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Between 2021 and 2022, two non-critical adult patients returning from the imaging department after an invasive procedure developed increased oxygen needs, which ended in death for on patient and a transfer to critical care for the other.

No formal guidelines exist for the intra-hospital transport by unlicensed personnel may be absent. An intra-hospital transport checklist was developed for non-critical care patients leaving the unit for procedures in the imaging department.


  • A "RN Pre-Invasive Procedure Transport Safety Checklist" was created by a telemetry RN (MSN student, Greta Titus) and CNS, Teresa Jahn
  • The checklist was designed to answer questions to determine a patient's hemodynamic and respiratory stability prior to transport by an unlicensed person
  • The checklist is to be completed prior to transport on all patients leaving the unit for a procedure in the imaging department (i.e. paracentesis, thoracentesis, biopsy, etc.)
  • If one of the questions answered is "yes", the next step is to prompt a huddle with Resource RN or Charge RN to identify f a patient is safe for transport without a RN.
  • The "why" for the change was presented by Greta Titus during the November 2022 CentraCare Heart and Vascular Center Clinical (CCHVC) Practice meeting
  • Staff were also notified of this change during Telemetry daily huddles and weekly updates
  • The trial started on Telemetry beginning 11/1/2022
  • Follow up on the progress of the practice change was presented by CCHVC CNS during Telemetry Education Days in January-February 2023

Publication Date





St. Cloud, MN


Intra-hospital transport, Patient monitoring, Physiological monitoring, Invasive procedures, Patient handoffs


Critical Care Nursing | Other Nursing


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