Page 647 - ACCCN's Critical Care Nursing

624 S P E C I A LT Y P R A C T I C E I N C R I T I C A L C A R E

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preventable deaths. Although this reduction appears healthcare facilities may occur for clinical reasons, such
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widespread, it has not been replicated in remote areas, as specialist or higher levels of care being required, or for
and is limited by the lack of examination of deaths that non-clinical reasons, such as bed availability. It is prefer-
occur before a patient reaches hospital or after discharge. able for patient transfer to be for clinical reasons only;
Additionally, the lack of examination of functional out- however non-clinical transfer is sometimes unavoidable.
comes limits interpretation of the trauma system, as it is Secondary transport of critically injured patients may
not clear whether the patients who survive have altered occur via either ground or air (by fixed-wing or helicop-
functional capacity. Despite these limitations, there is ter). The decision as to what form of transport to use will
widespread agreement on the benefits of trauma system depend on:
implementation, although the contribution of nursing
care in such trauma systems is rarely considered or mea- l the condition of the patient
sured. Furthermore, the precise components of a trauma l the potential impact of the transport medium on the
system that prove beneficial have not been identified. 12 patient
l the distance to be covered
PREHOSPITAL CARE l the urgency of the transport
The debate regarding the relative benefits of stabilising a l the environmental conditions
patient at the scene versus proceeding to the hospital as l the resources available
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quickly as possible, is not new. Benefits are somewhat l the expertise of the respective transport teams.
dependent on the proximity of effective trauma facilities, Amenities such as landing sites, particularly for helicop-
the level of knowledge and skills of the prehospital per- ters, being in close proximity to healthcare facilities must
sonnel available and the specific injuries and condition also be considered. Different jurisdictions activate air
of the patient. The principle of the ‘golden hour’ remains retrieval using helicopters when the distance for the trans-
in place today and suggests that, in order to improve port is beyond a certain point, with the minimum dis-
outcomes, definitive care should be provided to patients tance ranging from 16–80 km. 14,15,19,20
as soon as possible, and preferably within 1 hour of the
injury being sustained. 13,14 In countries with large dis- It is essential that the standard of care is not compro-
tances and sparse populations this aim presents particular mised during transport of critically injured patients.
challenges and cannot be met in many regions. Despite Minimum standards exist that outline the requirements
these distances and transport challenges, recognition of for transport of critically injured patients, and these
life-threatening conditions, application of appropriate should be referred to for full details. 13,18,19 The following
emergency interventions and prompt transport to the principles apply during such phases of care:
nearest appropriate hospital remain the principles of pre- l There must be adequate preparation of the patient and
hospital care. 13-15 equipment.
In a number of regions, processes are in place to facilitate l Transport must occur by personnel with appropriate
prehospital admission: personnel can notify the receiving levels of expertise.
hospital in advance, for those patients who meet pre- l Necessary equipment, including batteries and pumps,
defined criteria. Identified patients generally have severe should be secured.
physiological compromise, or injuries from high-velocity l Patients should be stabilised prior to transport (whilst
causes that result in significant injury and associated poor balancing the need for timely transport).
outcomes. Early notification allows the assembly of a l Monitoring of relevant aspects of the patient’s care is
multidisciplinary group of health professionals who can essential.
provide immediate, expert assessment, resuscitation and l Adequate vascular access and airway control must be
treatment of critically injured patients. 16,17 Such trauma secured prior to commencing transport.
teams have been shown to provide benefit in the early l Effective communication is mandatory between refer-
management of multiply-injured trauma patients, and ring, transporting and receiving personnel.
are reviewed later in this chapter. 10,16 l Documentation, including X-rays and scans, should
accompany the patient and should cover the patient’s
TRANSPORT OF THE CRITICALLY status, assessment and treatment before, during, and
ILL TRAUMA PATIENT on completion of, the transport.
Transport of critically injured patients occurs at two stages l Relatives should be informed of the transfer, includ-
in the patient’s care. Primary transport occurs from the ing destination, and provided with assistance for
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place of injury to the first healthcare facility to provide their own travel arrangements. Checklists itemising
care to the patient; this is sometimes referred to as pre- many of these principles, sometimes attached to an
hospital transport. Secondary transport occurs between envelope containing all transfer documentation, are
healthcare facilities; this is sometimes referred to as inter- often used to ensure that all necessary actions are
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hospital transport. This chapter concentrates on second- undertaken.
ary transport, although many of the principles are similar
for both stages of transport. Intrahospital transport prin- TRAUMA RECEPTION
ciples are also relevant for critically injured patients being Reception of the trauma patient at the emergency depart-
transferred within departments in a healthcare facility ment of the hospital is generally performed by the triage
(see Chapter 6). Transport of a patient between nurse, although in the severely injured patient it is usual