CHAPTER 10. Patient Assessment and Preparation for Transport
Reneé Semonin Holleran and Denise M. Treadwell
COMPETENCIES
1. Obtain initial, focused, and comprehensive subjective and objective data through history taking, physical examination, review of records, pertinent laboratory values and radiographic or diagnostic studies, and communication with other healthcare providers, including prehospital and referring personnel.
2. Recognize and anticipate critical signs and symptoms related to the patient’s illness or injury.
3. Perform critical patient interventions as indicated by the patient’s illness or injury.
4. Identify flight operations specific to air ambulance transport that may impact the delivery of care and the safety of the patient and team.
5. Prepare the patient for transport via ground vehicle or rotor-wing or fixed-wing aircraft.
6. Identify and prepare for issues related to international transport.
The first half of this chapter presents an overview of patient assessment and preparation for transport, including identification of the indications for transport, communication, consent for transport, all the factors involved in a patient assessment, and steps to prepare the patient for transport. The second half of this chapter discusses necessary knowledge for all air medical teams in regards to flight operations with an emphasis on those pertinent to fixed-wing transport, including international transport.
The transport process begins with identification of the need to transfer a patient. In many cases, this step has been initiated by members of the referring agency, such as prehospital care providers or healthcare providers in the transferring hospital.
Communication about the need for transport and the care the patient has received and will need from the transport team is an integral part of preparation. This communication begins before the transport team arrives, continues during transport, and concludes with patient follow-up information to the referring agency.
Patient assessment provides the transport team with an opportunity to identify problems and interventions needed before transport. Patient assessment also allows the transport team to anticipate and prepare for events that may occur during transport.
Patient assessment and preparation for transport are composed of multiple elements, including primary and secondary assessment, performance of critical interventions, and treatment of specific problems, such as pain management.
The transport environment is not always conducive to all of the components of patient assessment and preparation. However, the transport team must be familiar with all of these components of patient assessment and preparation so that they can perform the appropriate interventions necessary for safe and successful patient transport. Findings identified during the patient assessment may also be useful in determination of the most appropriate receiving facility and in advanced notification of anticipated therapies necessary immediately on the patient’s arrival or shortly thereafter.
INDICATIONS FOR PATIENT TRANSPORT
Currently, no universal agreement exists on what is an indication for transport. Numerous research studies have identified reasons to transport patients, and national organizations have suggested indications for air medical transport, particularly rotor-wing transport. 8,12,47 In general, the need to move or transfer a patient is based on the severity of the patient’s illness or injury, time, distance, terrain, weather, need for nursing and medical expertise or diagnostic procedures not available at the referring health facility, and a request by the patient’s family that the patient be transferred to another facility. 37,38,61,69
TRAUMA PATIENTS
Numerous guidelines for air medical transport of trauma patients are available. Air medical transport of trauma patients is commonly accepted probably because of its relation to the history of helicopters, which were first used to transport injured patients from the battlefield and were subsequently used to transport trauma patients in the civilian population (see Chapter 1 for the history of air medical transport). In 2002, the National Association of Emergency Medical Services Physicians published extensive guidelines for air medical transport use. 65 Scoring systems have also been used to determine indications for patient transport. Some examples of these scoring systems are the trauma revised trauma score, the trauma triage rule, the Glasgow coma score, Glasgow motor score (GMR; score greater than 5), and the vehicular trauma checklist.
The American College of Surgeons (ACS) 12 continues to include recommendations for the transfer of injured patients in both their Advanced Trauma Life Support Course and their Resources for the Optimal Care of the Injured Patient. In addition, the ACS recommends that the trauma patient should no longer be transferred to the closest hospital but to the closest appropriate hospital, preferably a verified trauma center. 11 Some of the recommendations of the ACS are listed in Box 10-1.
BOX 10-1
ACS CRITERIA FOR CONSIDERATION OF TRANSFER
A. Critical Injuries to Level I or Highest Regional Trauma Center
1. Carotid or vertebral arterial injury
2. Torn thoracic aorta or great vessel
3. Cardiac rupture
4. Bilateral pulmonary contusion with PaO 2 to FiO 2 ratio less than 200
5. Major abdominal vascular injury
6. Grade IV or V liver injuries that necessitate > 6 U RBC transfusion in 6 h
7. Unstable pelvic fracture that necessitates > 6 U RBC transfusion in 6 h
8. Fracture or dislocation with loss of distal pulses
B. Life-Threatening Injuries to Level I or Level II Trauma Center
1. Penetrating injury or open fracture of the skull
2. Glasgow Coma Scale score < 14 or lateralizing neurologic signs
3. Spinal fracture or spinal cord deficit
4. More than two unilateral rib fractures or bilateral rib fractures with pulmonary contusion
5. Open long bone fracture
6. Significant torso injury with advanced comorbid disease (such as coronary artery disease, chronic obstructive pulmonary disease, type 1 diabetes mellitus, or immunosuppression)
ACS, American College of Surgeons; PaO 2, partial pressure of oxygen in arterial blood; FiO 2, fractional concentration of oxygen in inspired gas; RBC, red blood cells.
Note: An injured patient may undergo operative control of ongoing hemorrhage before transfer if a qualified surgeon and operating room resources are promptly available at the referring hospital.
From American College of Surgeons: Resources for optimal care of the injured patient, Dallas, 2006, ACS.
PATIENTS WITH CARDIOVASCULAR AND MEDICAL EMERGENCIES
Most of the research related to the indications for transport involves trauma patients. The emergent transport of nontrauma patients from the scene is rarely practiced and has been shown to provide little to no benefit to the patient. 38 These patients are generally admitted to the local facility for immediate care and then transferred to a specialty facility as an interfacility transfer. Interfacility transfers allow for preliminary diagnoses, initial medical screening, and select diagnostic procedures before the transport. For cardiovascular patients, indications recognized for interfacility transfer include the need for cardiac critical care that is not available at the referring facility, cardiac catheterization, treatment for cardiogenic shock that may include insertion of a balloon pump, mechanical assistance devices, experimental medications, and organ transplant. 24,28,45,49 Research and case reports have shown that patients with cardiovascular emergencies tolerate the transport process well and have benefited from it. 45 For other nontrauma cases, indications for interfacility transfers are generally specific to the limited availability of specialty care and advanced equipment needed for the patient’s condition at the referring facility. 5.6. and 7.21,59
Loos, Runyan, and Pelch59 developed a Medical Classification Criteria Tool (MCCT) modeled on trauma classification tools to assist in determination of the severity of illness and what resources may be needed for appropriate transport. The advantages of this tool include enhancement of communication between the referring and receiving facility and advanced notification of the severity of the patient’s illness so that the receiving facility can be appropriately prepared. This tool can also be used to monitor the appropriateness of medical transfers. Box 10-2 details the MCCT.
BOX 10-2
Staff for Life Helicopter Service, University of Missouri Hospital and Clinics
MEDICAL CLASSIFICATION CRITERIA TOOL
Staff for Life Helicopter Service, University of Missouri Hospital and Clinics
Code blue: Cardiopulmonary arrest (nontraumatic source)
Class I: Life-threatening Illness or Unstable Vital Signs
A. Unstable airway
Acute respiratory distress (i.e., acute pulmonary edema, unconscious patient, patient needs recent intubation)
B. Patient needs ventilatory support (oxygen saturation, <80% via pulse oximetry)
C. Circulatory instability
Clinical signs and symptoms of shock
Symptomatic hypotension, <90 mm Hg systolic
Symptomatic hypertension, >200 mm Hg systolic or >110 mm Hg diastolic
Unstable or symptomatic cardiac rhythms
Uncontrolled chest pain
S/P arrest
Therapies to include but not limited to:
• Transvenous pacer
• Intraaortic balloon pump
• External pacer
• Vasopressor administration
D. GCS, <8 (i.e., acute mental status changes, status epilepticus)
Class II: Potentially Life-threatening Illness, but Vital Signs Currently Stable
A. Controlled pulmonary disease
B. Controlled or decreasing chest pain
C. Controlled acute cardiac dysrhythmias
D. S/P new-onset seizures
E. Vascular disorders
F. Thrombolytic therapy
G. Previously class I case that has been stabilized with treatment
H. GCS, 9-12
Class III: No Obvious Life-threatening Illness and Vital Signs Stable
GCS, Glasgow coma scale.
From Loos L, Runyan L, Pelch D: Development of prehospital medical classification criteria, Air Med J 17(1):14, 1998.
The appropriateness of interfacility patient transfer is by and large measured by comparing the benefits of the transfer to the patient and the risks. The Acute Physiology and Chronic Health Evaluation (APACHE) score is often used in the critical care setting as a predictor of the patient’s mortality. 21,72.73. and 74.80
PREGNANT WOMEN AND NEONATES
Other patients who may need transfer and transport include pregnant women and neonatal patients. The transport of these patients requires specially trained and equipped medical teams. 2.3. and 4.71 Indications for the transport of pregnant women include placenta previa, fetal distress, maternal trauma, prenatal complications, and perimortem delivery. Indications for the transport of neonates include the age and weight of the infant and neonatal illness and injury that cannot be appropriately cared for at the referring facility. 13,61 Teams must be able to monitor for maternal and fetal distress and have additional training and experience to manage those conditions during the transport.
APPROPRIATE PATIENT TRANSFER
In 1986, the Consolidated Omnibus Reconciliation Act (COBRA) was implemented. This legislation, coupled with the 1990 Omnibus Reconciliation Act amendments to COBRA, furnishes guidelines, regulations, and penalties that govern patient transfer and transport. The implications of this law and its recent revisions are discussed in Chapter 36.
In transport of an ill or injured patient, transport services should provide: (1) a transport team with the experience necessary to perform an initial assessment and stabilize the patient’s condition before and during transport; (2) staff who are capable of using the equipment and technology necessary to deliver care during transport to specific groups of patients, such as the critically ill or injured; and (3) the ability to demonstrate that the transport will make a difference in patient outcome. 8,10.11.12.13. and 14.21,27
The American College of Emergency Physicians has developed guidelines for appropriate transfer and transport of ill or injured patients. These guidelines are summarized in Box 10-3. In addition, the American College of Critical Care Medicine has proposed its own recommendations for the transport of critically ill or injured patients. Box 10-4 contains a summary of these guidelines, which address both interhospital and intrahospital transport of patients. Boxes 10-5 and 10-6 provide recommendations from the Air Medical Physician Association (AMPA) for air medical transport in acute coronary syndromes and acute stroke syndromes.
BOX 10-3
American College Of Emergency Physicians Guidelines For Transfer And Transport From Emergency Department To Another Facility
1. The optimal health and well-being of the patient should be the principal goal of patient transfer.
2. Emergency physicians and hospital personnel should abide by applicable laws regarding patient transfer. All patients should be provided a medical screening examination (MSE) and stabilizing treatment within the capacity of the facility before transfer. If a competent patient requests transfer before the completion of the MSE and stabilizing treatment, these should be offered to the patient and documented. Hospital policies and procedures should articulate these obligations and ensure safe and efficient transfer.
3. The transferring physician should inform the patient or responsible party of the risks and the potential benefits of transfer and document these. Before transfer, patient consent should be obtained and documented whenever possible.
4. The hospital policies and procedures or medical staff bylaws should identify the individuals responsible for and qualified to perform MSEs. The policies and procedures or bylaws must define who is responsible for accepting and transferring patients on behalf of the hospital. The examining physician at the transferring hospital will use best judgment regarding the condition of the patient when determining the timing of transfer, mode of transportation, level of care provided during transfer, and destination of the patient.
5. Agreement to accept the patient in transfer should be obtained from a physician or responsible individual at the receiving hospital in advance of transfer. When a patient requires a higher level of care other than that provided or available at the transferring facility, a hospital with the capability to provide a higher level of care may not refuse any request for transfer.
6. An appropriate medical summary and other pertinent records should accompany the patient to the receiving facility or be electronically transferred as soon as is practical.
7. When transfer of patients is part of a regional plan to provide optimal care at a specialized medical facility, written transfer protocols and interfacility agreements should be in place.
From American College of Emergency Physicians: Appropriate interhospital patient transfer, Dallas, 2002, ACEP.
BOX 10-4
Summary Of American College Of Critical Care Medicine Guidelines For The Transport Of The Critically Ill Or Injured Patient
1. The benefits of transferring the patient should outweigh the risks.
2. The practitioner needs to be aware of the legal implications of patient transfer and transport.
3. Before the patient is transported, physicians and nurses at the referring and receiving facilities should be in contact, a decision should be made about the mode of transportation to be used, and a copy of all medical records relevant to the patient’s care should be secured.
4. Accompanying transport personnel should include a minimum of two patient care providers and a vehicle operator. At least one care provider should be a registered nurse.
5. The equipment (including monitors) and medications necessary to manage the patient’s airway, breathing, and circulation should be available. Communication equipment used during transport should also be available.
6. Continuous monitoring should take place during transport. At a minimum, ECG monitoring and monitoring of vital signs are required. Patients with specific problems may require additional monitoring, such as capnography and invasive monitoring.
Modified from the Guidelines Committee of the American College of Critical Care Medicine Society of Critical Care Medicine and the Transfer Guidelines Task Force of the American Association of Critical Care Nurses: Guidelines for the transport of the critically ill patient, 2004. Accessed from http://www.sccm.org. June 30, 2008.
BOX 10-5
Position Statement of The Air Medical Physician Association Approved by the AMPA Board of Trustees, November 10, 2001
Appropriateness Of Air Medical Transport In Acute Coronary Syndromes
Position Statement of The Air Medical Physician Association Approved by the AMPA Board of Trustees, November 10, 2001
Background
Acute coronary syndromes are common reasons to utilize air medical transport. Regionalization of cardiac care to highly specialized centers, increasing use of invasive and time sensitive therapies, and efforts to minimize both the absolute time to therapy and the dangerous out of hospital time are significant drivers in improving cardiac care and for increasing the utilization of air medical transport.
AMPA Position Statement
The AMPA supports the use of air medical transport for adult patients with acute coronary syndromes requiring or potentially requiring urgent or time-sensitive intervention not available at the sending facility.
As outlined by the American Heart Association, acute coronary syndromes represent the spectrum of clinical disease presenting with syndromes ranging from unstable angina to Q-wave and non–Q-wave myocardial infarctions.
It is AMPA’s position that the determination for the need for urgent or time-sensitive interventions is made by a physician, as documented on a written Certification of Medical Necessity.
Furthermore, AMPA acknowledges that scene air medical transport of acute coronary syndromes occurs routinely and supports that the medical necessity is determined by the requesting authorized provider based on regional policy and their best medical judgment at the time of the request for transport. AMPA supports that a receiving physician or the transport program medical director may complete the Certificate of Medical Necessity on scene transports.
The AMPA does not support the use of discharge ICD-9 codes or other methodologies that retrospectively determine medical appropriateness of acute coronary syndromes as this may adversely restrict access to appropriate care and may contradict the intent of EMTALA regulations. AMPA also believes that retrospective determination of medical appropriateness negates the regional, environmental, level of prehospital care, and situational issues that are important factors at the time of transport in determining medical appropriateness for air medical transport in acute and potentially acute coronary syndromes.
Copyright © Air Medical Physician Association, 2001; All Rights Reserved
BOX 10-6
Position Statement of The Air Medical Physician AssociationApproved by the AMPA Board of Trustees, October 23, 2004
Appropriateness Of Medical Transport And Access To Care In Acute Stroke Syndromes
Position Statement of The Air Medical Physician AssociationApproved by the AMPA Board of Trustees, October 23, 2004
Background
Acute coronary syndromes are common reasons to utilize air and ground medical transport. Regionalization of primary stroke centers and effects demonstrated by rapid access to stoke treatment centers providing thromolysis and systematized stroke care as well as advance interventional neuroradiologic treatment for acute stroke syndromes are significant drivers for increasing the utilization of air and ground medical transport.
AMPA Position Statement
The AMPA supports the use of air and ground medical transport for patients with acute stroke syndromes requiring or potentially requiring urgent or time-sensitive intervention only available at stroke treatment centers.
It is AMPA’s position that the determination for the need for urgent or time-sensitive interventions is made by a physician or other qualified provider, as documented on a written Certification of Medical Necessity.
Furthermore, AMPA acknowledges that scene air medical transport of acute stroke syndromes occurs routinely and supports that the medical necessity is determined by the requesting authorized provider using standardized field identification and based on regional policy and their best medical judgment at the time of the request for transport.
The AMPA does not support the use of discharge ICD-9 codes or other methodologies that retrospectively determine medical appropriateness of acute stroke syndromes as this may adversely restrict access to appropriate care and may contradict the intent of EMTALA regulations. AMPA also believes that retrospective determination of medical appropriateness negates the regional, environmental, level of prehospital care, and situational issues that are important factors at the time of transport in determining medical appropriateness for air medical transport in acute and potentially acute stroke syndromes.
Copyright © Air Medical Physician Association, 2004; All Rights Reserved
Finally, in 1995, the Emergency Nurses Association (ENA) developed a document (revised July 2005) that provides guidelines for the transport of ill or injured children. Unlike the documents previously mentioned, this document specifically addresses the needs of the ill or injured child. These guidelines are available from the ENA.
THE DECISION TO TRANSPORT
Several factors must be considered by referring personnel when they decide whether to transport a patient. The first factor to be considered is the appropriateness of transport, which was previously discussed. Identification of a suitable receiving facility is a second factor that must be considered. When choosing a receiving facility, referring personnel must look at the resources available at the receiving facility, such as specialized care staff, equipment, bed availability, and expertise. The location of the receiving facility is also an important consideration.
Another factor that should be considered in the decision of whether to transport a patient involves the existence of written policies and agreements among the receiving and referring agencies. The identification of centers that are capable of certain types of services and generation of triage guidelines could save precious time.
COMMUNICATION
Communication is probably one of the most important components in the preparation of the patient for transport. Communications center operations are discussed in Chapter 8. This discussion focuses on the communication process among personnel at the referring and receiving agencies (either a healthcare facility or an emergency medical services [EMS] agency).
Communication should begin before the transport team arrives. Written policies, procedures, and triage guidelines should be in place at the referring agency. These documents should address the type of patient who should be transferred and the mode of transportation, the care that is needed before transport, whether or not passengers are allowed to accompany the patient and team during the transport, and the steps that need to be taken by the referring agency to prepare for the arrival of the transport vehicle. For example, if a helicopter will be transporting the patient, where will it land, who will meet it, and who will monitor it while the team prepares the patient for transport?
When initial contact has been made by the referring agency, information that should be provided for the transport team includes the patient’s chief symptom, the indications for transport, interventions and their effects, and the patient’s current condition. The reason for the patient transfer should be clearly identified and documented. Some transport programs require signed documentation by the treating or accepting physician to certify the need for transport before they transfer the patient because of recent reimbursement issues, particularly from Medicare.
The patient’s problem, age, and location must be communicated effectively so the most suitably trained and equipped transport team can be sent to provide care for the patient. For example, some areas of the United States have transport teams specifically designed to provide care for pregnant women, children, neonates, and critical care patients. As discussed previously, the equipment required by the patient’s illness or injury might influence the clinical skills that may be needed during transport (e.g., an intraaortic balloon pump necessitates personnel who are trained in its use in the transport environment).
Once the transport team arrives, they can obtain additional information about the patient directly from the staff at the referring agency. When the transport team members arrive at the scene, they should identify the person in charge and offer assistance.
During the initial assessment and preparation of the patient for transport, transport team members communicate with referring individuals. The communication process is composed of both verbal and nonverbal behaviors, and one’s attitude is an important intervention. Thus, the transport team should always involve those who have been caring for the patient with an attitude of respect and professionalism.
Any laboratory results and radiographic and diagnostic study results should be copied and sent with the patient. Technology continues to make some paperwork easier to transfer. For example, radiographic and diagnostic study results may be transmitted by means of telemedicine before the patient leaves the receiving facility. If the patient has any valuables, they must be accounted for. Valuables are sometimes easier left with a family member, but this may not be possible. Recording a list of what was brought with the patient and to whom it was given on arrival at the receiving facility may prevent problems. Clothing or other valuables are sometimes considered evidence and should be treated as such on the basis of evidence protocols.
CONSENT
Patients must consent to treatment and transfer. However, written or verbal consent for transport and for emergency treatment is not always possible to obtain directly from the patient or family. Consent for transport is usually implied. Implied consent is considered to be given only in an emergency situation, when the patient is incapacitated and in a life-threatening situation. 14,25
Although the patient’s consent is implied, the transport team should always explain to the patient and available family members all procedures and the transport process. If family members are available, they may be able to provide consent for treatment. If consent forms are part of the transport documentation, the transport team should ensure that they are transported with the patient. On interfacility transfers, the team may elect to leave a copy of the consent with the referring facility.
A TWENTY-FIRST CENTURY PATIENT TRANSPORT CHALLENGE
During the past few years, the closing of hospitals, the decrease in nursing and other healthcare providers, and the lack of funds to provide healthcare have created a unique crisis that has grave implications to patient transport. 79,92 Many facilities that in the past accepted patients without question have now adopted diversion policies, which means a decrease in available beds, longer waits for transfer, refusal of some patients, and diversion. The American College of Emergency Physicians has developed Guidelines for Ambulance Diversion. 9Box 10-7 contains a summary of these guidelines.
BOX 10-7
Guidelines For Ambulance Diversion
• Identify situations in which a hospital’s resources are not available (critical care beds, nursing staff) and temporary diversion is necessary.
• EMS systems and hospital personnel must be notified of such occurrences, and the notification must occur through a lead EMS agency or designated communication coordination center.
• The hospital’s diversion status must be regularly reviewed.
• Policies and resources need to be in place to provide for the safe, appropriate, and timely care of patients who continue to enter the EMS system during the period of diversion.
• The EMS system and other appropriate personnel should be notified when the diversion status has changed.
• Explore solutions that address the causes of diversion and implement policies that minimize the need for diversions.
• Continuously review polices and guidelines governing diversion.
EMS, Emergency medical service.
Modified from Brennan J: Guidelines for ambulance diversion, Irving, TX, 2006, American College of Emergency Physicians.
Transport programs need to ensure that the patient has a receiving facility, bed assignment, and accepting physician. Diversion notification should also include all services that provide patient transport to prevent any undue delay in patient transfer and transport.
PATIENT ASSESSMENT
Primary and secondary assessment, identification of patient problems, and initiation of critical interventions provide a framework for preparing a patient for transport. Each of these tasks must be performed in an organized, rapid, and complete manner. Patient assessment is a continuous process that occurs before, during, and after transport.
ASSESSMENT OF THE PATIENT IN THE PREHOSPITAL CARE ENVIRONMENT
Assessment of the patient in the prehospital care environment can be an intense challenge. The location of the patient (e.g., trapped in a vehicle; Figure 10-1), the limited availability of personnel and equipment, and the nature of the illness or injury present potential barriers to prehospital patient assessment.
 |
| FIGURE 10-1 Primary and secondary assessments can be difficult to perform depending on patient location. (Courtesy Stanford Life Flight.) |
The environment in which the patient is located during the transport may also pose barriers to assessment. Noise, a lack of light and space, vehicle movement and the speed at which the vehicle is moving, and outside weather can make normal assessment maneuvers, such as auscultation, difficult to perform.
The type of vehicle used to transport the patient may pose additional barriers to patient assessment. Ground, helicopter, and fixed-wing vehicles each have specific limitations that may complicate the team’s ability to assess the patient. Although equipment is now more portable, some pieces of equipment are still susceptible to movement and vibrations that could affect reliability when used for patient assessment. Noise hampers patient assessment no matter what mode of transport is used.
SCENE ASSESSMENT
Assessment of the patient before reaching the hospital begins with assessment of the scene, whether the transport team responds directly to the patient or to another facility. The transport team should assess the surrounding environment for hazards. Box 10-8 contains a summary of some of the hazards that may be encountered.
BOX 10-8
Potential Environmental Hazards
Hazards at the Scene
Wires
Uneven ground
Vehicles
Accident itself
People
Signs
Light poles
Water
Loose debris
Hazardous materials (HAZMAT)
EMS rescue apparatus
Fire
Smoke
Weather hazards
Heavy machines or construction equipment
Hazards at the Referring Facility
Buildings
People
Wires
Construction equipment
Shovels or other items used to clean landing zone area
On arrival at the referring facility, the transport team should survey the resources that are available to assist in preparing the patient for transport. Equipment and supplies necessary for patient stabilization may be limited, and thus, the team may need to bring additional equipment.
The principles of patient assessment used by the transport team are no different than those used when patients are assessed within the walls of a hospital. However, the prehospital environment dictates that the assessment be organized, direct, and rapid. Adaptation and flexibility are necessary when patient assessment is performed outside the hospital. Confined spaces, lack of light, noise, and equipment that may or may not be functioning can present challenges to patient assessment in the prehospital care environment.
HISTORY
Patient assessment begins with obtaining a history as the primary assessment is performed. The history of the illness or injury provides a guide for critical interventions, preparation of the patient for transport, and ongoing assessment during transport and also alerts the transport team to problems that may develop during transport. For example, the history of a patient who has multiple rib fractures and will be flown alerts the transport team to the potential for the development of a tension pneumothorax.
Generally, the transport team is given some information while en route to the patient. However, experience has shown that the situation on arrival may be quite different than that described beforehand.
General Principles of History Gathering
According to Henry and Stapleton, 50“history is the patient’s story of significant events related to and surrounding the present problem.” Some general principles should be followed when gathering information related to the patient’s illness or injury. One of these principles is that the patient’s chief symptom or problem should be identified. If the patient is unable to provide this information, the transport team may obtain it from others at the scene (prehospital care providers, police, or bystanders), referring personnel (nurses or physicians), or any persons who may be with the patient. A survey of the scene by the transport team can also provide valuable information about what may have happened. If the patient is unconscious, the transport team should look for medic alert jewelry, syringes, medications, pill bottles, or information in the patient’s wallet or purse.
A common mnemonic used to collect general history information is SAMPLE:
SSigns and symptoms reported.
AAllergies, alcohol, or substance abuse.
M Medications, including immunizations, particularly in a pediatric history.
PPast medical history, including illnesses and injuries.
LLast meal or intake.
EEvents that led to the emergency and everything that has been done before the arrival of the transport team.
If the patient’s chief symptom or problem is related to pain, the PQRST method is of use in collection of information on history. PQRST43,46,50,57,58 represents the following:
PProvoking factors: What caused or causes the pain? Does anything relieve the pain or make it worse? What was the patient doing when the pain began?
QQuality of the pain: Some of the words used to describe the pain may provide the nurse with clues to the origin of the pain. For example, patients who describe chest pain often use words such as “burning” or “crushing.”
RRegion and radiation: The patient should be asked to point to the area where the pain is felt. Pain patterns can provide the transport team with clues to the cause of the patient’s pain and may help guide the management of the patient’s pain.
SSeverity: Numbering, such as from 1 to 10, can be used to describe the severity of the pain.
TTime: The patient should be asked to describe the temporal nature of the pain, such as how long it has been present and when or at what time of day it began.
The transport team may find a history difficult to obtain in the prehospital care environment as a result of obstacles such as the patient’s inability to communicate because of illness or injury, the lack of witnesses to a particular event, or the absence of family members or significant others at the scene of the illness or injury.
When possible, and particularly when the patient is transported from a referring facility, as much information as possible should be collected and communicated with the receiving facility. At other times, particularly when patients are transported directly from the scene, much information may not be available. The transport team should keep in mind that history provides key information. History also alerts the nurse to problems that may develop during transport.
Trauma History
History gathering is different for the trauma patient than for the patient with a medical illness. The mechanism of injury generally triggers the trauma history. The transport team must find out when, where, and how the patient was injured. A complete description of the event is often limited. However, a general idea of the mechanism of injury provides clues regarding additional injuries and complications that may occur during transport. Box 10-9 describes predictable injuries that may occur as a result of motor vehicle crashes, as an example of taking a trauma history. 43,46,50,57,58
BOX 10-9
Predictable Injuries That Result From Motor Vehicle Crashes
Unrestrained Driver
Head injuries
Facial injuries
Fractured larynx
Fractured sternum
Cardiac contusion
Lacerated liver or spleen
Lacerated great vessels
Fractured patella and femur
Fractured clavicle
Restrained Driver
Caused by a Lap Restraint
Pelvic injuries
Spleen, liver, and pancreas injuries
Caused by a Shoulder Restraint
Cervical fractures
Rupture of mitral valve or diaphragm
Modified from McSwai N, Frame S, Salomone J: Basic and advanced prehospital trauma life support, ed 5, St Louis, 2003, Mosby.
In recent years, instant photographs, video recorders, and digital cameras have been used to provide information about the mechanism of injury. 67 Rescuers must use caution when taking photographs of the scene to prevent the violation of patient privacy laws or Health Insurance Portability and Accountability Act (HIPAA) regulations. Photographs should be of vehicles and property. Patient faces and deceased patients should generally not be photographed. Many transport services have strict HIPAA policies regarding disclosure of patient details, including the use of photographs; therefore, understanding of and strict adherence to company policies should be followed. 30,77 Dickinson, Krett, and O’Connor30 reported that when photography was used to provide details related to a motor vehicle crash, receiving physicians altered perceptions about the patient’s injuries in 46% of the cases. In addition, the receiving physician upgraded the severity of the motor vehicle crash after viewing the photographs in 22 of 26 cases (85%).
When obtaining the history of a trauma patient, the transport team should also gather information that describes the scene of the crash. Did the collision involve multiple victims? Are all of the victims accounted for? Were there fatalities? If the on-scene patients are unable to provide information about additional patients, the presence of schoolbooks, clothing, or toys may suggest that additional victims are present. 17
History Related to Medical Illness
A patient’s medical history begins with the chief symptom or current problem. The SAMPLE and PQRST mnemonics previously described can be of assistance when obtaining a medical history. The transport team should obtain history related to the present illness, including related signs and symptoms. Significant medical history and risk factors for a particular disease process (such as smoking and chronic obstructive pulmonary disease) can provide additional pieces of meaningful information.
Information about current medications should be provided. Drug interactions or the effects of not taking a scheduled medication may cause additional problems during transport.
Information about care initiated before the arrival of the transport team must be gathered. These data50 should include initial physical findings, initial treatments and results, vital sign trends, medications given, laboratory results, radiographic or diagnostic study findings, electrocardiographic (ECG) interpretation, intravenous infusions administered, intake and output measurements, and status of family notification.
DIVERSITY ASSESSMENT
Although the focus of patient care during the transport process is generally on critical needs, age, class, culture, ethnicity, gender, nationality, race, religion, and sexual orientation influence response to illness and injury. The transport team must take into consideration these factors when providing care and respect and, when possible, adapt the care to include the impact of diversity on response to illness, injuries, and the need to be transported. 28,31
Awareness and knowledge of all patient diversity is impossible. However, the transport process can be a little less stressful for the patient, the family, and the transport team when the multiple factors that influence a patient’s response to illness and injury are not ignored.
In 1997, the Emergency Nurses Association developed a Diversity Practice Model that can assist in approaching patient diversity. 33.34.35. and 36. The components of this model are summarized in Table 10-1. The use of this model may offer some added patient care information and help us recognize what makes us different and the same.
| Emergency Nurses Association Diversity Task Force: Approaching diversity: an interactive journey, Des Plaines, IL, 1997, ENA. | ||
| A | Assumption | What do we assume or take for granted about this individual or the community that they come from? |
| B | Beliefs or behaviors | How does my belief system affect the care I provide for this patient? |
| Are my beliefs mirrored in the way I behave toward the patient? For example, a patient who may not have bathed for a long period of time may be viewed as homeless. | ||
| C | Communication | How does the patient communicate? Does the patient speak English? If not, is a translator available? Can the patient hear, see? Has the patient had an injury such as a stroke that impairs the ability to communicate or understand? |
| D | Diversity or identification of how the patient differs | Some diversity is visible, such as skin color, age, or ethnic background. Some is invisible, such as sexual orientation or class. |
| E | Education | Education involves learning about the patient’s diversity. |
| Ethics | Ethical decisions are influenced by one’s diversity. | |
PRIMARY ASSESSMENT AND CRITICAL INTERVENTIONS
Primary assessment is based on assessment of the patient’s airway, breathing, circulation, neurologic disability, and exposure. During the primary assessment, as patient problems are identified, critical interventions are initiated. The basic steps remain the same, whether at a scene or an interfacility transport.
Airway
The patient’s airway is assessed to determine whether it is patent, maintainable, or not maintainable. For any patient who may have a traumatic injury, cervical spine precautions are used while the airway is evaluated. Assessment of the patient’s level of consciousness, in concert with assessment of the airway status, provides the transport team with an impression of the effectiveness of the patient’s current airway status (Box 10-10).
BOX 10-10
Summary Of Primary Airway Assessment
• Airway: Patent, maintainable, nonmaintainable
• Level of consciousness
• Skin appearance: Ashen, pale, gray, cyanotic, or mottled
• Preferred posture to maintain airway
• Airway clearance
• Sounds of obstruction
If an airway problem is identified, the appropriate intervention should be started. The decision to use a particular intervention depends on the nature of the patient’s problem and the potential for complications during transport. Airway interventions are addressed in Chapter 11. Supplemental oxygen should be given to all patients before transport. Specific equipment, such as a pulse oximeter or CO 2 detector, help provide continuous airway evaluation during transport. The indications and the procedures for use of these devices are included in Chapter 12.
Pharmacologic Adjuncts for Airway Management
Specific pharmacologic agents have been found to be useful in prehospital airway management. These agents include those that provide sedation and amnesia and neuromuscular blocking agents that facilitate intubation. An in-depth discussion of the use of these medications is provided in Chapter 11.
Transport team members must remember when these medications are used, particularly if the patient received neuromuscular blocking agents; they then are totally dependent on the transport team. Measures to ensure patient safety and comfort, including keeping the patient warm and providing sedation and analgesia, must be provided by the team during transport.
Breathing
The assessment of ventilation begins with noting whether the patient is breathing. If the patient is apneic or in severe respiratory distress, immediate interventions are indicated. If the patient has any difficulty with ventilation, the transport team must identify the problem and proceed with the appropriate interventions. Emergent interventions may include decompression with a needle or insertion of a chest tube (Box 10-11). Ventilation interventions are discussed in Chapter 12.
BOX 10-11
Summary Of Primary Breathing Assessment
• Rate and depth of respirations
• Cyanosis
• Position of the trachea
• Presence of obvious injury or deformity
• Work of breathing
• Use of accessory muscles
• Flaring of nostrils
• Presence of bilateral breath sounds
• Presence of adventitious breath sounds
• Asymmetric chest movements
• Palpation of crepitus
• Integrity of chest wall
• Oxygen saturation measured with pulse oximetry
Circulation
Palpation of both the peripheral and the central pulse provides information about the patient’s circulatory status. The quality, location, and rate of the patient’s pulses should be noted. The temperature of the patient’s skin can be assessed along with the pulses. Observation of the level of consciousness helps evaluate the patient’s perfusion (Box 10-12).
BOX 10-12
Summary Of Primary Circulation Assessment
• Pulse rate and quality
• Skin appearance: Color
• Peripheral pulses
• Skin temperature
• Level of consciousness
• Urinary output
• Blood pressure
• Cardiac monitor
• Invasive monitor
Active bleeding should be quickly controlled with interventions such as direct pressure. The transport team should observe the patient for indications of circulatory compromise. Skin color and temperature, diaphoresis, and capillary refill are appraised during circulatory assessment.
Intravenous access is obtained for administration of fluid, blood, and medications. Depending on the patient’s location and the accessibility of veins, peripheral, central, or intraosseous access may be used. Fluid resuscitation must be guided by the patient’s response.
Disability: Neurologic Assessment
Neurologic assessment includes assessment of the level of consciousness; the size, shape, and response of the pupil; and motor sensory function. The following simple method called AVPU may be used to evaluate the patient’s level of consciousness:
AAlert.
VResponds to verbal stimuli.
PResponds to painful stimuli.
UUnresponsive.
Both the Glasgow and the Pediatric Glasgow Coma Scales provide assessment of the patient’s level of consciousness and motor function and serve as predictors of morbidity and mortality after brain injury. 1,34
If the patient has an altered mental status, the transport team needs to determine whether the patient has ingested any toxic substances, such as alcohol or other drugs, or may be hypoxic because of illness or injury. A patient with an altered mental status may pose a safety problem during transport. Use of chemical paralysis, sedation, or physical restraints may be necessary to ensure safe transport. 63
Exposure
As much of the patient’s body as possible should be exposed for examination, with the effects of the environment on the patient kept in mind. Discovery of hidden problems before the patient is loaded for transport allows the transport team to intervene and prevent potentially disastrous complications. Although exposure for examination has been emphasized most frequently in the care of the trauma patient, it is equally important in the primary assessment of the patient with a medical illness.
Team members should always look under dressings or clothing, which may hide complications or potential problems. Intravenous access can be wrongly assumed underneath a bulky cover. Clothing can also hide bleeding that occurs as a result of thrombolytic therapy or rashes that may indicate potentially contagious conditions (Box 10-13).
BOX 10-13
Summary Of Exposure Assessment
• Appropriate tube placement: Endotracheal tubes, nasotracheal tubes, chest tubes, nasogastric or orogastric tubes, and urinary catheters
• Intravenous access: Peripheral, central, and intraosseous
• Identification of injury; active bleeding; indication of a serious illness such as presence of purpura
Once patient assessment has been completed, the patient needs to be kept warm. Hypothermia can cause cardiac arrhythmias, increased stress response, and hypoxia. Medications such as neuromuscular blocking agents interfere with the patient’s ability to maintain a stable body temperature.If extended transport times are necessary, the team should reassess the patient’s temperature during the transport.
Prevention of hypothermia should be considered a critical intervention, and methods to decrease the risk of heat loss initiated during the primary assessment should be initiated by the transport team. These include the following48,51,66:
▪ Covering the patient with blankets or an insulated layer.
▪ Limiting exposure when examinations are needed.
▪ Keeping the patient away from metal or anything that may draw heat away from the patient.
▪ Shielding the patient from wind rotor wash.
▪ Using warmed humidified oxygen and warmed intravenous fluids.
Equipment Assessment
Although the concept of equipment assessment has not been routinely included in previous descriptions of primary assessment, it is an important process that must be performed. Before the patient is transported, the transport team should ensure that the patient is wearing an appropriately sized cervical collar, that the chest tube drainage system is functioning, and that the patient is correctly restrained. The team should also confirm that the equipment in use is approved for continued use in the transport environment. This assessment of equipment helps prevent problems during transport that could potentially leave the patient at risk for further injury.
SECONDARY ASSESSMENT
Whether a secondary assessment can be performed depends on the patient’s condition and the amount of time needed for transport. Lack of space in the transport vehicle, lack of light, and noise may interfere with the transport team’s ability to perform a secondary assessment during transport.
Secondary assessment is done after the primary assessment is completed and involves evaluation of the patient from head to toe. 1,12,23,34 Patient data are collected by means of inspection, palpation, and auscultation during secondary assessment. Whether the patient has had an injury or is critically ill, the evaluator should observe, touch, and listen to the patient.
Secondary assessment begins with an evaluation of the patient’s general appearance. The transport team should observe the surrounding environment and evaluate its effects on the patient. Is the patient aware of the environment? Is there appropriate interaction between the patient and the environment?
Additional systems that should be assessed include the integumentary (color, presence of wounds, temperature); head and neck (deformities, crepitus, pain); eyes, ears, and nose (drainage); thorax and lungs (chest movement and heart and breath sounds); abdomen; genitourinary; and extremities and back (Box 10-14).
BOX 10-14
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Summary Of Secondary Assessment
Skin
• Presence of petechia, purpura, abrasions, bruises, scars, birthmarks
• Rashes
• Abnormal skin turgor
• Signs of abuse and neglect
Head and Neck
• Presence of lacerations, contusions, raccoon eyes, Battle’s sign, or drainage from the nose, mouth, and ears
• In the infant, examination of the anterior fontanel
• Gross visual examination
• Abnormal extraocular movements
• Position of the trachea
• Neck veins
• Swallowing difficulties
• Nuchal rigidity
• Presence of lymphadenopathy or neck masses
Eyes, Ears, Nose
• Lack of tearing
• Sunken eyes
• Color of the sclera
• Drainage
• Gross assessment of hearing
Mouth and Throat
• Mucous membranes
• Breath odor
• Injuries to teeth
• Drooling
• Drainage
Thorax, Lungs, Cardiovascular System
• Breath sounds
• Heart sounds
Abdomen
• Shape and size
• Bowel sounds
• Tenderness
• Firmness
• Masses (e.g., suprapubic mass)
• Femoral pulses
• Pelvic tenderness
• Color of drainage from nasogastric or orogastric tube
Genitourinary
• Blood at meatus
• Rectal bleeding
• Color of urine in catheter
Extremities and Back
• Gross motor and sensory function
• Peripheral pulses
• Lack of use of an extremity
• Deformity, angulation
• Wounds, abrasions
• Equipment is appropriately applied (e.g., traction splints)
• Vertebral column, flank, buttock
PAIN ASSESSMENT
Determination of the amount of pain the patient has as a result of illness or injury is an important component of patient assessment. Physiologic indicators of pain include tachypnea, controlled respirations (splinting), tachycardia, hypotension, hypertension, nausea and vomiting, and diaphoresis. Behavioral indications of pain are crying, protective behavior, guarding, moaning, and self focusing.
SCORING SYSTEMS
Scoring systems were initially developed to identify patients who were in need of critical care that was not available at referring facilities, 8,19 such as patients who needed to be transported to a level I trauma center. Scoring systems can be used in the field and for evaluation of patients who may need interfacility support. Scoring systems have most commonly been used for the trauma patient. These systems include the Prehospital Index Score, CRAMS Scale Score, Triage-Revised Trauma Score, and Baxt’s Trauma Triage Rule. Little research has been done regarding triage scores and severity scores that can be used for other medical problems. 23,32,68,78,95
PREPARING THE PATIENT FOR TRANSPORT
This section summarizes patient preparation for transport. More in-depth discussions about patient preparation are contained in the clinical care sections of this book. The patient is prepared for transport on the basis of information obtained from the primary and secondary assessment, the type of vehicle used for transport, the amount of time of the transport, and the problems that may develop in relation to the patient’s illness or injury during transport. Patient preparation includes anticipatory planning; anticipation of potential patient problems makes patient care easier and safer.
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