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Avoid a terrible outcome with ED patient transport
While Sabrina Jung, RN, was transporting an uncontrolled seizure patient from the ED at St. Anthony's Medical Center in St. Louis, MO, for a CT scan, the patient had another seizure.
"I was prepared and had an order from the physician to take [lorazepam] with me and give as needed," says Jung.
Jung gave the medication as soon as the seizure activity started, but the patient stopped breathing on his own. "I called over to the ED, while having my tech bag the patient, and asked for the physician and charge nurse to come over to help intubate the patient," says Jung.
Within minutes, the physician and charge nurse were in the room with the appropriate medications and equipment. "If I had not been with my patient during the transport, the situation could have had a very poor outcome," says Jung.
When transporting a critically ill patient from the ED for diagnostic testing or another unit, be ready for the unexpected to happen. "Nothing is worse than having your patient change right in front of your eyes, and knowing that you may have been able to prevent it if you would have just taken a few minutes to double check all equipment," says Jung. "Think about what might go wrong, just in case." Take these steps:
Notify the area receiving the patient, with a timeline for transport.
Give a comprehensive patient report, says Dawn Wotawa Bennett, BSN, RN, a clinical nurse educator for emergency and pediatric services at St. Anthony's Medical Center in St. Louis, MO.
"If there is poor communication between ED caregivers and accepting diagnostic area staff, the receiving area may not be prepared for the patient," says Bennett. "Verify that the receiving area is prepared to take the patient and has all of the resources needed." These might include patient transfer equipment, monitors, pumps, ventilators, respiratory therapist support, and appropriate nursing and medical staff, says Bennett.
Complete a full set of vital signs.
"Do a focused patient assessment prior to leaving the ER," says Bennett. This should include monitor rhythm and pain control, as well as documenting the patient's general appearance and mentation, she says.
Document whether the patient's condition has improved or worsened since arrival to the ED.
"The nurses in the unit may see the patient as a complete train wreck, but in reality the patient was much worse and is looking better since receiving care in the ED," says Bennett. "Or, the patient's condition may be declining, and the unit staff must know that, too."
Your documentation must include any drips or drugs with rates, fluids with rates, whether family is present, any patient and/or family teaching that was done, and any pending labs or procedures that need to be completed in the unit, says Bennett.
Are supplies all there and in working order?
It can save a patient's life
Dawn Wotawa Bennett, BSN, RN, a clinical nurse educator for emergency and pediatric services at St. Anthony's Medical Center in St. Louis, MO, was transporting an unstable patient with low blood pressure and heart rate to get a diagnostic magnetic resonance imaging (MRI) for a brain injury.
"The patient had a head bleed which needed MRI to verify the exact location," says Bennett. "Typical medication pumps cannot be used, or will quit working, due to the magnet that is in the MRI."
For this reason, a special type of medication pump that can be used in the MRI area suddenly became necessary. "If the medications were not able to be administered to maintain the blood pressure and heart rate, the patient might have coded during the long MRI procedure," says Bennett.
The patient ultimately went to the OR and had a good outcome. Bennett was thankful that ED nurses had been in-serviced on use of the MRI pump before the incident. "For those staff members I was not able to meet with one on one, I sent out an e-mail that included all of the information that was given during roving rounds," she says.
After ED nurses read the information and looked at the pump, they e-mailed Bennett an acknowledgement. "The patient had a head bleed which needed MRI to verify the exact location," says Bennett. "Without prior knowledge of the MRI pump and its use, the MRI would not have been completed until the patient stabilized, possibly days later. This could have led to a poor outcome or even death."
When transporting a patient, Bennett says to include the patient's chart with therapeutic support order such as "do not resuscitate" or full advanced cardiac life support (ACLS), airway box, monitor/defibrillator, ACLS medications, emergency supplies in the event a chest tube is accidentally removed, medication pumps, and a ventilator with respiratory therapy support.
Is it working?
Before you leave the ED, Bennett says to check these things:
The monitor and defibrillator are charged for transport.
A systems check on the monitor has been completed in the last 24 hours.
The defibrillator pads are with the monitor.
A bag valve mask is on hand, in the event the patient's respiratory condition changes.
The oxygen tank is full and functioning.
A respiratory therapist is accompanying you when transporting a patient on a ventilator, so one of you can bag the patient while the other pushes the ventilator.
Intravenous pumps are in good working order and charged.
Chest tubes are secure and functioning well without leaks.
Jung says taking a few extra minutes to make sure everything you need is with you and working properly before leaving the ED "can save precious moments if your patient takes a turn for the worst."
For more information on transporting ED patients, contact:
Moving a patient? Protect the ET tube
When a patient is intubated, the endotracheal tube (ETT) is their lifeline, says Ann Heywood, RN, BSN, CEN, SANE, trauma nurse coordinator for the Emergency Care Center at Champlain Valley Physicians Hospital Medical Center in Plattsburgh, NY.
"It is your responsibility to protect that lifeline," Heywood says.
The most likely time that a ETT will be dislodged or pulled out is when the patient is moved, whether from the ambulance stretcher to the ED stretcher, or the ED stretcher to the CT table or intensive care unit bed, says Heywood. "This is a high-risk time," she warns.
Heywood advises that you take these steps:
"The disconnect is only for the brief time of the actual transfer," says Heywood. "What you do not want is the respiratory therapist or other health care provider to be standing there with the bag valve mask with an ETT hanging off the end of it, and the patient on the table without the ETT and not breathing."