CHAPTER 2. Preparation for Practice
Reneé Semonin Holleran and Sally Houlston
Critical care patient transport requires skilled and experienced personnel to meet the needs of complex cases in a challenging environment. It also necessitates clinical competency, critical thinking skills, and flexibility. The education, clinical proficiency, and knowledge needed to provide this care both before and during transport must be diverse and comprehensive. Transport teams vary and may be composed of registered nurses, paramedics, physicians, respiratory therapists, or others, as dictated by patient needs. Although no central reporting agency makes up a transport team, most teams within the United States continue to be staffed by registered nurses and paramedics. 4,15 However, all team members must possess some basic information: for example, aircraft safety, use of radios or communication devices, and survival training. The transport team staffing and education should be commensurate with the mission statement and scope of care of the medical transport service. The transport vehicle, by virtue of how it is staffed and medically equipped, becomes a patient care unit specific to the needs of the patient. The team that transports that patient must be appropriately educated and trained on patient management before and during the transport process. 4,16
The make-up of a transport team varies across the world. The Commission on Accreditation of Medical Transport Systems (CAMTS) 4 defines team members on the basis of the mission of the transport. Table 2-1 describes the different types of missions and teams that may be involved in transport with use of the CAMTS definitions.
| EMT-P, Emergency medical technician-paramedic; EMT-B, Emergency medical technician-basic; IABP, Intra-aortic balloon pump. | |
| Mission | Definition |
|---|---|
| Critical care | Critical care is defined as transport from a scene or clinical setting of a patient whose condition warrants care commensurate with the scope of practice of a physician or registered nurse. |
| Advanced life support | Advanced life support mission is defined as transport from an emergency department, critical care unit, or scene of a patient who needs care commensurate with the scope of practice of an EMT-P. |
| Basic life support | A basic life support is defined as the transport of a patient from an emergency department or scene who requires care commensurate with the scope of practice of an EMT-B. |
| Specialty care | These team members have a specific specialty and are added to the regularly scheduled transport team (e.g., neonatal, pediatric, perinatal, or IABP transports). |
QUALIFICATIONS FOR TRANSPORT PRACTICE
Transport Nurse
The registered nurse has had a role in patient transport and the prehospital environment for numerous years. Discussion continues about what qualifications a nurse should have to practice. States, local emergency medical services (EMS) regulations, and even some national EMS and physicians associations have provided input into transport nursing practice. The Air and Surface Transport Nurses Association (ASTNA) 1 developed a position paper that addresses some of these issues. The preparation for patient care required to practice nursing, along with the appropriate experience and education, provides a sound foundation for practice in the prehospital and transport environments. However, that preparation rarely includes the skills needed to deliver patient care in the prehospital environment. ASTNA supports that State Boards of Nursing, or in other countries, the equivalent regulatory bodies for the profession of nursing. ASTNA seeks recognition by state EMS agencies or their equivalent for the unique role of a registered nurse to practice in the prehospital environment. The registered nurse who practices in the prehospital and transport environment must be properly prepared to deliver patient care safely and competently in this exceptional and challenging environment. 1,17
The ASTNA published a specific position paper that recommends the qualifications a transport nurse should have when hired. These qualifications are summarized in Box 2-1. 2
BOX 2-1
Qualifications for Transport Nurses
• Registered nurse (with appropriate state/provincial licensure)
• Minimum of 2 years of critical care or emergency department experience
• Specialty certification commensurate with previous experience (CEN, CCRN, CFRN, or CTRN within 2 years of hire)
• Basic cardiac life support or equivalent
• Age-specific advanced cardiac life support (ACLS or PALS)
• Transport nurse advanced trauma course (TNATC), advanced trauma life support course (ATLS), or equivalent
• Objective assessment of the transport nurse applicant’s qualifications for transport based on, but limited to, the following characteristics:
• Educational and experiential background
• Technical and clinical competence
• Leadership skills
• Critical thinking skills
• Proficient communication and interpersonal skills
• Appreciation of public and community relations
CEN, Certificate for Emergency Nursing; CCRN, Critical Care Registered Nurse; CFRN, Certified Flight Nurse; CTRN, Certified Transport Registered Nurse; ACLS, advanced cardiac life support; PALS, Pediatric Advanced Life Support; TNATC, Transport Nurse Advanced Trauma Course; ATLS, Advanced Trauma Life Support.
Transport Paramedic
The International Association of Flight Paramedics (IAFP; formally the National Flight Paramedics Association) proposes that the paramedic functions well in the air medical and critical care transport environment. 6 However; some confusion has been seen because of the several definitions of paramedic practice in the transport environment. Most definitions are determined by the area of the country (and even the world) in which the paramedic practices. The certified flight paramedic examination was developed to help clarify what preparation is necessary for an advanced role as a paramedic performing air medical and critical care ground transport. Box 2-2 provides a summary of the IAFP’s recommendations for both the flight paramedic and the certified flight paramedic. 6
BOX 2-2
Qualifications for a Transport Paramedic
• Minimum of 3 years experience in the field as an EMT-P working as an Advanced Life Support Provider
• Minimum of 5 years basic paramedic practice after graduation for the certified paramedic
• Basic Life Support
• Advanced Cardiac Life Support
• Basic Trauma Life Support
• Prehospital Trauma Life Support or Advanced Trauma Life Support audit
• Pediatric Advanced Life Support
• Neonatal Resuscitation Program
PREPARATION FOR PRACTICE
The CAMTS standards provide an outline for the Initial Training Program Requirements for each of the mission types (air or ground) for transport programs. 4 These requirements provide a strong framework on which a program’s initial orientation and continuing education are built. A summary is found in Box 2-3. 4
BOX 2-3
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CAMTS Initial Training Program Requirements
Didactic Component
• Advanced airway management
• Altitude physiology/stressors of flight
• Anatomy, physiology, and assessment for adult, pediatric, and neonatal patients (specific to program’s scope of care)
• Transport vehicle (aviation and road) orientation/safety and in-transport procedures as appropriate
• Cardiac emergencies and advanced cardiac critical care
• Disaster and triage
• EMS radio communications
• Hazardous materials recognition and response
• Hemodynamic monitoring, pacemakers, automatic implantable cardiac defibrillator (AICD), intra-aortic balloon pump, central lines, pulmonary arterial and arterial catheters, ventricular assist devices, and extracorporeal membrane oxygenation (ECMO)
• Human factors: crew resource management, air medical resource management
• Infection control
• Mechanical ventilation and respiratory physiology for adult, pediatric, and neonatal patients (specific to program’s scope of care)
• Oxygen therapy in the medical transport environment: mechanical ventilation and respiratory physiology for adult, pediatric, and neonatal patients
• Pediatric medical emergencies
• Pediatric trauma
• Pharmacology
• Quality management
• Respiratory emergencies
• Scene management/rescue/extrication
• Survival training
• Didactic education that is mission specific and specific to scope of care and patient population
• Burn emergencies (thermal, chemical, and electrical)
• Environmental emergencies
• Equipment education
• High-risk obstetric emergencies (bleeding, medical, trauma)
• Metabolic endocrine emergencies
• Multitrauma (chest, abdomen, facial)
• Neonatal emergencies (respiratory distress, surgical, cardiac)
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