RESEARCH ARTICLES
Knowledge of the nurse on the intra-hospital transport of critically ill patients
Larissa Chaves PedreiraI; Iuri de Matos SantosII; Muller Almeida FariasIII; Elieusa e Silva SampaioIV; Cláudia Silva Marinho Antunes BarrosV; Ana Carla Carvalho CoelhoVI
INurse. PhD. Adjunct Professor of the Nursing School of the Federal University of Bahia. Salvador, Bahia, Brazil. E-mail: larissa.pedreira@uol.com.br.ABSTRACT: Intrahospital transportation of critically ill patients is a complex activity, and the preservation of the clinical conditions of the patient on the route to the medical procedures must be preserved. The study aimed to verify the preparation of nurses in the intrahospital transportation of critically ill patients and identify facilities and difficulties in this act. This is a qualitative and descriptive research performed with nine nurses working in an intensive care unit of a public hospital in Salvador in 2011. For the purpose of analysis, the content analysis steps were used, and three categories were evidenced: the nurse in the preparation of the critically ill patient for transportation, the nurse accompanying the transportation of the critically ill patient and, the nurse stabilizing the patient after transportation. It is concluded that most of the nurses are prepared to work during the transportation, nevertheless specific training is necessary in order for them to perform in a more secure manner.
Keywords: Intensive care; nursing; monitoring; transportation of patients.
INTRODUCTION
Critical patients often need hospital transportation for procedures or diagnostic tests. Some of these methods are performed on the edge of the bed, others need to be transfer to a place outside the sector of origin. In this way, it is necessary to adapt support equipment and monitoring1.
The decision to transport a critical patient should be based on risk/benefit evaluation and the need for additional care (technology and/or experts), not available in the location where he is2.
In this sense, hospitals should have a specific plan to transport critical patients, involving an efficient system of communication, material, human resources and documentation to ensure security, because this procedure has a lot of risks3.
It is observed in practice and the literature reports, that the transport of these patients often is performed automatically, not being valorized by keeping him within the hospital environment, giving security to the team of fast clinical compensation in case of complication. This devaluation prevents effective planning for proper use of materials and equipment needed4.
As a frequent problem in relation to this procedure, the authors brings the failure in the control of Cardiology and respiratory functions, through equipment malfunction and physiological instability with injury of tissue oxygenation and may entail consequences for the patient, especially when in critical situation5-7.
About it, Austrian study showed that, of a sample of 452 intrahospital transportation, the occurrence of adverse events was small. However, the authors warn of the risk of complications in patients under mechanical ventilation and use of vasoactive drugs8.
Incidents during transport may occur and, although some of them are harmless, others can be potentially fatal, and can be predictable. The main incidents verified in clinical studies were: loss of EKG reading, monitor failure, inadvertent subcutaneous tissue infiltration and disconnection of vasoactive drug infusion and sedation, which occurred in 34% of transportation. Unlike predicted, 60% of these events occurred in elective transport and 40% in emergency transportation; reflecting greater preparation and monitoring in emergency situations and in largest inattention situations2.
In this sense, training and constant improvement of professionals involved, the standardization of actions and equipment to guarantee the perfect condition of use and review of the materials necessary, are important factors for the success of this activity, which must ensure patient safety and benefit4.6.
The transport must be carried out by properly trained professionals, and the patient monitored properly to control the vital signs through at least electrocardiographic monitor, pressure monitor and Pulse Oximeter. It is important other equipment for any complications, like the defibrillator7.
Taking into account this context and the importance of the role of nursing in transporting the patient safely, since the preparation until the return to his bed, it arose the interest in research, which brings as question: what are the nurses´ knowledge about the critical patient's intrahospital transportation? It objectively check the nurses´ knowledge about the intrahospital transportation of critical patients and identify facilities and difficulties in the realization of this dislocation.
LITERATURE REVIEW
The intrahospital transport is temporary or permanent defined of patients by healthcare professionals within the hospital environment, for diagnostic or therapeutic purposes. Because it is a complex activity, it must ensure the patient, the preservation of clinical conditions throughout the course of the procedure9.
With the growing discussion about security, and the significant technological advance in the prevention, diagnosis and treatment of diseases developed by health area, in recent years, health professionals are commited, since their formation, the provision of services for a quality assistance. However, despite all efforts, the patient who needs care can be placed in situations of risk and damage, especially when out of their healthcare unit of origin.
Patient´s safety studies show great concern about the errors, more procedures related with those assisted in the units. However, the removal of the patients to perform diagnostic procedures and/or therapeutic, also requires rigorous care at risk of complications.
The Decree 1071 of July 4, 2005, which provides for on the National Policy of Attention to Critical Patient, points to the requirement of hospital institutions in deploying and implementing the hospital organization and qualification commissions of attention to this type of patient. In this sense, among their duties, there is the responsibility of building the hospital plan of attention, that also involves the transportation planning10.
The Federal Council of Nursing Care (COFEn), in its resolution 376 of 2011, which rules on participation of nursing professionals in the transport of patients in hospital environments, also establishes the function of nursing staff with regard to the preparation, monitoring and return of these patients, pointing to several submissions and procedures that must be followed to ensure a safe transportation11.
METHODOLOGY
This is a descriptive, analytical and qualitative study. The place was the intensive care unit (ICU) of a public institution, for treatment of critical patients, in the city of Salvador, where there is no training plan to transport critical patients. The institution is the practice of nursing residence intensivist from nursing school at the Federal University of Bahia (UFBA) in partnership with the Instituto Socrates Guanaes (ISG) and the Secretary of Health of Bahia (SESAB).
The participants were nine nurses who met the inclusion criteria: membership of the nursing staff of the unit, directly involved in transporting critical patients, be available to be interviewed and take participate in the research signing an informed consent. The collection was completed after saturation of the data.
The project was submitted to the Ethics Committee in Research of the Maternity Climério de Oliveira da UFBA, approved under the opinion n° 017/2011.
The data collection was performed by three researchers, nursing graduates, without close relationship with the subject, between 18 September to October 18, 2011, through semi-structured interview, recorded and transcribed in their entirety, with characterization of participants and implementation of issues related to the object: what is your role with the transportation of the patient? Did you receive training to carry out this function? What do you know about safe transportation of critical patient? What facilities and difficulties do you face when you perform this procedure?
Content analysis guided by Bardin12 was used for the formation of categories of analysis from reading lines, through the pre-analysis, with the organization and transcription of the taped interviews and superficial reading of them; exploration of the material, through comprehensive and deepen readings of the material obtained, turning them into units of registration; treatment of results and encoding, where the raw results were interpreted, by making appropriate inferences from the best evidence brought by the literature.
RESULTS AND DISCUSSION
Nine intensivists nurses were interviewed. Five owned intensive nursing resident, a nursing with specialization in work, and three did not possess specialization, however had more practice time on the unit. The time of experience with critical patients transport ranged from 6 months to 27 years, corresponding to the length of service. All the nurses were female and had already performed transports of critical patients in the unit.
The analysis has identified three categories: nurse in preparation for the critical patient transportation; the nurse in the monitoring of critical patient transportation; and the nurse in stabilizing after the critical patient transportation. The facilities and difficulties pointed out were related to the process of preparing the patient for transportation, and are cited as subcategory of this planning.
For the purposes of preservation of anonymity, the participants were referred to by the letter E, followed by numbering from one to nine.
The nurse in preparation for the critical patient transportation
In this category, there were the following testimonials:
[...] I have to arrange everything, equipment, solutions that the patient is using, both I and the nursing technicians [...] The preparation of the patient is the transport monitor, O2 if it has with ventilatory support, ventilator of transport, asking that the physiotherapy put this ventilator. If he is with other devices, take them in bed, and what he needd as material for intubation, ambu bag if needed, all that you have to evaluate. (I3)
Before preparing the patient along with the nursing staff, the nurses have to assess, together with the doctor, risks and benefits [...]. (I7)
[...] prepare the equipment, monitoring, remove the diet at the time of transportation, if the patient are with nasoenteral probe. Put appropriate monitoring, catch monitors materials to connect the cables properly. Look at the hygiene is important, to transport the patient without their results, with the clean diaper. Empty the urine collection bag, and materials during transportation have to be as light as possible, for people pushing less weight, counting also with the team's security. (I9)
In the step of preparation, which includes the time to plan for the transfer of the patient to the destination area, it is necessary that the nursing staff carry out some procedures to enable a transport without risk. Thus, it is necessary to evaluate the risk/benefit, and it is important that the professional review the change that the examination or procedure will bring to the patient, predicting possible physiological changes5.
It is observed that the nurses are involved in transportation and have some knowledge about the preparation of the patient, even without specific training on this procedure, once they cited in their lines, important elements with respect to this preparation, when compared to what the literature recommends, as part of their daily practice, despite the thematically be little explored in the scientific world.
However, it was not evidenced, in the speeches, the importance of patient conditions on record chart, before or after forwarding him. This observation is also not referred to in the literature consulted about the topic, although important for the legal support of professional and patient´s safety13.
Observing the general picture, paying attention to instabilities, is another care that should be taken, primarily for the state of consciousness, hemodynamics and ventilation. The instability is a contraindication for the deslocation of the patient of his unit1.6.
In this sense, it is evidenced that professionals need to be attentive to hemodynamics and ventilation, reviewing the access of airway, oxygenation, patency rates of venous access, values of blood pressure and heart rate, as well as the need for use of vasoactive drugs and sedative properties. It is important to determine the existence of any intervention that can provide a safer transportation, as for example, promote tracheal intubation of patients in respiratory distress, or sedation if the patient is excited1.
The critical patient transportation planning is a key piece in the prevention of possible instability, ensuring, for example, adequate oxygen reserve, sufficient number of professionals involved, as well as the verification of materials needed, as oxygen connectors, defibrillator and suction points in the walls14. Predict and provide materials and equipment necessary for assistance during displacement, are essential care, which can interfere with the success of the procedure as reported by the nurses.
According to the interviewees, having materials and equipment is a safe way of transporting patients, because during the journey, he could have complications and the team has to be prepared to act.
Some materials, such as basic drugs for resuscitation, should accompany the patient, including epinephrine, antiarrhythmics agents and other complementary medicines and sedatives and narcotic pain relievers, as well as oxygen with a reserve of 30 minutes. Equipment for artificial airway access of appropriate size for each patient, pulse oximetry, cardiac monitors, defibrillators, blood pressure monitor invasive, are equipments that must also be present3.
It is necessary to watch for the distance to be traveled, possible obstacles like elevators, and communicate to the sector the time of transfer to be prepared and not having delay. Interlocution with the services which the patient will be transported to occur for that delay being avoided during transit. If the target location is in different floor, the elevator must be ready5.
In the subcategory related to difficulties and facilities of patient transportation, the statements were:
Communication with the sector is one of the main difficulties. Sometimes you call several times, noone answers and you there are waiting, with the patient, for the exam. We prepare the patient, let him monitored and we stay trying to communicate with the sector and it's hard (I9).
The thing is the sector not being ready to receive that type of patient, or to get there, call saying you're going and have another patient on the table, wait for the serious patient waiting in the Hall, this is a difficulty found (I3).
Facilities, I think it's the team supports each other, we see that people have a good dynamic and everything happens faster (I6).
Facilities are always available, human resources have stretcher bearers, nursing technician who are there to help. (I9)
In relation to the difficulties, the lack of prior communication with nursing staff target sectors was unfavourable item to perform the appropriate procedure. Communication problems can trigger difficulties and adverse events in hospital environments15 and, in carrying out intrahospital transportation, these can lead to delays in the forwarding of patients too, or at the entrance of them in the exam room, leaving them more exposed16. Authors showed also the communication as one of the main points of an effective transportation, minimizing errors and increasing safety of patient and team17.
Thus, it is necessary to observe if the team of the unit where the patient will be received is prepared, reinforcing the importance of prior communication. These prerequisites are important also to prevent complications related to the lack or problems in equipment and human resources14.
About the facilities, the deponents pointed support in the team, availability of material and personnel, as stretcher bearers and technicians of nursing. This demonstrates the importance of the preparation and use of protocols that direct this procedure, for the material and required team in varied situations17.
Considering the previous information, hospitals that meet critical patients, should develop and implement a plan of attention to critical patient, containing all service team training plans10.
The nurse in the monitoring of critical patient transportation
With regard to monitoring, it is recommended a minimum of two people, usually a nurse that has guidelines for critical care nursing, additional team which may include nursing technicians, physical therapist and a doctor with training in artificial airway access and cardiac life advanced support4. The important thing is that the multiprofessional team meet the risks and perform the procedure-related decision-making for a secure transportation18.
It was evidenced that the nurses are prepared as to some necessary care during the forwarding of patient when compared to what the literature1.2.5.4 and COFEN resolution 376/2011 advocate11.
This step is comprised from the mobilization of the patient of the bed of the unit to the means of transportation until their withdrawal from the means of transportation to the bed of the receiving unit. Some care is needed to ensure both their hemodynamic stability, as physical integrity11.
Monitoring during transportation requires the same level of monitoring of physiological functions received in the origin unit, including monitoring of pulse oximetry, electrocardiogram, heart rate, respiratory rate and continuous measurement of blood pressure. In addition, some patients, depending on the clinical picture, may require monitoring of pulmonary artery pressure and intracranial pressure3.
With respect to material resources, I believe they are: heart monitor, ventilator of transport that we also have, transport monitor, carrying case with vasoactive drugs and medications needed for a possible complication, and disposable. Be provided with cover, glove, circuits, all that we have to have. Material to safely transport, not only the patient and the professional. (I2)
In this sense, during the procedure, it is mandatory to general evaluate the clinical state. The vascular access must be accessible during all transfer, and the level of attention in monitoring should be the same as the room of origin, because vibrations from the vehicle can interfere in all this. All materials must be adequately protected monitoring and the patient should be sure the vehicle through the seat belt and lifting the bars. Furthermore, the battery life of the monitors should be long enough to cover the whole way19.
However, despite the lines of the subjects contemplate some aspects highlighted in the literature, as hemodynamic assessment and permeability of catheters, there was no mention about the elevation of bars and patient protection as regards their exposure during the procedure, in addition to the host and preserve their intimacy.
The nurse in stabilizing after the critical patient transportation
After transportation, put him back on the bed, replace the drugs he has been using, monitor and provide essential care, feed him, verify that you have closed the devices, such as probe, access, access control, invasive pressure monitoring. (I2)
After the transportation, placing the patient in bed, monitor, making a brief evaluation of the level of consciousness, mainly the neurological issue. (I5)
[...] to observe if there was any change, loss of devices, complication, if he continues with the same state as it was, so this is all part of the nurse´s job. (I8)
As regards the stabilization phase, understood by the first thirty to sixty minutes after the return of the patient the origin unit, the nurse of the receiver unit should be attentive to changes in hemodynamic and respiratory parameters11.
In the study on the screen, they will evaluate and perform the necessary care to patients on arrival to the sector after transportation, as advocated by the literature1-3.6.
In the post-transportation phase, the team receiving the patient must reevaluate the hemodynamic patterns, observing whether there has been any change in relation to monitoring, as the value of arterial gases and blood pressure18. In this sense, a study showed that 67.2% of patients after the intrahospital transportation had cardio-respiratory problems and in those undergoing invasive ventilation, these changes have occurred in 75.7% of them7.
It is also important to be checked the setting and permeability venous access, tubes, probes and drains. In practice, it is observed frequently, after transportation, unscheduled withdrawals of those devices, exteriorization of nasoenterals and nasogastrics probes, phlebitis and infiltration of access. Study reveals that these situations are currently the most frequent adverse events20.
Arriving at the receiving unit, it is necessary that the team check the vital signs, connect the equipment, as monitors and ventilator, monitor the arterial gas values and watch out for complications that may happen until four hours after the transportation1.
In addition to the evaluation of patient's standards, all relevant documentation must be redelivered to the team that accompanies the origin unit and the record of his condtion when arriving should be performed. In relation to the registration, any account directed to this was not observed, in the speeches of the nurses. Studies show that nursing does not register important data relating to the physical examination of patients, or the transport and the care provided during such transfers21.22, which reflects an important care gap.
CONCLUSION
The study identified three categories: nurse in preparation for the transportation of the patient, the nurse in critical monitoring of the transportation of the patient and the nurse critical in stabilizing after the critical patient transportation. Through these, it was observed that the nurses have knowledge about the procedure, according to which the literature recommends. However, lack of specific training, as the speeches are complementary, no professional brought complete information about the peculiarities of transport serious patients, and the answers have emerged mostly from knowledge acquired through practice.
A point noted was the lack of nursing records before and after the procedure.
As regards the difficulties and facilities found, the nurses described as facilities, staff support and the availability of materials needed to proceedings on the unit and as difficulties, communication with the sectors where the patient will be referred.
There is no doubt that there is a need for training with this approach, especially when it is observed the speeches of intensivists nurses with residence. It is obvious that the technical and scientific capacity is much greater when there is improvement with theoretical and practical classes.
The study brought as limitations the fact that it has been held in a teaching hospital, where many of the nurses interviewed were residents, and it has been accomplished only with intensivists nurses. Studies are recommended to get a closer look at expanded on the situation.
The results presented here may provide data for training programs, developing and implementing protocols which govern this practice safer, since the scarcity of publications on the subject.
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