Page 610 - ACCCN's Critical Care Nursing

Emergency Presentations 587

significant of the advanced practice roles in modern RETRIEVALS
health care. 29
Australasia has a variety of retrieval or transport models,
The NP scope of practice is determined by the clinical although most retrieval teams comprise doctors, nurses
setting of the authority to practise. There are three points and paramedics with specialised training in critical care.
in this central to the nature of the role: The skills of the escort personnel need to match the acuity
of the patient, so that they can respond to most clinical
1. Extended practice: The scope of practice of the NP problems. 47,48 Retrieval team staff therefore need to deliver
is subject to different practice privileges that are high-level critical care equal to the standard of the receiv-
protected by legislation, and occur outside the ing centre, but need to be familiar with the challenges
scope of practice for a registered nurse. These associated with working outside the hospital environ-
extended practice privileges mean that the NP ment. Standards for the transport of critically ill patients
functions in a grey area that incorporates some of have been established by the College of Critical Care
both medical and nursing activities. 28-31 Medicine (CICM) and the Australian College of Emer-
2. Autonomous practice: The NP engages in clinical gency Medicine (ACEM). 48
practice with significant clinical autonomy and
accountability, including responsibility for the When transporting an unstable patient it is essential that
complete episode of care. This autonomy means a minimum of two people focusing solely on the clinical
that the NP works in a multidisciplinary team in care aspects of the patient are present, in addition to
a clinical partnership role to optimise patient other staff transporting the patient and equipment. The
outcomes. 28-31 transport team leader is usually a medical officer with
3. Nursing model: Practice is firmly located in a advanced training in critical care medicine, or for the
nursing model, and an extensive, but evolving, transport of critical but stable patients, a registered nurse
body of literature relating to the NP role and with critical care experience. The skillset includes advanced
practice. 28-31 cardiac life support, arrhythmia interpretation and treat-
ment and emergency airway management. 48
National and international experience has demonstrated
a specific service that is highly regarded 32-35 and in PREPARING A PATIENT FOR
demand. 36,37 The NP service provides care to many under-
serviced groups such as the homeless, women and chil- INTERHOSPITAL TRANSPORT
38
dren, the elderly, rural and remote communities 36,40 and Adequate and considered preparation of the transport of
39
41
specialist services in acute care areas. Nurse practitioners a critically ill patient from one hospital area to another
are effective in managing common acute illnesses and should be appropriately planned and not compromised
39
injuries and stable chronic conditions, and provide an by undue haste. While strong evidence to support a ‘scoop
emphasis on health promotion and assessment and and run’ approach to patients in the field exists, this
disease prevention. 42 principle does not apply to interhospital or intrahospital
transport of a critically ill patient. Appropriate evaluation
The Australian experience has demonstrated that pressure and stabilisation is required to ensure patient safety
on EDs can be relieved when NPs manage lower priority during transport, including assessment of ABCs and suit-
cases. Waiting times and overall length of ED stay are able IV access. 48
significantly reduced when NPs manage triage category
3–5 presentations such as sprains and superficial If potential airway compromise is suspected, careful con-
wounds. 37 sideration should be given to an elective intubation rather
than an emergency airway intervention in a moving
vehicle or a radiology department. A laryngeal mask
RETRIEVALS AND TRANSPORT OF airway is not an acceptable method of airway manage-
CRITICALLY ILL PATIENTS ment for critically ill patients undergoing transport,
48
because of the associated problems of movement. A
The care of an acutely ill patient often includes transport, nasogastric or orogastric tube is inserted in all patients
either within a hospital to undergo tests and procedures requiring mechanical ventilation.
or between hospitals to receive a higher level of care or Fluid resuscitation and inotropic support are initiated
to access a hospital bed. The movement of critically prior to transporting the patient. Planning for the trip
ill patients places the patient at a higher risk of complica- needs to include adequate reserves of blood or other
tions during the transport period, 50-53 because of condi- IV fluid for use during transport. If the patient is com-
tion changes, inadequate available equipment to or bative or uncooperative, the use of sedative and/or
support from other clinicians, or the physical environ- neuromuscular blocking agents and analgesia may be
ment in the transport vehicle. For this reason the standard indicated. 51-53 A syringe pump with battery power is the
of care during any transport must be equivalent to, or most appropriate method for delivering medications for
better than that at the referring clinical area. 43,44 Safe sedation and pain relief. A Foley catheter is inserted for
transport of patients therefore requires adequate plan- transports of extended duration and all unconscious
ning and stabilisation from a team of staff with appropri- patients. 52-54
ate skills and experience. This section focuses on the
movement of critically ill patients by nurses, doctors and/ The patient’s medical records and relevant information
or paramedics between hospitals. 45,46 such as laboratory and radiology findings are copied for