Are you putting patients at risk during transport?
Critical care patients being held in your ED for hours at a time are probably a familiar sight. You’re probably aware of the increased patient care needs these patients have, such as additional monitoring and assessment. But there is another factor putting these patients at risk: The chance of severe injury or death during transport for diagnostic tests such as computed tomography (CT) scans and magnetic resonance imaging (MRI).
"Our protocols for transporting patients for the ED to a diagnostic area are based on Murphy’s law of emergency medicine: If your patients are going to crash, they will do it in the area [where] you are least prepared to handle it," says Teri Howick, RN, nurse educator for the ED at McKay Dee Hospital in Ogden, UT.
New recommendations for patient transport from the American College of Critical Care Medicine and the Society of Critical Care Medicine, both based in Des Plaines, IL, give specific practice changes ED nurses must make to avoid problems. The transportation guidelines recommend a plan to address pre-transport communication and coordination, transport personnel and equipment, patient monitoring during transport, and documentation.1 (See resources at the end of this article to obtain complete guidelines.)
To avoid adverse outcomes during patient transport, do the following:
• Require a "patient passport."
At Caritas Holy Family Hospital and Medical Center in Methuen, MA, ED nurses complete "passports" for all patients requiring transport for diagnostic testing, says Laura Crawford, RN, BSN, director of emergency and ambulatory nursing. The passport documents patient identifiers, allergies, whether the patient must be transported with a nurse, and the name of the nurse and physician caring for the patient.
"The transporter cannot move a patient out of the department without the passport," Crawford says.
The transporter signs the passport and documents verification of the correct patient to be transported, says Crawford. "In addition, the technician in the ancillary department uses this to identify that they have the correct patient for diagnostic testing," she says.
The following patients are required to have a nurse accompany them:
- all trauma patients traveling to CT scan;
- all patients in cervical spine immobilization;
- any patient with a triage acuity level of one or two on the ED’s five-level system;
- any patient requiring cardiac monitoring.
In addition, documentation of vital signs during transport and testing is required, says Crawford.
• Have immediate access to lifesaving supplies.
When nurses transport patients from the ED, a portable monitor is used to watch vital sign trends, and two bright orange tackle boxes marked "airway box" are brought, says Howick. The first contains airway management tools, and the second is a drug box with advanced cardiac life support medications. "These are stowed under the stretcher just in case.’" says Howick.
These supplies saved the life of a young man with a tricyclic overdose who was tachycardic, recalls Howick. "He seized on the elevator on the way to the ICU, and we used the airway kit to intubate him and the bicarb to stop the seizing," she says. "He was truly a save."
At Memorial Hospital in Colorado Springs, CO, the ED and all receiving areas have "difficult airway boxes" containing laryngeal mask airways, self-inflating bags, and special laryngoscopes for adults, pediatrics, and neonates ready on a moment’s notice if needed during transport, says David Lucero, RRT/BS, clinical coordinator for transport care services.
• Use portable phones.
Patient transporters always carry a portable phone so they can be immediately be reached throughout the hospital, he says. If a patient is seizing or apneic, the transporting nurse can call the receiving unit to let them know blood needs to be ordered or a ventilator set up, or a code team can be called to respond if there is a problem, says Lucero. "In some special procedure rooms, there is not a phone available," he notes.
• Monitor patients during procedures.
While in the diagnostic area, the monitor always is placed where the nurse can see it without entering the room, says Howick. "When necessary, the nurse will don a leaded apron and stay with the patient during the procedure," she adds.
• Perform procedures at the bedside whenever possible.
Howick recalls an elderly farmer with blunt trauma to the abdomen who had stable vital signs, who was being transported by wheelchair for an ultrasound before bedside testing was done. "I was noticing the top of his head, which was getting paler, then cyanotic. I kept chatting with him, and suddenly there was no reply," she recalls. "Had I been able to see his face, I would have known he’d become unconscious. He was in cardiac arrest when we reached the X-ray department."
If at all possible, you should perform diagnostic testing at the bedside, urges Howick. "Any procedures that can be done at the bedside, are," she says. "Most X-rays and ultrasound can be brought to the patient."
1. Warren J, Fromm RE, Orr RA, et al. Guidelines for the inter- and intrahospital transport of critically ill patients. Crit Care Med 2004; 32:256-262.
For more information about transporting patients for diagnostic testing, contact:
- Laura Crawford, RN, BSN, Director of Emergency and Ambulatory Nursing, Caritas Holy Family Hospital and Medical Center, 70 East St., Methuen, MA 01844. Telephone: (978) 687-0156, ext. 2128. E-mail: Laura_Crawford@cchcs.org.
- Teri Howick, RN, Nurse Educator, Emergency Department, McKay Dee Hospital, 4401 Harrison Blvd., Ogden, UT 84403. Telephone: (801) 387-2286. Fax: (801) 387-2244. E-mail: email@example.com.
- David Lucero, RRT/BS, Clinical Coordinator/ Transport Care Services, Memorial Hospital, 1400 E. Boulder St., Colorado Springs, CO 80909. Telephone: (719) 365-5615. E-mail: David.Lucero@memhospcs.org.
The American College of Critical Care Medicine and the Society of Critical Care Medicine developed guidelines for transport of critically ill patients. The complete guidelines can be downloaded free of charge on the Society of Critical Care Medicine’s web site (www.sccm.org). Click on "Professional Resources," "Guidelines," "Table of Contents," and "Guidelines for the Inter- and Intrahospital Transport of Critically Ill Patients."