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#1 randyl

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Posted 30 November 2012 - 03:30 PM

We are developing checklists for our transport teams to utilize during patient handovers and what we call "At the door of the aircraft". The push is from a patient safety perspective to ensure that items are not missed during the patient hand over phase (either from the sending or at the receiving site) and also prior to departure in the aircraft. This is a new concept for us and although some drafts have been developed would like to share ideas with other programs that may be doing the same thing. I look forward to any interest or comments people may have.
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#2 Jwade

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Posted 30 November 2012 - 10:37 PM

We are developing checklists for our transport teams to utilize during patient handovers and what we call "At the door of the aircraft". The push is from a patient safety perspective to ensure that items are not missed during the patient hand over phase (either from the sending or at the receiving site) and also prior to departure in the aircraft. This is a new concept for us and although some drafts have been developed would like to share ideas with other programs that may be doing the same thing. I look forward to any interest or comments people may have.



Randy,

Not sure I fully understand the point of making a checklist from a " patient safety perspective".........

What is the end goal of developing more paperwork and increasing transport times?

Seems redundant and unnecessary.

What are you guys routinely missing that has affected patient safety enough to warrant developing a checklist? There has to be a causative factor, unless this is some nurse manager who took a weekend management course and now is trying to justify their existence......

1. You should be gathering any and all information available from sending facility upon arrival.

2. You should be getting a thorough report from the RN or MD

3. The sending MD and RN should have already called report over to the accepting facility.

4. The accepting facility should have already asked the important questions.

5. The medical crew should be working together to ensure cohesion.

6. You give a detailed report upon your arrival at the accepting facility and any pertinent changes during the flight.


I am just not seeing where a conscientious medical crew would miss things routinely enough to affect patient safety in the above steps........I've been doing this a long time and I am just not seeing the benefit. From a business perspective, all I see is more opportunity for inefficiency.


Looking forward to hearing what you have to say so i can better understand the thought process.

JW
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John Wade MBA, CCEMT-P, FP-C, RN

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#3 MSDeltaFlt

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Posted 02 December 2012 - 12:41 AM

Are you referring to "third party" flights where you guys supply the aircraft and assist the pt care crews with any supplies etc from your aircraft?
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Mike Hester, RRT/NRP/FP-C
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#4 striker21w

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Posted 02 December 2012 - 09:03 PM

Randy,
I believe I understand what your asking for. I don't have an answer for you but I too have thought we could improve patient safety by using a standard approach to transferring patient care. It's done in other area's of medicine and aviation on a regular basis, why not utilize it for transferring care as well. i.e. when pilots are starting the ACFT they utilize a checklist to make sure they don't miss anything.

To give an example of why I think this is a good idea for transferring pt care; I recently saw a patient flown (not by me) with their ET tube secured with IV tubing and no capnography hooked up. Obviously this wasn't done maliciously. ETCO2 was just forgotten. Luckily the patient did fine, but the standard of care wasn't met and the patient was put at undue risk. If crews always used a checklist before leaving a facility with a pt (or at the door of the ACFT), it's less likely this sort of thing would get missed.

I don't think we need a checklist for everything, but for situations where there is a large amount of information being transferred while complex tasks are being done, a check list might be a simple way to reduce risk.

If anybody out there has a list they use I too would be very interested in seeing it.

Thanks
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#5 randyl

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Posted 02 December 2012 - 10:18 PM

Randy,

Not sure I fully understand the point of making a checklist from a " patient safety perspective".........

What is the end goal of developing more paperwork and increasing transport times?

Seems redundant and unnecessary.

What are you guys routinely missing that has affected patient safety enough to warrant developing a checklist? There has to be a causative factor, unless this is some nurse manager who took a weekend management course and now is trying to justify their existence......

1. You should be gathering any and all information available from sending facility upon arrival.

2. You should be getting a thorough report from the RN or MD

3. The sending MD and RN should have already called report over to the accepting facility.

4. The accepting facility should have already asked the important questions.

5. The medical crew should be working together to ensure cohesion.

6. You give a detailed report upon your arrival at the accepting facility and any pertinent changes during the flight.


I am just not seeing where a conscientious medical crew would miss things routinely enough to affect patient safety in the above steps........I've been doing this a long time and I am just not seeing the benefit. From a business perspective, all I see is more opportunity for inefficiency.


Looking forward to hearing what you have to say so i can better understand the thought process.

JW


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#6 randyl

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Posted 02 December 2012 - 10:28 PM

Are you referring to "third party" flights where you guys supply the aircraft and assist the pt care crews with any supplies etc from your aircraft?


This is for our dedicated bases that conduct transport. They perform transport with our dedicated aircraft.
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#7 flightrrt

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Posted 03 December 2012 - 12:14 AM

Randy,

Not sure I fully understand the point of making a checklist from a " patient safety perspective".........

What is the end goal of developing more paperwork and increasing transport times?

Seems redundant and unnecessary.

What are you guys routinely missing that has affected patient safety enough to warrant developing a checklist? There has to be a causative factor, unless this is some nurse manager who took a weekend management course and now is trying to justify their existence......

1. You should be gathering any and all information available from sending facility upon arrival.

2. You should be getting a thorough report from the RN or MD

3. The sending MD and RN should have already called report over to the accepting facility.

4. The accepting facility should have already asked the important questions.

5. The medical crew should be working together to ensure cohesion.

6. You give a detailed report upon your arrival at the accepting facility and any pertinent changes during the flight.


I am just not seeing where a conscientious medical crew would miss things routinely enough to affect patient safety in the above steps........I've been doing this a long time and I am just not seeing the benefit. From a business perspective, all I see is more opportunity for inefficiency.


Looking forward to hearing what you have to say so i can better understand the thought process.

JW


John:

Respectively, I disagree with your premise that these checklists are burdensome. I further disagree with your snarky statement about a nurse manager trying to justify their estistance. Your precise attitude is what makes healthcare an unsafe environment. Concepts of CRM go beyond aircraft operations. These identical concepts should be developed in all of our clinical practices. I would have thought, you of all people who preach organizational behavior, you would have been familiar with concepts of high reliability organizations. However, maybe they didn't teach that in your graduate program.

Respectfully,

Aaron
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#8 Jwade

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Posted 03 December 2012 - 01:33 AM

John:

Respectively, I disagree with your premise that these checklists are burdensome. I further disagree with your snarky statement about a nurse manager trying to justify their estistance. Your precise attitude is what makes healthcare an unsafe environment. Concepts of CRM go beyond aircraft operations. These identical concepts should be developed in all of our clinical practices. I would have thought, you of all people who preach organizational behavior, you would have been familiar with concepts of high reliability organizations. However, maybe they didn't teach that in your graduate program.

Respectfully,

Aaron



Aaron,

I think you are mis-interpreting my response:

I of all people know CRM like the back of my hand. I use it all the time when i fly my own airplane. I tell my passengers to speak up if they see something that is unsafe or another aircraft that I might not see. I use checklists before take-off, cruise flight, before landing, before flying an ILS or GPS approach to minimums, etc..........

I've studied high-reliability organizations ( organizational culture / behavior ) extensively in grad school.......The problem is, there are very FEW of them in HEMS......I can name a few which are well run, organized, efficient, effective, and safe. MOST of those are run by Program Directors who have a graduate business education, to go along with their medical background........I have seen far too many who are run by incompetent nurse / medic managers who only are in the position because of their tenure with the company. It's these people who i take issue with, who think because they take a weekend warrior leadership / management seminar they are suddenly blessed with great knowledge and experience. Pumping out policies which, have no ROI and further burden the crews with unnecessary paperwork.

I have also lived the nightmare firsthand at my last rotor wing program. When i was initially hired, the program was highly respected on a national level.....It was run by a program director who was AWESOME......She was fair, she took care of her employees, she made sure we had the latest safety equipment, she mandated helmets, she got us NVG's before most other programs, etc......People wanted to work there, people stayed there a LONG TIME........I turned down a lot more money at a competing program to work there.....Fast forward, she leaves her position, they hire a dude with only line level flight medic experience, no previous mgt experience, no college degree, much less a graduate business or healthcare admin degree, to run a multi-millon dollar program..........Who just happens to be good friends with the 2nd in charge of the medical division of the company.......NEPOTISM at it's finest.........He promptly ran the company into the ground. Reputation went down, long tenured people left in droves, made horrible business decisions to open bases where they had no chance to survive long term........Hence, today, all those bases are now closed..........Was very sad to watch such a great program go downhill because of one or two people........

Furthermore, I worked in surgery for over 8 years, where we use checklists every day. Instrumentation counts, sponge counts, needle counts and the most important one is the " Timeout" checklist we do before starting every single surgery to make sure we have the right patient, right procedure and right limb / area of the body to be worked on.....So, for you to say, my attitude is suspect is unreasonable at best.......

I also qualified my response to the OP as it " SEEMS redundant" based on the superficial information he gave to the forum. Hence, my questions for him to expand what exactly he was trying to do, so I could better understand his position to make a more informed response. His initial comments were stating this is being derived from a patient safety perspective, gave me pause for thought, in my experience these policies are usually born out of a reactive decision versus a pro-active one. Thus, my question of what has happened routinely enough to affect patient safety that warrants a brand new checklist. I did not categorically say it was a bad idea, i just could not see the benefit based on the information provided. From a business perspective i can tell you, knee jerk polices have a better chance at causing more ineffectiveness and inefficiency than being helpful.


Bottom line, I was intrigued by his comments of this being born out of patient safety.......You can make as many checklists as you want, it is still up to the human to use them and follow them, as we well know, this does not always happen and work out so well..........


JW

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John Wade MBA, CCEMT-P, FP-C, RN

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#9 pureadrenalin

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Posted 03 December 2012 - 03:32 AM

Going to agree with John on this one. A squared away crew shouldn't miss routine stuff. Perhaps a simple, "please ensure these items are documented in your narrrative" memo or policy is the way to go. A checklist may also be required to be filed with the patients permanent documentation, or file, depending on local regulations. Here, anything written on a formal document, aside from scratch paper notes, is required to be stored for 21 years.

Also, I'm unsure of what needs to be "checked off"....


If it's an IFT you know you need paperwork and imaging if included, perhaps a MAR, pertinent nursing notes etc..

Fieldwork, it would be anything pertinent to the patient care, which should already be documented in the PCR, including IV and ET patentcy, and method of verification...


If anything, developing a pre-arrival checklist for referring facilities to ensure THEY'VE completed everything that you need for the transfer might be benificial. That, potentially, could reduce waiting, or "stand-around" time.
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#10 randyl

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Posted 03 December 2012 - 03:58 AM

Randy,

Not sure I fully understand the point of making a checklist from a " patient safety perspective".........

What is the end goal of developing more paperwork and increasing transport times?

Seems redundant and unnecessary.

What are you guys routinely missing that has affected patient safety enough to warrant developing a checklist? There has to be a causative factor, unless this is some nurse manager who took a weekend management course and now is trying to justify their existence......

1. You should be gathering any and all information available from sending facility upon arrival.

2. You should be getting a thorough report from the RN or MD

3. The sending MD and RN should have already called report over to the accepting facility.

4. The accepting facility should have already asked the important questions.

5. The medical crew should be working together to ensure cohesion.

6. You give a detailed report upon your arrival at the accepting facility and any pertinent changes during the flight.


I am just not seeing where a conscientious medical crew would miss things routinely enough to affect patient safety in the above steps........I've been doing this a long time and I am just not seeing the benefit. From a business perspective, all I see is more opportunity for inefficiency.


Looking forward to hearing what you have to say so i can better understand the thought process.

JW


John
Thanks for your feedback and this has generated some interesting discussion by the other people posting. Certainly aviation has utilized the checklist format and hospital systems has and continues to utilize checklists for many different areas that are doing patient handoffs or areas such as surgery. Transport medicine has become increasingly complex and as the acuity of the patients and treatment modalities increase, there is always potential for over looking things, even with teams that perform at a high level in a high volume environment. We are considering a type of checklist that would ensure critical elements are acknowledged amongst the team prior to departing the sending site, when handing over at the receiving site, or to a different transport team that may be continuing the transport. Items such as drip rates, patent lines, vent settings are pieces that we feel would be important to include. Our teams are highly skilled and perform tremendous work every day. We aren't looking to add a layer of paper to the transport process but feel there is a value add in covering off potential items that if accidently over looked could put the patient at risk. The concept certainly isn't borne from a flavor of the month quality idea but rather as an opportunity to look at how we currently manage our handovers and where there might be opportunity to make a safe transport even safer.
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#11 pureadrenalin

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Posted 03 December 2012 - 05:23 AM

I just don't see the benefit. With all of the transfers I've done in my time, BLS/ALS or CC...I can't say I've ever missed anything that would be detrimental to patient safety. Before we ever transfer a patient the receiving facility must accept and sign for them, after listening to my handoff report and understanding it, and repeating back drip rates/interventions etc if pertinent... It's something I've always done, and expect my people to do.


I think you could easily get by with a "street sheet" that would act as a scratch pad. Just a few areas for vent settings, drip rates, drugs running, and other access items such as foleys, chest tubes apnd places of lines/sizes that would act as a reference for the crew if they needed it. But, beyond that, I see no point, and IMO feels like this is a micro-managed area that doesn't require it.
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#12 old school

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Posted 03 December 2012 - 06:11 PM

I'm not so sure about a "checklist" per se, but we had transfer forms for our Code STEMI & Code STROKE transports that proved very helpful.

Basically, every ED that was part of our health system's transfer network agreed to follow a uniform protocol for these transfers. Central to that protocol was a transfer form that was stocked in every ED. It was very concise - only 1 page - and included a very brief patient history, time of onset of pain, time of arrival at ED, pertinent VS, and then checkboxes for each intervention that was done in the referring ED.

The referring ED would fax a copy to the receiving facility and also give us a copy, with a face sheet and the EKG's stapled to it.

Even though these transfers were usually pretty routine anyway, communication had always been a problem and that simple form got everyone on the same page and made report and transfer a little smoother for sure. It would probably also have worked for trauma, though we didn't use them for that.

So I'm not so sure I'd want to use a checklist for every transport, but I would say that anytime you need everyone (referring, HEMS, receiving) to move quickly and be on the same page as far as info and protocols, something like this can work well.
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#13 USDalum97

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Posted 03 December 2012 - 08:12 PM

John...Transport medicine has become increasingly complex and as the acuity of the patients and treatment modalities increase, there is always potential for over looking things, even with teams that perform at a high level in a high volume environment.


Are you trying to start a fight with people here? HAHA, just kidding.

Seriously though, I've worked at multiple facilities that have tried the faxed report from ER to ICU, Med/Surg, Tele, etc. It never seemed to work. The receiving nurse always had questions. Usually, it was either answered on the form, or something simple that they could have just asked the patient during their assessment. Eventually the ER nurses resented filling out a form that they then had to report verbally again, and the floor nurses just didn't care enough to read it because they felt "more comfortable" hearing the info rather than reading it. It always went away.

We are required to leave a PCR at the receiving facility. Every ER in town has a printer that is loaded into the ToughBook. We fax a completed report to the out of county facilities when we get back to the station.
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#14 randyl

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Posted 03 December 2012 - 08:21 PM

Are you trying to start a fight with people here? HAHA, just kidding.

Seriously though, I've worked at multiple facilities that have tried the faxed report from ER to ICU, Med/Surg, Tele, etc. It never seemed to work. The receiving nurse always had questions. Usually, it was either answered on the form, or something simple that they could have just asked the patient during their assessment. Eventually the ER nurses resented filling out a form that they then had to report verbally again, and the floor nurses just didn't care enough to read it because they felt "more comfortable" hearing the info rather than reading it. It always went away.

We are required to leave a PCR at the receiving facility. Every ER in town has a printer that is loaded into the ToughBook. We fax a completed report to the out of county facilities when we get back to the station.


Thanks for your feedback. What we are trying to do isn't related to paper work going back and forth but rather a tool for the team to confirm amongst themselves before they head out the door or upon handing off to another team that they cover off critical elements. During the transfer process one member gets report and the other does the changeover of lines, tubes etc. The concept is that when the team comes back together, they can quickly review the patency of lines, tube, drip rates etc, before they head out the door.
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#15 Thinking

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Posted 04 December 2012 - 02:47 AM

Interesting discussion. I'm a fan of the idea, my partner and I have been having an ongoing conversation around creating a series of checklists. We both have 10+ years of high volume HEMS critical care experince and a couple of fixed wing before that, so we aren't what you could call new to the job. We have come to the belief that checklists would help improve patient safety by ensuring that critical items are acknowleged, and communicated between us.
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#16 USDalum97

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Posted 07 December 2012 - 02:10 AM

Thanks for your feedback. What we are trying to do isn't related to paper work going back and forth but rather a tool for the team to confirm amongst themselves before they head out the door or upon handing off to another team that they cover off critical elements. During the transfer process one member gets report and the other does the changeover of lines, tubes etc. The concept is that when the team comes back together, they can quickly review the patency of lines, tube, drip rates etc, before they head out the door.


OK, I have a better understanding of what you are getting at now. We don't have anything like that.

I try to run through things 3 different times. Before we leave a facility, I will take one last look around for missing stuff and confirm that no one has any questions (me, the pilot, my partner, the bedside nurse, pt or family, etc).

I will run through a verbal checklist of our gear when we get into the helicopter. I will say it out loud "monitor, 2 IV pumps, vent, my bag (med bag), your bag (1st in bag), paperwork, patient." I've "heard" of things getting left behind before ;)

Once we get going, I will run through a basic recap of the patient. DX, BP, pulse, EtCO2 waveform and value, vent settings, IV drips and pt status. I usually turn to my partner and ask "Can you think of anything we are missing?" Maybe he sees something I don't. Maybe he heard something from the staff I missed. Sometimes I will say something and he will ask why I did what I did because he missed something in the report. It just gives us a chance to talk out the pt before we get too deep into the transport.

So no, nothing formal. This is just what I have found works best for me.
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#17 Macgyver

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Posted 07 December 2012 - 05:29 PM

@RandyL

I am not SURE where you work but what you describe sounds more like FW scene calls where you are picking up a pt brought to the airport by a lesser trained crews (with or without a RN) from the sending hospital. And a handoff at the destination airport to another ground crew. Not Critical Care in my opinion, but BLS or ALS (depending on crews involved). If you are where I think you are I understand the driving economics/history and practice of this but still feel it is poor practice.

Would LOVE to see a well designed study comparing complications in flight as well as both ground legs, and of course outcomes, between flights with bedside to bedside CCT -vs- the crew shuffle...

In that setting however, a checklist is a great idea to make sure all the equipment/lines etc are covered and to prompt the ground crews to give 100% of the report they got -vs- the 80% that usually is remembered without prodding. It would also serve as a way to improve the pt care if they arrive without needed interventions (distressingly common).

That said - we don't have one either despite 10-30% FW scene calls historically.....
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#18 Macgyver

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Posted 07 December 2012 - 05:32 PM

There has to be a causative factor, unless this is some nurse manager who took a weekend management course and now is trying to justify their existence......

1. You should be gathering any and all information available from sending facility upon arrival.

2. You should be getting a thorough report from the RN or MD

3. The sending MD and RN should have already called report over to the accepting facility.

4. The accepting facility should have already asked the important questions.

5. The medical crew should be working together to ensure cohesion.

6. You give a detailed report upon your arrival at the accepting facility and any pertinent changes during the flight.



All true - but assumes sending facility has their stuff together, and that the crew with the checklist is at the sending facility not doing a hot or cold load of a patient (and receiving a pt packet) at the side of the aircraft with all the added confusion of a cross loading procedure.
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#19 randyl

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Posted 08 December 2012 - 03:23 AM

@RandyL

I am not SURE where you work but what you describe sounds more like FW scene calls where you are picking up a pt brought to the airport by a lesser trained crews (with or without a RN) from the sending hospital. And a handoff at the destination airport to another ground crew. Not Critical Care in my opinion, but BLS or ALS (depending on crews involved). If you are where I think you are I understand the driving economics/history and practice of this but still feel it is poor practice.

Would LOVE to see a well designed study comparing complications in flight as well as both ground legs, and of course outcomes, between flights with bedside to bedside CCT -vs- the crew shuffle...

In that setting however, a checklist is a great idea to make sure all the equipment/lines etc are covered and to prompt the ground crews to give 100% of the report they got -vs- the 80% that usually is remembered without prodding. It would also serve as a way to improve the pt care if they arrive without needed interventions (distressingly common).

That said - we don't have one either despite 10-30% FW scene calls historically.....


BC. These would be for our inter-facility, fw, rw or ground. At times the teams hand off at receiving airports to another team due to operational issues such as timing out or other transports holding. As well, as previously mentioned, a safety check prior to heading out the door of the sending facility as well.

Randy
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