Avoid problems when you transport a patient
A 68-year-old man with chest pain was being transported to the intensive care unit (ICU) to be admitted to rule out a myocardial infarction. The elevator became stuck between floors. After about 20 minutes, the patient coded. "Fortunately, we were carrying a code box’ with cardiac medications, and the patient was on a monitor with a defibrillator," recalls Tracy Evans, APRN, MS, MPH, emergency medical services director and trauma program manager at Norwalk (CT) Hospital. "The only thing that we could not do was intubate."
After defibrillation, ventilation with a bag valve mask, and administration of epinephrine and lidocaine, the man had a spontaneous return of pulses, says Evans. He was transferred out for a coronary artery bypass graft and was discharged to home, she says. "Without a code box and cardiac monitor in the elevator, the patient would have died," says Evans.
There always are substantial risks when you transport a patient, says Timothy Murphy, RN, MSN, APN, C, CS, CEN, trauma program manager at Robert Wood Johnson University Hospital in New Brunswick, NJ. "These events, often called road trips,’ should be treated similarly to interfacility transports," he argues.
If your gut tells you that something may go wrong, then plan for that to happen, advises Reneé Holleran, RN, PhD, chief flight nurse and clinical nurse specialist at University Hospital in Cincinnati. "For example, many of us have known’ that the patient would arrest once outside of the [emergency department]," she says.
Here are ways to reduce risks during patient transport:
• Bring appropriate resuscitation equipment.
At a minimum, this should include a defibrillator and a bag-valve mask, says Evans. "For patients at higher risk or in large centers with long distances in between units, bringing intubation equipment and cardiac medications also may be a good idea," she advises. Depending on the patient’s condition, you may need to bring additional equipment, emphasizes Murphy. "If the patient experiences a problem in an elevator, having the right equipment will be very helpful," he says.
Murphy recommends the following. If the patient has:
- problems with airway secretions, bring a portable suction device;
- risk for cardiac instability, bring a monitor with a defibrillator;
- an unstable spine, bring a backboard;
- has a requirement for oxygen, bring a full oxygen tank.
• Consider needs for areas performing diagnostic testing.
These areas should be stocked with a code cart and other age-appropriate resuscitation equipment, says Evans. For hospitals verified as trauma centers by the Chicago-based American College of Surgeons, a criteria deficiency can be given to facilities without appropriate resuscitation and monitoring equipment in radiology, she adds. "This could result in loss of trauma center verification," warns Evans.
Always be familiar with the location of oxygen outlets and suction when going outside of the emergency department (ED) for testing, advises Holleran.
• Bring appropriate personnel.
Transport personnel should be familiar with the patient’s illness or injury and be qualified to assess and intervene if a problem occurs en route, says Murphy. He gives the following example: A patient having a myocardial infarction and receiving thrombolytics should be accompanied by a nurse familiar with this type of patient.
Evans cautions against taking high-risk patients alone. "Take another nurse or a technician who has been trained in CPR," she says.
• Identify special needs that may not be apparent.
Murphy recommends discussing the patient’s specific transport needs with the physician, to avoid misunderstandings and further clarify orders. "For example, has the patient’s cervical spine been cleared, or should a collar remain on?" he asks.
• Address impeded access to the patient during computed tomography (CT) or magnetic resonance imaging.
Holleran warns that it’s difficult to watch a patient’s airway when he or she is placed in the CT scanner. "Cardiac monitors and pulse oximeters must be placed so that you can see them," she says. A pulse oximeter and cardiac monitor also can help, adds Holleran. However, she cautions that if there is any possibility that the patient may suffer an airway compromise, it is safest to use elective intubation to protect the patient’s airway and ensure adequate oxygenation.
• Be especially careful with sedated patients.
Patients may require sedation and neuromuscular blocking when they are intubated, to prevent them from pulling out endotracheal tubes or lines, says Holleran. "Sedation and analgesia also may be needed to decrease the patient’s anxiety and pain that can occur with moving them from one place to another," she says. Holleran urges you to pay extra close attention to medicated patients. "They must be closely monitored and emergency equipment, such as a crash cart, [must be] readily available," she says.
Sources
For more information about patient transport, contact:
• Tracy Evans, APRN, MS, MPH, EMS Director and Trauma Program Manager, Norwalk Hospital, 34 Maple St., Norwalk, CT 06856. Telephone: (203) 855-3990. Fax: (203) 852-2530. E-mail: [email protected].
• Reneé Holleran, RN, PhD, University of Cincinnati Medical Center, P.O. Box 670736, Cincinnati, OH 45267. Telephone: (513) 584-7522. Fax: (513) 584-4533. E-mail: reneeflight [email protected].
• Timothy Murphy, RN, MSN, APN, C, CS, CEN, Trauma Program Manager, Robert Wood Johnson University Hospital, One Robert Wood Johnson Place, New Brunswick, NJ 08903-2601. Telephone: (732) 418-8095. Fax: (732) 418-8097. E-mail: [email protected].
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