| Theme: in-hospital transport of the critically ill patient |
| Target audience: 4th year undergraduate nursing students |
| Requirements: |
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To have taken the theoretical class on in-hospital transport of the critically ill patient
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To know the material resources necessary to perform the transport
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To know the main adverse events that occur during transport and how to intervene
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| Number of students: 4 |
| Scenario 1: preparation for in-hospital transport of the critically ill patient |
| Duration of simulated activity: 10 minutes |
Debriefing: 20 minutes |
| Scenario 2: in-hospital transport of the critically ill patient |
| Duration of simulated activity: 10 minutes |
Debriefing: 20 minutes |
| At the end of this training, the student should be able to: |
| General objective: |
Perform in-hospital transport, aiming to ensure safety and prevent/reduce the occurrence of adverse events |
| Specific objectives: |
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Orient the patient and the companion about the performance and purpose of the in-hospital transport
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Assess the patient’s clinical conditions and documentation for in-hospital transport
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Plan the in-hospital transport
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Assemble the appropriate team and the necessary equipment for the in-hospital transport
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Register the transport, complications, and respective interventions, if any, in the medical record
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| In-hospital transport |
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In-hospital transport is defined as the temporary or definitive transfer of patients by health professionals within the hospital environment, ensuring their integrity and safety(1)
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Critically ill patients require interventions that often cannot be performed in bed, requiring transportation for diagnostic or therapeutic procedures. Adverse events are frequent during in-hospital transport of critically ill patients, and may lead to respiratory and hemodynamic instability, which often result from lack of knowledge of professionals, communication failures between the team, and equipment used during transport. Thus, safety during in-hospital transport is extremely important and can be achieved with teaching and simulated training of good practices, aiming at clinical reasoning for accurate assessment of risks and benefits related to transport, and the development of technical skills for its realization, to ensure patient safety and reduce the occurrence of preventable damage during the route.(2-5)
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The nursing student needs to understand the importance of the correct identification of the patient to be transported, as well as the purpose of the transport, planning, and carrying out the transport, preventing or reducing the occurrence of adverse events. Thus, it is fundamental that the nursing student develops the following skills: communication, organization, critical thinking, dexterity, safety, and leadership. These actions have the purpose of preventing and reducing adverse events during transport
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| Scenario 1: preparation for in-hospital transport of the critically ill patient |
| Briefing: before the beginning of the activity, give a presentation of the case, the environment, and the resources available for care |
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Case summary: Mr. J.S., age 42 years, was a victim of a fall from approximately 5m height, 48 hours ago, and will be referred for examination since he presented with a decreased level of consciousness. A computed tomography scan was ordered and the Diagnostic Center is already waiting. Mr. J.S. is sedated, with a clean and dry external dressing on the head, closed nasoenteric tube, maintaining orotracheal intubation on mechanical ventilation - volume controlled mode, 50% fraction of inspired oxygen (FiO2), central venous catheter in the right subclavian vein receiving propofol 15mL/L, and an indwelling urinary catheter with a closed drainage system. There is no description of allergies in the medical record.
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Vital signs: blood pressure (BP): 120x60mmHg; heart rate (HR): 79bpm; respiratory rate (RR): 14rpm; oxygen saturation: 96% and RASS: -5
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| Preparation of the high-fidelity set and manikin |
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The patient/manikin must be in bed with raised head, rails up, and wheels locked
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The patient/manikin should be in the following conditions/with the following devices: closed nasoenteric tube in right nostril; orotracheal cannula coupled to mechanical ventilator, central venous catheter in right subclavian vein coupled to an infusion pump system; identification bracelet on right upper limb; and indwelling urinary catheter coupled to a closed drainage system
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| Material needed for the set |
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Patient/manikin
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Identification bracelet
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Bed
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Procedure gloves
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Tracheal cannula no. 7.0
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Fixation for tracheal cannula
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Complete mechanical transport ventilator
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Oxygen cylinder
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Complete transport monitor/defibrillator
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Electrodes
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Crepe bandage
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Crepe tape
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Nasoenteric tube
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Indwelling urinary catheter
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Closed collector for indwelling urinary catheter
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Saline support attached to the bed
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Bag of saline solution 0.9%
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Infusion pump set
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Infusion pump
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Electrodes for cardiac monitoring
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Central venous catheter
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Request for test
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Medical prescription
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Control sheet
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Medical chart
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Carrying case containing:
- Procedure gloves - surgical gloves - Bag-valve-mask device - Laryngoscope kit with backup battery - Tracheal cannula (several sizes - adult) - Guidewire - Cannula fixation material - Laryngeal mask (several sizes - adult) - Peripheral venous catheter (several sizes - adult) - Spigot - Hypoallergenic tape for bandages - Syringe (several sizes) - Needle (various sizes) - Infusion set (macro drops) - Infusion set (for pump) - Saline solution 0.9% (ampoules and bag) - 70% alcohol - Absorbent cotton
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Emergency medications:
- Hypertonic glucose - Epinephrin - Amiodarone - Atropine - Etomidate - Fentanyl - Midazolam - Succinylcholine - Diazepam
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| Preparation for transport |
| Expected actions: |
Guidelines/parameters provided: |
| Check the test order and the complete name on the patient’s wristband |
( ) Order identification matches the patient’s identification |
| Instruct the accompanying person on the performance and purpose of the transport |
( ) The student instructs the accompanying person on the need to transport the patient to the Diagnostic Center for a computed tomography scan of the skull |
| Get the medical chart |
( ) The chart is on the counter |
| Check the patient’s chart for allergy history and preparation for the test |
( ) The student identifies the patient has no history of allergies and maintains fasting |
| Assess the patient’s level of consciousness/sedation |
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| Assess the patient’s ventilatory/respiratory status |
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( ) The student checks the positioning of the tracheal tube through pulmonary auscultation, which is present bilaterally
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( ) The student checks the fixation of the tracheal cannula, which is adequate
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The student checks the ventilatory parameters:
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( ) Volume controlled mode
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( ) Tidal volume=500mL
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( ) FiO2=50%
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( ) Respiratory rate=14rpm
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( ) PEEP=5mmHg
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( ) Student checks oxygen saturation, which is 96%.
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| Assess heart rate and blood pressure |
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( ) The student assesses the heart rate, which is 79bpm
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( ) The student assesses the blood pressure, which is 120/60mmHg
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| Check the prescription to see which infusions the patient is receiving and for how long |
( ) The student identifies that the patient is receiving propofol by infusion pump at 15mL/hour and the volume of solution (200mL) is sufficient for transportation to the intensive care unit |
| Adapt the necessary equipment for transportation |
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The student must adapt the:
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( ) Transport ventilator
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( ) Oxygen cylinder
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( ) Transport monitor/defibrillator
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( ) Saline drip stand
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( ) Continuous infusion pump
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| Request the team that will do the transportation |
( ) The student requests the team, which is available |
| Shift handover/effective communication |
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The team that prepared the patient communicated to the team that will perform the in-hospital transport, about:
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( ) Clinical conditions of the patient
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( ) Test that will be performed
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( ) Preparation for the test
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| The scenario must be interrupted when: at the end of the proposed activity or reaching the 10-minute time limit |
| Scenario 2: in-hospital transport of the critically ill patient |
| Expected actions: |
Orientations/parameters given: |
| Shift handover/effective communication |
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The team that will perform the in-hospital transport properly did handover and confirmed:
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( ) Clinical conditions of the patient
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( ) Tests that will be performed
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( ) Preparation for the test
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| Assess the distance to be traveled, possible obstacles, and time to be spent at the destination |
( ) Students discuss among themselves the distance to be traveled, whether there will be any obstacles that might hinder transportation, and the time allotted |
| Anticipate possible complications that may occur with the patient during the journey |
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The student discusses possible complications with the transport team:
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( ) Displacement of the tracheal/extubation
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( ) Transport ventilator failure
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( ) Drop in saturation
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( ) End of oxygen supply from the cylinder
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( ) Hemodynamic instability
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( ) Displacement/loss of central venous access
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( ) Running out of propofol solution
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( ) Failure of transport monitor/defibrillator
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( ) Nasoenteric tube displacement/loss
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( ) Displacement/loss of indwelling urinary catheter
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| Carry out communication between the unit of origin and the unit receiving the patient |
( ) The student communicates with the Diagnostic Center, informing them the patient is being referred for testing |
| Keep the rails raised to ensure the patient’s physical integrity |
( ) The student raises and keeps the rails up all the way |
| Transport the patient to the Diagnostic Center |
( ) Determine the team that will be responsible for transporting the patient |
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Adverse event |
Expected action |
| Intervene during transport if the adverse event occurs |
( ) Tracheal tube displacement/extubation |
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The patient will present with a drop in saturation: |
| ( ) Transport ventilator failure |
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( ) Maintain ventilation with bag-valve-mask device
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( ) Correct failure, if possible
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( ) Replace transport ventilator
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| The ventilator will sound the alarm and display the message “LOW VOLUME”: |
| ( ) End of oxygen supply from the cylinder |
( ) Replace oxygen cylinder |
| ( ) Tracheal cannula cuff deflated |
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( ) Listen for air escaping from the patient’s mouth
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( ) Auscultate the patient’s cervical region and confirm the passage of air through the site
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( ) Check the low cuff tension
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( ) Inflate the cuff until the air leak is corrected
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| Displacement/loss of central venous access: |
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( ) Puncture new peripheral venous access |
| The pump sounds the alarm with the message “KVO”: |
| ( ) Running out of propofol solution |
( ) Replace solution |
| The alarm sounds with the message “ELECTRODE LOOSE”: |
| ( ) Failure in the transport monitor/defibrillator |
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| Displacement/loss of nasoenteric tube: |
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| Return the patient to the intensive care unit |
( ) The team returns the patient to bed |
| Accommodate the patient in bed |
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The student switches the resources used during transport to intensive care unit resources:
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( ) Transport ventilator
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( ) Oxygen cylinder
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( ) Transport monitor/defibrillator
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( ) Saline drip stand
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( ) Continuous infusion pump
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| Assess the patient’s condition after returning from the transport |
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| Record the procedure in the patient’s chart |
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The student records the procedure in the patient’s chart with the following information:
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( ) Date
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( ) Time
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( ) Procedure performed
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( ) Intercurrent events, if any
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| The scenario must be interrupted when: at the end of the proposed activity or reaching the 10-minute time limit |
| Structured debriefing |
Duration: 20 minutes |
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How do you feel after the simulated activity?
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What drew your attention the most? Why?
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Please mention strengths in the development of the simulated activity.
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Please mention points for improvement. What would you do differently?
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What did you learn from this simulated activity?
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What abilities were developed during this activity?
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References
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1. Conselho Federal de Enfermagem (CFE). Resolução 376/2011. Dispõe sobre a participação da equipe de enfermagem no processo de transporte de pacientes em ambiente interno aos serviços de saúde, 2011. Brasília (DF): CFE; 2011 [citado 2017 Set 10]. Disponível em: http://www.cofen.gov.br/resoluo-cofen-n-3762011_6599.html
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2. Silva R, Amante LN. Checklist para o transporte intra-hospitalar de pacientes internados na unidade de terapia intensiva. Texto Contexto Enferm. 2015;24(2):539-47.
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3. Almeida AC, Neves AL, Souza CL, Garcia JH, Lopes JL, Barros AL. Intra-hospital transport of critically ill adult patients: complications related to staff, equipment and physiological factors. Acta Paul Enferm. 2012;25(3):471-6. Review.
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4. Australian and New Zealand College of Anaesthetists (ANZCA). Guidelines for transport of critically ill patients. Melbourne: ANZCA; 2015 [cited 2015 Aug 30]. Available from: https://www.anzca.edu.au/resources/professional-documents/guidelines/ps52-guideline-for-transport-of-critically-ill-pat
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5. Morais SA, Almeida LF. Por uma rotina no transporte intra-hospitalar: elementos fundamentais para a segurança do paciente crítico. Rev HUPE. 2013;12(3):138-46.
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