CHAPTER 4. Members of the Transport Team

Reneé Semonin Holleran, Frank Thomas, Jonathan D. Gryniuk and Debbie K. Martin

With the advent of advanced treatment methods and the delineation of specialties at specific tertiary care centers, the need for available critical care transportation has become an integral component of many healthcare systems. Transport may be needed to ensure that the patient is able to receive life-saving care. Critical care transport is a collaborative practice and process. The scope and mission of the transport program, state nursing boards, emergency medical services (EMS) agencies, and types of patients transported contribute to crew member configuration. However, in the United States, the primary member of most critical care transport teams is generally agreed to be the registered nurse. An important note is that the primary member may vary both in the United States and globally. ^8,^33,^37,³⁹

The team approach has proven effective in providing a holistic method to patient transport. The goal of the transport team is to provide seamless patient care, maintain or enhance the level of care from the referring facility or agency, and render interventions as appropriate. This chapter provides an overview of some transport team members.

THE TRANSPORT NURSE (FLIGHT, PREHOSPITAL, SURFACE)

In 1998, the Emergency Nurses Association (ENA) and the National Flight Nurses Association (NFNA; now known as the Air and Surface Transport Nurses Association [ASTNA]) released a joint position paper that described the role of nursing in the prehospital environment. Both organizations believe that nurses who practice in the prehospital care environment need to be appropriately educated to function successfully in that role and that practice should be regulated by state boards of nursing in the state in which the transport nurse practices. Box 4-1 presents a summary of this position paper.

BOX 4-1

Summary of the ENA/NFNA Position Statement: The Role of the Nurse in the Prehospital Care Environment

1. ENA and NFNA qualified practicing nurses in the prehospital environment should not be required to certify as emergency medical or flight medical technicians.

2. ENA and NFNA endorse the need for special educational requirements for nurses practicing in the prehospital environment. Nurses need focused education and subsequent maintenance of specifically identified and recognized prehospital knowledge and skill.

3. ENA and NFNA recognize that EMS personnel possess a specialized body of knowledge and skills. Collaboration and communication are needed.

4. ENA and NFNA support that state boards of nursing are the regulatory body of the profession of nursing.

5. ENA and NFNA seek recognition of registered nurses by state EMS agencies for their unique role in the prehospital care environment.

6. ENA and NFNA endorse a collaborative role for the delivery of prehospital care.

7. ENA and NFNA support the use of the National Standard Guidelines for Prehospital Nursing Curriculum as developed by ENA and collaborating EMS agencies as a foundation for designing a course to meet the state and local requirements to practice in the prehospital environment. Competency-based testing should also be used. ENA and NFNA also support the utilization of the Flight Nursing Principles and Practice, Air Medical Crew National Standard Curriculum in conjunction with Practice Standards for Flight Nursing as the basis for training and education.

Please note this is a summary from the position statement. To obtain the entire document go to http://www.ena.org/services/posistate/data/rolreg/htm.

From ENA and NFNA Position Statement: Role of the registered nurse in the prehospital environment, adopted 1987 and revised 1998, available at http://www.ena.org/services/posistate/data/rolreg/htm

Bader et al¹ conducted a national survey to discover the characteristics of flight nursing practice. The study results showed that one third of flight nurses who participated in flight programs were prepared at the baccalaureate level (BSN) and had 10 to 15 years of nursing experience. Most flight nurses had either emergency or critical care experience, had completed a trauma course, and were verified in pediatric advanced life support (PALS) and prehospital trauma life support/basic trauma life support (PHTLS/BTLS) and certified in emergency nursing (CEN). If the flight nurses were members of a professional organization, they belonged to NFNA or ENA. ¹

Currently, four curriculums outline the recommended education and skills needed to practice transport nursing: the Transport Nurse Advanced Trauma Course (TNATC) from ASTNA; the Air Medical Crew National Curriculum, developed by the US Department of Transportation; the National Standard Guidelines for Prehospital Nursing from ENA; and the Flight and Ground Transport Nursing Core Curriculum, ³⁸ developed by the Air and Surface Transport Nurses Association. In addition, ASTNA has published standards of practice that provide nurses with a framework for air and critical transport nursing practice. Box 4-2 contains a description of the professional standards for transport nurses.

BOX 4-2

Professionalism Standards

The flight nurse practices autonomously within the scope of practice defined by each institution.

The flight nurse practices in accordance with the state Nurse Practice Acts, state regulations governing prehospital care, NFNA standards, and policies and procedures set forth by medical direction and institution.

The flight nurse assumes responsibility and accountability for actions.

The flight nurse identifies self to patients, significant others, and healthcare providers.

The flight nurse participates in the education of the healthcare team, clients and their significant others, and the community.

From Hepp H: National flight nurses standards of flight nursing practice, St Louis, 1995, Mosby.

In 2006, the Air Medical Physician Association published Principles and Direction of Medical Direction. This document provides foundations for the education, roles, and required skills for transport team members and the framework of medical direction in the transport of patients.

A few states have prehospital care courses that serve as bridge courses for nurses to meet the requirements for emergency medical technician (EMT) and paramedic certification. An example of this is the Prehospital Nursing Course (PNC) that has been proposed in Maryland. ²³ The PNC contains various modules related to prehospital care, and nurses may challenge all but four of these modules. The remaining modules reflect specialized didactic and practical training that is integral to clinical paramedic practice. Specific topics required by such bridge courses include: disaster/triage, rescue/extrication, vehicle operation, and orientation/role socialization.

Optimally, transport nurses should be prepared to function in the prehospital care environment. Even if nurses are not first responders, they must be familiar with the potential hazards of scene work and how to keep themselves and others with whom they work safe. The prehospital environment is dynamic and unforgiving. Most nurses have limited or no experience in this environment before they begin their transport careers.

Bader et al¹ found that flight nursing practice consists of both critical care and emergency nursing skills. The procedures that flight nurses performed included intubation, thoracentesis, cricothyroidotomy, escharotomy, intraosseous insertion, cutdowns, chest tube insertion, central line insertion, high risk obstetric management, and transport of patients with intraaortic balloon pumps in place. The ability to perform the skills necessary to carry out these procedures depends on the transport program mission, scope of practice, medical direction, level of the crew training, and state boards of nursing or State Bureau of Emergency Medical Services.

Acquiring these technical skills and remaining competent in them can be accomplished through laboratory practice, realistic interactive simulators, and supervised patient care. Many critical care transport programs require that a specific number of procedures be completed in a designated period of time. Box 4-3 contains a summary of some of the procedures performed by critical care transport nurses.

BOX 4-3

Summary of Skills for Transport Nursing Practice

Airway Management

1. Intubation

Oral

Nasotracheal

Digital/manual

Intubating laryngotracheal mask

2. Cricothyroidotomy

Needle

Surgical

3. End-tidal CO ₂ monitoring

4. Pulse oximetry

Ventilation Management

1. Needle decompression

2. Chest tube insertion

3. Open thoracotomy-assisting

4. Pericardiocentesis

5. Ventilator management

Circulation Management

1. Vascular access

Central line placement

Venous cannulation

Arterial cannulation

Intraosseous line placement

Seldinger technique

2. Medication administration

Fluids

Blood

Blood products

Vasoactive drugs

Experimental and research medications

3. Intraaortic balloon pump management/left ventricular assist device

4. Pacing devices

Internal

External

5. Vital sign monitors

6. Invasive line monitors

Blood pressure

Pulmonary catheters

Intracranial monitors

7. Urinary catheters

8. Gastric catheters

9. ECG monitors

10. 12-lead ECG monitors

11. Temperature management

12. Wound care

Control of hemorrhage

Protection from contamination

Additional Skills

1. Pain management during transport

Movement

Motion sickness

2. Emotional care

3. Family care

Critical-thinking skills constitute one of the most important interventions transport nurses bring to the transport environment. Critical care transport nurses constantly question, analyze, and reevaluate all components in the transport process. Critical thinking involves the use of knowledge and skills to explore practice situations. ^12,²⁴ Critical-thinking skills include the nurse’s ability to be autonomous and organized and to view practice situations in an in-depth comprehensive way to better understand the experiences of the air medical patient. ^12,²⁴ This unique competence was identified in Bader et al, ¹ who stated that flight nurses were held accountable for these skills: “These complex skills included decisions regarding the administration and titration of medications, initiating therapeutic treatment based on physical assessment findings, communicating and documenting significant findings and performing follow-up activities.”¹

Transport nursing requires education, training, experience, and continuous evaluation of competence. Transport nurses must be physically and emotionally ready to meet the demands of patient care during transport. ^37,³⁸ Although some general characteristics of transport nursing do exist, the specific responsibilities and practice protocols depend on the type of service provided, the crew matrix, the type of vehicles used for transport, and state regulations. Box 4-4 summarizes general educational preparation for critical transport nursing practice. ^28.^29.^{and 30.}³⁸

BOX 4-4

Summary of Educational Requirements for the Transport Nurse

Registered nurse (some programs require multiple licensure with provision of care across the state line)

Advanced Cardiac Life Support (ACLS)

Pediatric Advanced Life Support (PALS)

Emergency Nursing Pediatric Course (ENPC)

Prehospital care orientation course (determined by state EMS agency)

Prehospital Registered Nurse Course

EMT/EMT-P certification

Certification in a nursing specialty

Certified Emergency Nurse (CEN)

Certified Critical Care Nurse (CCRN)

Certified Flight Registered Nurse (CFRN)

Certified Transport Registered Nurse (CTRN)

Trauma course

International Trauma Life Support (ITLS)

Prehospital Trauma Life Support (PHTLS)

Advanced Trauma Life Support (ATLS)

Transport Nurse Advanced Trauma Course (TNATC)

Trauma Nursing Core Course (TNCC)

PARAMEDICS

Today, specially trained skills that had previously been reserved for the hospital setting have found their way into the paramedic’s skill set. Most notably, after appropriate education, paramedics have shown their abilities to perform advanced procedures that have historically been areas of practice for physicians, nurses, or respiratory therapists. Rapid sequence induction (RSI), 12-lead electrocardiographic (ECG) interpretation, and administration of fibrinolytics are a few of the advanced practice skills successfully and appropriately performed by the trained paramedic. ^2,^5,^7,^9,^11,^13.^14.^15.^16.^17.^{and 18.}²²

Paramedics who perform these skills were once viewed as advanced practice paramedics in that they performed skills outside those taught within the Department of Transportation’s EMS curriculum. The paramedics of today not only are responsible for prehospital patient care but also can frequently be found transporting patients between medical facilities or working as allied healthcare providers within the hospital setting. ³² This broadened scope of responsibility has given rise to subspecialty groups of paramedics: the critical care paramedic and the flight paramedic (Figure 4-1).

FIGURE 4-1

Flight medic.

Critical Care Paramedic

The resource-scarce healthcare environment of the 1990s spurred an increase in the number of patients needing critical care transport and thus an increase in the need for competent critical care–trained transport providers. Born of this need was the concept of the critical care paramedic (CCP or CC-EMTP) who could complete transports that previously required supplementation with hospital staff. CCPs receive training beyond that of “street” paramedics, which prepares them to appropriately assess and manage the patient who has already received significant medical interventions, including the use of advanced pharmacologic agents and the insertion of hemodynamic monitoring and assist devices. ²⁶ Use of this new healthcare provider has shown promising results. ¹⁰

Concerns have been raised regarding the ability of the CCP to use the critical-thinking skills that are often necessary in the management of the critical care case. However, the development of critical-thinking skills can be successfully instilled in the paramedic through an effective scenario-based approach to education and training. ¹⁴ Furthermore; no education is complete without the opportunity to apply newly learned skills in a clinical setting under direct observation of another skilled practitioner. Although a variety of CCP training programs offer a clinical practice component, no universal requirement has been established for inclusion of clinical training. ^9,^19.^20.^{and 21.}

Other concerns regarding the CCP have centered on the paramedic’s ability to truly identify the critical nature of the patient’s condition and ensure that appropriate resources are available during transport. Education and training, again, are the cornerstones to decrease this concern. Paramedics have shown their ability to correctly identify and plan for the transport of the critical care case after receiving appropriate education. ³¹ The CCP is generally partnered with either a critical care transport nurse or respiratory therapist, which can further enhance the transport team.

Although a variety of commercial educational courses offer to train and graduate “critical care paramedics,” an important note is that the use of the title CCP is not currently governed by any private, state, or federal agencies. Currently, no agreement exists on the content or length of CCP training programs. ^31.^32.^33.^34.^35.^{and 36.}

In 2008, the International Association of Flight Paramedics (IAFP) partnered with a nationally recognized university to complete a comprehensive survey to identify the skill set and education associated with critical care paramedic practice. The survey data have been collected and are being tabulated and analyzed to create a functional definition for the Critical Care Transport Paramedic (IAFP reference).

Flight Paramedic

The flight paramedic has played a pivotal role in the development of air medical transport. In 1970, the Maryland State Police instituted the first statewide EMS helicopter service. This multifaceted air transport, air rescue, and police program was staffed by emergency medical technician-paramedic (EMT-P)/police officers (Trooper Paramedic) and has remained in continuous operation to this day. ^9,¹³

In 1986, flight paramedics united to form the National Flight Paramedics Association (NFPA). The NFPA is now known as the International Association of Flight Paramedics (IAFP). The NFPA was formed to represent the global interests of flight paramedics within the air medical industry with an emphasis on safety and education. In 1990, the NFPA furthered its goals to promote quality within the industry by serving as a founding member of the Commission on Accreditation of Air Medical Services (CAAMS), now known as the Commission on Accreditation of Medical Transport Systems (CAMTS).

In 2005, the NFPA answered a global request for improved representation of flight paramedics from around the world by redefining their mission and adopting a new name: the International Association of Flight Paramedics (IAFP). Although the concept of the critical care paramedic is fairly new, the ability of the paramedic to function in this advanced capacity is not. Most air medical transport programs have used the flight paramedic in a critical care provider capacity since the early beginnings of air medical transport. Because of the complex nature of the cases transported by air medical programs, expanding the role of flight paramedics beyond that of their ground counterparts quickly became necessary. Additional responsibilities, such as surgical airway management, use of anesthetic agents to facilitate intubation, and the use of portable ventilators, became necessary to optimize the care of the critically ill and injured patients during air transport. A host of other skills followed as flight paramedics proved their ability to grasp and maintain competency in skills previously afforded to physicians and advanced practice nurses. These skills commonly include pericardiocentesis, chest tube insertion, escharotomy, and insertion of central venous access devices.

With advances in medical care came the need to maintain care of increasingly complex cases, which required a critical care–like setting during transport. Invasive hemodynamic monitoring, administration of blood products, initiation and titration of vasoactive and sedative medications, and analysis of a variety of laboratory data through portable devices became an integral part of air medical transport. ¹² Today, it is not uncommon to find flight paramedics trained in monitoring and managing patient populations from the adult cardiac patients with an intra-aortic balloon pump or a left ventricular assist device to the preterm infant undergoing extracorporeal membrane oxygenation. ^1,^6,¹⁶

RESPIRATORY THERAPIST

Respiratory therapists (RTs) typically work in hospitals, where they perform assessments, diagnostics, intensive critical care procedures, and patient interventions for all patient populations, including the neonate and the elderly. They also function as a vital part of a hospital’s lifesaving response team.

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