. Both Tfr cells and non-Tfr Treg cells suppressed the proliferation of autologous CD4+CD25- T cells; however, the Tfr cells displayed slightly reduced suppression capacity. Subsequently, B cells were co-incubated with autologous Tfr cells or non-Tfr Treg cells. Interestingly, we found that the frequency of IL-10+ Breg cells was significantly higher following incubation with Tfr cells than with non-Tfr Treg cells, which suggested that Tfr cells were more potent at inducing IL-10+ Breg cells. Together, these results demonstrated that Tfr cells were a similar but distinctive subset of Treg cells. Given that Tfr cells were strongly enriched in ARDS patients, especially in the lung infiltrates, they may exert critical ameliorating effects in ARDS.