President's Message How do they get there? On quality equipment and personnel for patient transport Rene~ Semonin-HoUeran, RN, PhD, CEN, CCRN, CFRN, Milford, Ohio

A s hospitals undergo changes including work re- design and elimination of services (e.g., trauma

care), how the patient is transported to the hospital and with whom has become an important issue. Even though the Consolidated Omnibus Reconciliation Act of 1986 provides direction related to how patients should be transported and with what type of crew, these regulations are not always followed for a num- ber of reasons--limited access to advanced life sup- port units, cost concerns, and lack of education about the potential risks when the wrong care providers are used to transfer patients. Because of these changes, the quality of care during patient transport deserves our renewed attention.

No one knows for certain when the first patient was officially transported. Historically, patient trans- port evolved with man 's military expertise. Napoleon's surgeon, Dominique Larrey, developed an organized system to transport the injured from the battlefield by a horse-drawn cart), 2 Rapid transport from the bat- tlefield continued to improve, decreasing both mor- bidity and mortality rates, from the time of the Civil War until the Vietnam War. During that time, vehicles changed from horse-drawn carts to winged vehicles. Caregivers were also transformed, from uneducated attendants to specially trained medics, nurses, and physicians. The art and science of transport gradually evolved.

The first ambulances, as we know them, origi- nated in Cincinnati and New York (Figure 1). They generally were dispatched from the hospitals that supported them and were staffed by either nurses, physicians, or teams of both.

During the 1950s concerned physicians and nurses, many with military experience, began to question why we were so successful in providing care in the military for the injured, but had such limited

J EMERG NURS 1996;22:1-2 Copyright {9 1996 by the Emergency Nurses Association. 0099-1767/96 $5.00 + 0 18/61/70220

Figure 1 Early ambulances were dispatched by the hospitals that supported them. Photo courtesy of University of Cincinnati Archives.

success with the civilian population. 3 These funda- mental concerns contributed to the formation of the emergency medical system.

In 1973 the Emergency Medical Services Systems (EMSS) Act was passed, which set the framework for the Division of Emergency Medical Services. The ini- tial EMS Act focused on the establishment of systems of care for patients with major trauma, burn injuries, spinal cord injuries, poisoning and overdoses, acute cardiac emergencies, high-risk neonates, and behav- ioral and psychiatric emergencies. Guidelines were developed for the training of personnel, the number of personnel required to provide safe care, accessibility, transportation, and disaster planning. 4

The repeal of this act in the 1980s made it nec- essary for state and local governments to assume some of the roles that the federal government had managed. Because state size, resources, and regu- lations vary, EMS care varies from state to state, county to county, even city to city. Some communities have advanced life suppor t care available in both

February 1996 t

JOURNAL OF EMERGENCY NURSING/Semonin-Holleran

ground and air vehicles , w h e r e a s o thers m a y have n o n e at all.

Fo r tuna te ly for pa t i en t s , b u t a source of g rea t cha l l enge to t hose who prov ide t ranspor t , no pa t i e n t is " too s ick to move . " Even the mos t c o m p l i c a t e d cr i t ical care equ ipmen t , such as in t raaor t ic bal loon p u m p s , mu l t i channe l infusion pumps , and mul t i func- t ional vent i la tors , have b e e n a d a p t e d for use du r ing

E v e n t h o u g h p a t i e n t s are no longer m o v e d in h o r s e - d r a w n carts, if the appropr iate e q u i p m e n t and p e r s o n n e l are not u s e d dur ing transport , p a t i e n t s fare no better .

p a t i e n t t ranspor t . This c o m p l i c a t e d e q u i p m e n t re- qu i res tha t the s a m e level of care p rov ided before t r anspor t be c o n t i n u e d during the t r anspor t p roces s so t ha t t he p a t i e n t ' s s t a tu s is no t compromised .

It is e s sen t i a l t ha t t hose ca r ing for p a t i e n t s dur ~ i ng t r anspo r t b e bo th e d u c a t e d and exper i enced . Transpor t nurs ing; w h e t h e r b y air or ground, chal- l enges nu r ses wi th un ique ca re s i tua t ions . L imi ted

space , env i ronmen ta l diff icult ies such as lack of light, w e a t h e r c h a n g e s such as hea t and cold, e q u i p m e n t failure, and a f inite n u m b e r of supp l i e s are only a few e x a m p l e s of the d e m a n d s of pa t i en t t ranspor t . Nurses n e e d to rely on thei r a s s e s s m e n t skills and e xpe r i ence to ident i fy and in t e rvene w h e n the suppl ies , pe r son- nel, and the safe ty of the e m e r g e n c y d e p a r t m e n t or i n t ens ive ca re uni t a re no t avai lable at 60 m p h or a t 10,000 feet.

Pa t i en t s will a lways n e e d to b e moved, and the n u m b e r of interfaci l i ty t r anspor t s p r o m i s e s to con- t inue to r ise d ramat ica l ly in r e sponse to m a n a g e d ca re con t rac t s d i c t a t i n g w h e r e p a t i e n t s r ece ive their care, as well as t h e spec ia l i za t ion of facilit ies. Even t h o u g h p a t i e n t s a re no longer m o v e d in ho r se -d rawn carts , if t he app rop r i a t e e q u i p m e n t a n d pe rsonne l are not u s e d dur ing t ranspor t , p a t i e n t s fare no bet ter . Nurses are a vi ta l c o m p o n e n t of the t r anspor t p rocess . Pa t i en t t r anspor t requ i res e d u c a t i o n and exper ience . We n e e d to con t inue to ensure , for e th ica l as well as legal rea- sons, tha t p a t i e n t s r ece ive t he be s t care poss ib le unti l t hey reach the hospital .

References

1. Stewart R. Historical overview. In: Kuehl AF,, ed. Medical director's handbook. St Louis: Mosby-Year Book, 1989:3-6. 2. Hackel A. History of medical transport systems: air, ground, and pediatric. In: McClosky K, Orr R, eds. Pediatric transport medicine. St Louis: Mosby-Year Book, 1995:5-15. 3. Semonin-Holleran R. Prehospital nursing: a collaborative approach St Louis: Mosby-Year Book, 1994. 4. Cleary V, Wilson P~ Super G. Prehespital care. Rockville, Maryland: Aspen, 1987.

2 Volume 22, Number 1