Step 5: Working Diagnosis and Disposition
By this time, the team leader has enough information from clinical observations and initial laboratory results to form a working diagnosis. The leader continues to keep an open mind. Once the working diagnosis is clear, Volume III Diagnosis/Treatment and Transition to Definitive Care Portals help to assist the team leader when additional information is needed. Patient disposition is arranged. The team makes sure that transfer information is complete and checks to be sure that, as much as possible, the patient's medical safety has been provided for.
The information learned from the completion of a patient evaluation (physical examination, diagnostic tests, and observation) plus working through pertinent clinical pathways should result in the development of a working diagnosis. When this is attained, ongoing care or continued resuscitation can continue with some confidence that the patient is stabilized or at least getting better. The team can now take the time to refer to Volume III for more information or details.
The health care team must remain vigilant, looking for clues to additional critical problems that may either alter the treatment plan or indicate the need for additional treatment. Tunnel vision at this stage can be catastrophic to the patient as critical abnormalities may be overlooked during the resuscitation process.
Disposition of the patient may include:
1. Discharge home following resolution of the problem.
2. Admission to a local hospital for further evaluation and treatment.
3. Transfer to a tertiary care center for continuing care.
Consult liberally, particularly if the patient is not responding to the initial resuscitative actions. If transfer is anticipated, the patient needs to be packaged appropriately to facilitate a safe transfer.
Packaging
up the patient is a team effort that includes pulling together data;
securing tubes, monitors, and the patient; assuring that optimal fluid
resuscitation has taken place; and maintaining vital signs. Packaging
up may include consultation with a tertiary care physician and/or
physician-to-physician and nurse-to-nurse contact in preparation for
transfer to another facility.
See Volume I, ACUTE CARE 2, PATIENT TRANSPORT ALGORITHM.
Who to admit and who to transfer
Base
the decision to transfer a patient on probability of severe clinical
deterioration (ie, death or significant morbidity) if interventions
available only at the
receiving facility are delayed. Transfer agreements established ahead
of time help to smooth the transfer process and to enhance continuity
of patient care.
Selecting a mode of transport
Using the
appropriate team and mode of transport is vital to positive patient
outcomes. Basic considerations include whether or not the patient is
stable as well as an individual facility’s capabilities at a particular
time. Some presumably stable patients are at high risk of sudden
decompensation. Consider these patients unstable.
Transport of unstable patients is time sensitive. The sicker the patient, the shorter the transport time. Be mindful of the maxim time is tissue.
Goals of Transport
• To minimize out-of-hospital time
• To keep care moving in the right direction
Ideally, transport is dispatched from the emergency scene, prior to patient arrival at a facility. If a patient has arrived and the decision to transport has been made, do not delay transport because of diagnostics.
Transport Criteria for Adultsa
Unstable vital signs; HR >120 and BP < 90 systolic
Glasgow Coma Scale < 13
Less than alert on AVPU scale
Loss of consciousness > 5 minutes
Respiratory rate of < 10 and > 29 per minute; need for
intubation
Other Considerations
Limb amputation
High-risk obstetric patient
Burn > 20% BSA
Unstable/complex fractures (especially cervical)
PEDS: Transport Criteria for Pediatric Patients
Abnormal responsiveness
GCS < 13
Less than alert on AVPU scale
Abnormal or absent cry or speech
Decreased response to parents or environmental stimuli
Floppy or rigid muscle tone or not moving
Loss of consciousness > 5 minutes
Airway/breathing compromise
Obstruction to airflow
Gurgling, grunting, gasping
Wheezing, stridor, or noisy breathing
Increased/excessive retractions or abdominal muscle use
Nasal flaring, decreased/absent respiratory effort
Respiratory rate outside normal range
Circulatory compromise
Cyanosis, mottling
Paleness/pallor
Obvious significant bleeding
Absent or weak peripheral or central pulses
Pulse rate or systolic BP outside normal range
Capillary refill > 2 seconds with other abnormal findings
Mechanism of Injury Risk Factors that Increase the Risk of Unfavorable
Outcome from Trauma
Death in same vehicle
Age < 5 years or > 60 years
Consider Air Transport from the Scene Directly to a Trauma Center if:
1. Ground transport time to local hospital is > air transport
time to a trauma center; or
2. Ground transport leaves the 911 Primary Service Area coverage
compromised.
Levels of Care
Three
levels of care are available when transporting a patient from the scene
of an accident or critical access facility to tertiary care: Basic Life
Support (BLS), Advanced Life Support (ALS), and Critical Care.b
Basic Life Support
According
to the Minnesota Statutes, “BLS means rendering basic-level emergency
care, including, but not limited to, basic airway management,
cardiopulmonary resuscitation, controlling shock and bleeding, and
splinting fractures. . . .” EMTs are trained in initial and focused
surveys. Many BLSservices have protocols to dispatch Advanced Life Support (ALS) ground
crew and flight teams after making an initial survey.
Components of Basic Life Support
• Airway Management
-Administer oxygen.
-Other skills include mouth-to-mouth resuscitation, BVM, or
oxygen-powered ventilation, as well as use of adjuncts.
• Automatic External Defibrillator (AED)
• Spinal immobilization techniques
• Keep-open IV administration
Advanced Life Support
According
to the Minnesota Statutes, the definition of Advanced Life Support
(ALS) is “. . . rendering basic life support and rendering intravenous
therapy, drug therapy, intubation, and defibrillation. . . .”
Components of Advanced Life Support
• All the components of BLS apply.
• Manual defibrillation/cardiac monitoring
• Advanced airway management
-Intubation
-Needle jet insufflation
-Some may perform cricothyrotomy.
-Ventilator (rate and volume only)
• IV therapy
-Treatment of hypovolemia
-Continuation of IV drips but usually do not titrate
• Medications
-As described in American Heart Association’s ACLS course
-Analgesias
-Glucose and bicarbonate
-Some may have RSI capacity
Critical Care
Critical
care teams are staffed (minimally) with one nurse and one paramedic.
Teams may consist of two nurses or one nurse and a nurse practitioner
or physician’s assistant. This service is available by both air and
ground.
Specialized teams are sometimes available, including neonatal and high-risk obstetrics teams. A crew may include a variety of specialists to suit patient care. (For example, a patient with a balloon pump may include ICU staff or a perfusionist.)
Components of Critical Care
• Usually two care providers in patient care area
• Initiate and titrate drips
• RSI
• Ventilator
-Rate/Volume
-PEEP
-Various oxygen concentration
-Various I:E ratios
• Pericardiocentesis
• PRN medications without on line medical control
• Blood administration
• Central lines
• Pacemakers
• Invasive monitoring
Modes of Transport
Three
types of transport are ground ambulance, helicopter (rotor wing), and
airplane (fixed wing). Each mode of transport carries risks and
benefits.
Ground Transport
Use ground transport when time is not
critical to patient survival. Transferring a patient by ground might be
necessary when weather limits the ability of aircraft to fly or when
aircraft are simply unavailable.
Though ground transport is appropriate for many patients, since the advent of helicopters, it is often not considered. One advantage of ground transport is the availability (upon request) of all three levels of care. Another advantage is that there is no weight limit for patient or personnel (as there is with air transport). For bariatric patients, ground transport may be more comfortable as well as the only suitable type available. Ground ambulances contain more working space and can accommodate patients with special needs, such as additional personnel or equipment. Ground transport is beneficial to stable pediatric patients who are generally accompanied by caregivers. Ground transport can also accommodate extremely tall patients (> 6’6”) who may be too long to fit in average-sized aircraft.
Helicopter (Rotor Wing)
Transport
by air is no longer considered a heroic measure. Though helicopters are
undeniably expensive, the best standard of care remains that which minimizes
time between incident and definitive care (sometimes called the golden
hour). Critical care flight crews offer the highest level of care in
less time.
Another advantage of helicopter transport is maneuverability. Helicopters are often able to access patients in places ground ambulances are unable to reach, thus reducing patient extrication times at the scene. The required 100-feet diameter landing area makes virtually every rural hospital a temporary heliport.
Airplane (Fixed Wing)
Fixed-wing
aircraft have different capabilities than helicopters. Because of the
flying altitude they can attain, they may be able to fly above
inclement weather conditions. Fixed-wing transport offers the same
levels of care as ground and rotor wing. Consider fixed-wing transport,
which is often faster and less expensive, when a patient must travel
over 150 to 200 miles. The disadvantage of fixed-wing aircraft is
accessibility to rural areas. Additionally, fixed-wing aircraft must
land at an airport, making response times considerably longer.
Selecting the transporting team preparedness level
Identify and survey intercept points for patient and transport team
safety. Some
questions to consider might be: Would it be best if the critical care
expertise came to the rural facility rather than risk decompensation
during transport? Could close communication between the referring
physician and the consultant provide the time needed to bring a
specialized transport team to the facility?
In certain cases, the transporting team may need to take along special equipment, such as an intra-aortic balloon pump or a neonatal ventilator. Special fluids and medications may need to be brought to the rural facility. Critical care providers may also accompany the transport team.
Communication
Communication
is key to the efficiency and effectiveness of any complex system of
transportation. Make telephone, radio, and telemedicine (desktop
computer platform or dedicated line) communications available at the
rural facility for ready and easy communication between referral
centers and nearby rural facilities. During severe weather, nearby
rural facilities may be able to pool equipment and skilled personnel
for certain cases (such as obstetric emergencies) until transfer
becomes an option. This requires planning and open communication.
Early notification of the possible need for transfer of certain cases—such as a multiple trauma or burn patients—may save many minutes of resuscitation and transportation time. Prehospital personnel can be given the option to notify distant transporting systems of a possible need to transport, even before the patient reaches the rural facility.
Physician Responsibilities in Planning Patient Transfer
In
addition to the role of team leader, the responsibility of the
physician (or designee—physician’s assistant or nurse practitioner) is
to stabilize the patient to the level of the facility’s capability and
plan for the appropriate mode/level of transport. This includes
contacting an accepting physician and consulting on treatments given
prior to transport and en route.
Often physicians in rural communities are placed in the role of medical director of the local ambulance service. The two types of medical direction include direct and individual. Direct medical direction is communication that transpires by voice either via a radio system or cell phone. EMS staff report clinical findings and receive orders to intervene and continue patient care. Individual medical direction is given by a physician through written protocols and involves the development and ongoing monitoring of protocols and procedures. This involves reviewing prehospital reports to ensure compliance with predetermined procedure. High quality emergency care is dependent on all prehospital personnel understanding, complying with, and applying all treatment protocols consistently, including those protocols beyond primary and secondary assessment. Protocols include transport methods and destination facilities in a geographic region.
“Weather” or Not to Transport
•
Don’t make a transport decision based on weather. Weather may clear a
short distance from you, and intercepting ground to air may be in the
patient’s best interest.
• Dispatch transport early. The majority of
air transfer requests are viable transports. There are no negative
consequences to calling and then canceling a transport. Keep in mind
when dispatching air transport that weather may not be forecasted
between reporting stations or change rapidly. If transport is arranged
early enough, alternate transport plans may be made with minimal
negative impact to the patient.
How Best to Help the Transport Team
•
Communication. Know that each transport is unique. Dispatcher and
transport personnel are trained and skilled at orchestrating the most
efficient transport plan. Be open to conferring with teams in order to
choose the best option.
•
ABCs. It is not necessary to have a patient’s ABCs stabilized before
you call. Flight crews are highly trained at advanced or difficult
airways and line placements.
• Transfer forms. Send all documents with the patient.
•
Diagnostic results. It is helpful for transport teams to have copies of
pertinent diagnostic findings. Minimally, provide a verbal account of
abnormal findings to help aid in the appropriate treatment regimen. See
Vol I, ACUTE CARE 2, PATIENT TRANSPORT ALGORITHM.
• Secure a landing
zone when utilizing a helicopter. For safety’s sake, designate a
specific person to secure a landing zone throughout the entire
interface (about 10 minutes prior to aircraft landing to liftoff and
clearing of helipad).
Stable patients may usually be moved by ground transport staffed by appropriately trained personnel. If the distance is long, air transport may also be used.
Caveats for Transport
Once the need for transport is recognized, do not delay the process for lab or diagnostic procedures that have no impact on the transfer process or immediate resuscitation.
The probability of positive outcome can be improved by minimizing the time from injury to appropriate definitive care.
Health care providers in community hospitals and regions of the state should develop specific guidelines based on local resources that will help to identify patients who will benefit from early transfer to a trauma center.
The purpose of triage/transport procedures is to facilitate early transport of critical trauma patients to the most appropriate health care facility.