Risk Management Handbook for Health Care Organizations - Essay Example

? Retrieval Medicine College Pre-hospital retrieval Case Pre-hospital plan includes designation of responsibilities of the whole team. This must be done in a brief and concise way. Members of the entire team must be aware of their designated responsibilities once they arrive at the scene. Police officers can be assigned to secure the perimeter and they are expected to implement crowd control while the medical team is responding to the victims of the accident. Fire and rescue team will be assigned to check on the safety of the exact accident area. These members are responsible for checking involved vehicles for possible combustion and explosion. All personnel are to bring and wear their personal protective equipments (Curtis & Ramsden, 2011). It is of utmost importance that the members of the rescue team are able to protect themselves through wearing their respective PPEs. The nearest facilities such as trauma centre and hospital must be pre-informed regarding the event. Despite the possible scarcity of the details regarding the incident, information must still be relayed to the centres which are more likely to receive the injured. The time frame to perform extrication, assessment and stabilisation must also be estimated. It is more convenient to perform rescue operations such as extrication when the weather is not hazardous. A rainy weather can add risks to the conduct of rescue. Example of such risks includes slippery grounds that may pose as a threat to safety of both the victims and the team (Beebe & Myers, 2011). Upon arrival, safety of the scene must be established first, prior to the rescue team’s approach to the victims. Continuous assessment of the situation is needed (Caroline, 2010). Immediate mobilization of police to keep bystanders off the area must be implemented. Members of the rescue team will not be able to function optimally when the crowd is around. Securing a definite perimeter will not only enable the rescue team to function, but it will also avoid addition to the injured persons. Traffic rerouting is also important, especially, if there is a need for extrication. It is much better that less people gather around the scene. All members of the team must wear their respective PPEs to protect themselves while they perform their duties. Changes on the pre-hospital plan are communicated precisely with all members of the rescue team. Immediate assessment of the patients is done through triage (Caroline, 2010). Based on assessment, patient 2 is the most critical and therefore must be attended immediately. Decreased air entry on left lung field entails immediate support of airway through intubation. The patient’s rigid abdomen and bruised pelvis can be an indication of internal bleeding. Fluctuating vital signs as evidenced by systolic BP of 90 and decreased consciousness (GCS=6) is indicative of shock and requires immediate transfer to a hospital. Hence, air retrieval operation must be prioritized to patient 2. The rescue team must be aware that patient 2’s condition is minutes away from irreversible deterioration. Coordination with the trauma centre must be urgently facilitated. An intravenous line is started and plasma expanders are given to prevent ongoing hemorrhagic shock to progress. Whenever possible, blood for transfusion should be coordinated and prepared to facilitate immediate transfusion. Absent vital signs and open skull fracture are indicative signs of severe intracranial injury and death of Patient 1. At this point, cardiopulmonary resuscitation may be deemed as unnecessary due to three facts: first, the patient lacks vital signs, second, due to the obvious extent of brain damage and third, in consideration of the time that has elapsed since the accident. In some cases, cardio pulmonary resuscitation may be performed, although attempts ensure zero benefit. In this case, scarcity of the resources and the patient’s condition are all important key points in deciding not to proceed with CPR (Miller & Truog, 2011). Authorities must be informed. Keep in mind that accurate information and documentation is a must in any scenario (Caroline, 2010), especially, in accidents like this where court mitigation is always possible. Other members of the team such as police personnel can facilitate notification of the deceased’s relatives. Fractures in children are critical conditions warranting immediate attention (Dolan & Holt, 2008). Patient 3 with bilateral femoral fractures must be given analgesics to help lessen the pain. Moreover, immobilization of the parts affected is necessary to avoid inflicting further damage (Dolan & Holt, 2008). The child has sustained serious injury and is also a candidate for immediate transfer. However, his vital signs are considerably near normal as compared to Patient 2’s vital signs. The child must be transferred to the nearest trauma centre via the available ambulance. Patient 4, who has ankle pain, may be assessed for other injuries. Once immobilization and supportive measures for the ankle has been established, transfer to a hospital can be coordinated. Another clear option is for patient 4 to arrange himself a visit to the nearest facility. This is in consideration that patient 4 is not directly related to the incident that occurred. References Beebe, R. & Myers, J. (2011). Paramedic Professional: EMS Operations. New York, NY: Cengage. Caroline, N. (2010). Nancy Caroline’s Emergency Care in the Streets. Boston, MA: Jones & Bartlett Curtis, K. & Ramsden, C. (2011). Emergency and Trauma Care for Nurses and Paramedics. Australia: Mosby. Dolan, B. & Holt, L. (2008). Accident & Emergency: Theory into Practice. Philadelphia, PA: Elsevier. Miller, F. & Truog, R. (2011). Death, Dying and Organ Transplantation: Reconstructing Medical Ethics at the End of Life. New York, NY: Oxford. Pre-hospital retrieval Case 2 Considerable amount of time will pass before any fastest response team arrives at the scene. A coordinator can make use of this time in requesting the lay person who reported the incident to provide more details of the current scenario (Carroll, 2011). Whenever possible, the informant can be instructed to assess the unconscious motorcyclist. The resulting assessment, although vague and incomplete, can be enough to guide the initial decision making process (Carroll, 2011). If the assigned person reported seeing movement in the motorcyclist, it can then be concluded that the moment of unconsciousness is temporary. An estimation of time must be done to note the period between unconsciousness and response of the motorcyclist. An ambulance can be dispatched and the responding rescuers may need to coordinate if the motorcyclist will need emergency transport via aircraft. On the other hand, if the motorcyclist is reported to remain unconscious, the lay person can be instructed on assessing the patient’s airway, breathing and circulation while the ambulance team is being dispatched on the area. The urgency of the medical situation is not the sole factor in considering activation of air transport. Several hindrances can occur. In any situation, the priority is to secure safety of the whole area. A dangerous scene, such as a shooting incident, hampers progress of action for the response team (Haskell, 2006). Given the fact that they will be able to arrive fast at the area, the team will not be able to perform any rescue actions if it is still an active site for shooting. The risk that one of the rescue team will be shot is tantamount. If the response team is jeopardized, rescue and medical care cannot be started (Pante & Pollak, 2009). In the shooting incident, police team must first respond to the scene. Once safety is ensured, the unconscious man can be assessed. It is safe to assume that the man has gunshot wounds and the paramedic must look for it (Pante & Pollak, 2009). Upon confirmation that the man has indeed gunshot wounds, control of bleeding and further assessment of the area must be done. In addition, inspection of the victim’s body for other injuries must be meticulously and thoroughly done in a way that provides minimal disruption of possible evidences. The responder must bear in mind the possibility of being requested to attend a court hearing as a witness. Accuracy of the descriptions and minimal disruption of evidences will help a lot in future litigations. Weather also impacts the retrieval operation significantly. Rain and other inclement forms of weather more often create delay in transport of patients (Haskell, 2006). In severe weather conditions, the safety of the whole response team and the patient may become far more in danger if air retrieval push through (Haskell, 2006). It must then be thoroughly considered on whether to proceed with air retrieval or to maximize the land resources available. A conscientious and objective decision must be reached. Benefits of transport must exceed the risks that a certain retrieval operation has. Communication is a critical tool at this point. Clarity of communication and the details of the situation will matter significantly in weighing risks and benefits of air transportation. Optimisation of resources, especially manpower, for response team is always significant. In this scenario, cardio pulmonary resuscitation entails that there is an ongoing arrest (Miller & Truog, 2011). The time it will take before the response team can get into the situation and the irreversible condition of the patient must be thoroughly considered. Furthermore, it can be taken into consideration that a local team is already attending to the 75 year old man. Dispatch of an air retrieval team will only limit the personnel who can respond to other emergency situations (Miller & Truog, 2011). In addition, Clumpner (2011) cited that ongoing cardiac arrests are not suitable for air transport. If the patient shows improvement while resuscitation is ongoing, then immediate air transport must be activated. On the contrary, unresponsiveness to CPR and emergency meds after several minutes will make additional attempts unbeneficial (Miller & Truog, 2011). The most critical among the patients is the victim of a vehicular accident. Immediate extrication must be planned and implemented for the patient trapped inside the vehicle. His symptoms of severe abdominal pain and SBP of 90 can be an indication of internal haemorrhage and impending shock (Pante & Pollak, 2009). Extrication must be done in the fastest way possible without inflicting additional injuries to the patient. Upon successful extrication, patient must be thoroughly and quickly assessed. Head to toe examination must be done, noting deformities and other signs indicative of fracture and bleeding from the accident (Haskell, 2006). Air transport to the nearest trauma centre or tertiary hospital must be immediately conducted so that patient can be attended surgically and hemorrhagic shock can be prevented. References Carroll, R. (2011). Risk Management Handbook for Health Care Organizations. San Francisco, CA: John Wiley & Sons. Clumpner, M. (2011). Aircraft Fundamentals. A. Pollak (Ed.). Critical Care Transport (pp. 64). Sudbury, MA: Jones & Bartlett. Haskell, G. (2006). Paramedic Pearls of Wisdom. Sudbury, MA: Jones & Bartlett. Miller, F. & Truog, R. (2011). Death, Dying and Organ Transplantation: Reconstructing Medical Ethics at the End of Life. New York, NY: Oxford. Pante, M. & Pollak, A. (2009). Advanced Assessment and Treatment of Trauma. Sudbury, MA: Jones & Bartlett. HOSPITAL RETRIEVAL Case 1 Critically ill patients needing urgent response from a specialized centre are almost always highly prioritized for air transport. Dispatch personnel gather patient information and relay it to the coordinator, who then decides the mode of transportation applicable to the patient (Martin, 2006). A coordinator receives details of all patients requesting transport and does a critical decision through the patient data given by the responders to the scene. In cases of exogenous risks such as inclement weather, the coordinator and response team perform a risk assessment weighing benefits and risks. This act guides them in deciding whether to proceed with the air retrieval operations. It is imperative that benefits must outweigh the risks in order for the air retrieval to proceed. Clumpner (2011) stated that EMS, police and fire rescue teams are the authorities that communicate with a flight team for a possible transport. Weather and other important factors that may affect flight conditions are considered by the pilot when accepting flight missions (Clumpner, 2011). It is important to note that aside from external factors, there are also physiological events that occur to patients and medical team once on the air (Grissom, 2003). Altitudes exert bodily changes. There are certain patient conditions that can deem air transport deleterious to the patient. Despite the fact that air transport is the fastest, major alterations in patient condition brought by altitude can hamper the decision to choose this kind of transportation. If there is proven evidence that the patient’s condition will deteriorate due to altitude then air retrieval cannot be considered as an option. In addition, the team can also experience changes in themselves upon take off. Members of the team must be able to ensure that they can still provide adequate and quality care while on air. This is mainly the reason why air retrieval personnel are thoroughly trained. After thorough but quick consideration of these factors, the acceptance of the flight mission is made. Once the flight mission is accepted, coordination and planning is essential. The receiving hospital must be well informed on the conditions of the patient prior to patient’s arrival. Pre-arrival notification and information can help the receiving hospital to prepare the necessary facilities and gather the necessary equipment for the patient. In some critical cases, pre-arrival information enables the receiving facility to contact additional specialists necessary for the patient’s condition. Time and resources are consumed in any kind of patient transportation (Brindley & O’Leary, 2011). The difficulties of transporting a critical patient who is intubated are tantamount. Ample space is needed in the aircraft to bring the equipments for patient’s ventilation, alongside other emergency devices. In this case, a fixed wing aircraft must be utilized so that machines and other devices, plus an adequate number of medical team can fit in the aircraft (Clumpner, 2011). The flight team must be aware of the possibility of accidental extubation and the need for another intubation while on transfer (Brindley & O’Leary, 2011). Like all retrieval operations, continuing patient assessment is done while on flight. Significant changes and deterioration of patient condition will require flexibility of the plan and immediate landing to the nearest facility must be coordinated. This proves to be a disadvantage for fixed wing aircraft because the latter always require a runway, in comparison to a rotary wing aircraft (Clumpner, 2011). In consideration of the fact that the patient has intracranial haemorrhage and spinal injuries, full strict immobilization of the patient is necessary (O’Shea, 2005). Brindley & O’Leary (2011) emphasized that in intubated patients, slight extension and flexion of the patient’s head may result in either extubation or hypoxemia. In addition to this, movements of the head may create extensive damage of the spinal cord. A patient with a critical condition, such as spinal cord injury and intracranial haemorrhage, are also easily affected by flight effects such as vibrations, altitudes and pressures (Martin, 2006). Hence, the transport must be secured enough to avoid further complications. The brain and spinal cord are essential to life. A slight change in patient’s condition can inflict a deleterious effect on the patient. Furthermore, a clear and uncompromised respiratory system is necessary for patients with spinal injury to survive. Sufficient supply of oxygen and other medications must be carried on the flight. Adept medical team must be informed of the complete history, management and details of the patient. Gathering of such data can be done while the transport is ongoing. Optimisation of the time and resources is a skill that every rescuer must possess. The medical team must also be aware of possible complications that may happen along the way. They must be alert and prepared to respond in possible worsening of the patient’s condition such as neurogenic or hypovolemic shock (Martin, 2006). Given the patient’s critical condition, an advance directive from patient’s family can be of help in future decisions. References Brindley, P. & O’Leary, T. (2011) Transportation of the Critically Ill: Moving in the Right Direction. J. Vincent (Ed.). Annual Update in Intensive Case and Emergency Medicine 2011. New York, NY: Springer. Clumpner, M. (2011). Aircraft Fundamentals. A. Pollak (Ed.). Critical Care Transport (pp. 64). Sudbury, MA: Jones & Bartlett. Grissom, T. (2003). Critical-Care Air Transport: Patient Flight Physiology and Organizational Considerations. W. Hurd & J. Jernigan (Eds.). Aeromedical Evacuation: Management of Acute and Stabilized Patient (pp. 111-115). Dayton, OH: Springer-Verlag. Martin, T. (2006). Aeromedical Transportation: A Clinical Guide (2nd Ed.). Burlington, VT: Ashgate. O’Shea, R. (2005). Principles and Practice of Trauma Nursing. Philadelphia, PA: Elsevier. HOSPITAL RETRIEVAL Case 2 Thermal, chemicals, electricity and radiation can all be causes of burns (Gregory & Mursell, 2010). In these cases, several concerns must be raised so that clarity can be achieved. Given that the patient is intubated, the condition of the patient prior to intubation must be determined. Patient intubation can either be a passive supportive measure for airway or an active immediate action for ongoing respiratory failure. The cause of intubation and administration of sedatives are factors that can be used in future medical decisions regarding patient care. Moreover, a 360-degree perspective of the situation must also be taken into consideration. It is important for a rescue team to be able to get a 360 degree perspective on the incident. Explosion in a mining area can also cause other injuries apart from the burn itself. Debris and other hazardous materials may have flown in the scene, hence creating pertinent fractures, trauma or wounds. Cephalo-caudal assessment of the patient must be completely done while noting ABCs, extent of burn wounds and presence of other injuries. Airway must be thoroughly secured and a back-up plan must be prepared in case the existing advance airway fails. Sufficient and alternative equipments for another advance airway must be known to all personnel and must these must be present at all times. Intravenous solutions must be initiated as burn patients lose significant amount of body fluids, particularly water. At least two accesses using large bore needles must be inserted. Depending on fluid loss, hydration of patient is critical from the time of injury. Insertion of Foley catheter helps elimination of infused solution and is a good measurement of the patient’s urinary system. If possible, patient’s condition prior to explosion must also be taken into account by asking witnesses, particularly co-miners. The reason for this is that the patient may be suffering from other health conditions prior to gas explosion. A history of tetanus immunization is significant because burn cases are prone to contracting tetanus (Moonblatt, 2005). In this case, the patient suffered burns in 25% BSA. Hardin & Kaplow (2008) mentioned that one of the most commonly used formulas in determining volume of fluid replacement needed by a patient is Parkland formula. By multiplying the patient’s body weight in kg and the BSA and further multiplying the product by 2 to 4, the amount yields an answer that is the range for fluid replacement within the first 24 hrs (Hardin & Kaplow, 2008). The patient must receive an infusion of 4 to 8 litres, half of which is in the first 8 hours and the remaining volume is to be infused within the next 16 hours (Hardin & Kaplow, 2008). Regulation of patient temperature is also significant and will help prevent further complications such as hypothermia. Because the face has also suffered from burns, the eye must be inspected to assure that there are no minute foreign bodies that can affect vision. Wound care and burn dressing must be aseptically done. Unsterile techniques impose harm to burn patient because it can cause infections later on. Patient must be properly positioned. The affected burnt leg must be elevated after wrapping it in a clean dressing (Gregory & Mursell, 2010). Ongoing observation of the patient for other symptoms such as inhalation injury must be done. Transfer, after proper coordination with the nearest burns special unit, is extremely significant. Facial burns may result in swelling and hence, it is suggested that the head be elevated to 30 degrees during transport (Coule, Pecora, Rabrich & Sherrod, 2011). This must be done after careful assessment that there is no suspicion for spinal cord injury (Coule et al., 2011). The extent of the burn wound must be determined. Bourn (1993) cited that cases of limb escharotomy on site, prior to hospital admission, are rare. Circumferential and full-thickness burns require escharotomy at once (Moonblatt, 2005). Furthermore, Moonblatt (2005) enumerated several considerations prior to deciding whether the patient immediately needs limb escharotomy. According to him, if a patient’s limb exhibited abnormality in colour, changes in circulation and is cool to touch, an escharotomy may be performed as these are indicative of impending or settled tissue injury. Incision of burned tissue on the unaffected site, commonly on medial and lateral areas, will prevent further damage and aid in circulation (Moonblatt, 2005). Coule et al. (2011) enumerated the steps in escharotomy. First is to prepare the necessary materials while keeping in mind a review of the aseptic technique. Pain medication and sedation must be administered, however, in cases where the nerve endings are totally destroyed, anaesthetic medications may have no benefit at all (Coule et al., 2011). An incision is made on the skin lateral to the burn. Adequate dressing is applied over the area of the incision to prevent further infection (Coule et al., 2011). Transfer to a specialized burns hospital unit is coordinated and implemented. References Bourn, M. (1993). Escharotomy and Fasciotomy. J. Proehl (Ed.), Adult Emergency Nursing Procedures (pp. 481-484). Boston, MA: Jones & Bartlett. Gregory, P. & Mursell, I. (2010). Manual of Clinical Paramedic Procedures. West Sussex, UK: John Wiley & Sons. Hardin, S. & Kaplow, R. (2008). Synergy for Clinical Excellence: The AACN Synergy for Patient Care. New York, NY: Auburn Moonblatt, S. (2005). Escharotomy. M. Greenberg (Ed.), Greenberg’s Text-Atlas of Emergency Medicine (pp. 21 & 697). Philadelphia, PA: Lippincott Williams & Wilkins. Coule, P., Pecora, D., Rabrich, J. & Sherrod, W. (2011). Burns. A. Pollak (Ed.). Critical Care Transport (pp. 459-460). Sudbury, MA: Jones & Bartlett. HOSPITAL RETRIEVAL Case 3 Air transportation is always the fastest way of transferring patients to nearest hospitals and trauma centres. In the situation, given that the nearest tertiary centre is two hours away through an air craft, the patient and his family must be well informed of the benefits and risks of the flight. In case of emergency situations, it is easier to find a nearby hospital when the team is in land as compared when they are in the air. However, the shortest and most immediate route is almost always travelled through air (Greaves, Hodgetts, Porter & Woollard, 2006). The decision to transfer via aircraft is supported by the fact that land travel may cause delays in time and thereby, can affect the physiological condition that the patient is currently in (Holleran, 2009). The team must bring patient’s ongoing medications, along with the standard emergency medicines, as preparation for patient response during the flight. Adequate supply of oxygen is needed considering that the patient is suffering from chronic renal failure. As with all cases, continuous monitoring of patient’s condition is a must (Greaves et al., 2006). Flexibility of the plan must be imposed and changes must be made in response to patient conditions. The patient’s condition is most likely to be compared to a propeller that directs the way the team will perform. Necessities of the situation are always brought about by changes in patient condition. It is during the flight that more information can be gathered on patient’s condition. When the patient vomits blood, members of the response team must do initial assessment of the patient (Follin, 2004), while they manage the patient’s airway and keep it patent. Another member must inform the pilot regarding the situation. The deterioration of patient’s condition entails emergent actions. When confronted with in flight emergencies like this, it is essential that the pilot is aware of the urgency of the present condition of the patient so that he will be prepared in case there will be an immediate need to land the air craft. Prioritization of the airway is a must. Drop in patient’s level of consciousness and vomiting of blood are risks for patient’s normal breathing. The whole staff must be prepared on inserting an advance airway. It is noteworthy that a patient with low Glasgow coma score implies its inability to maintain spontaneous respiratory function too (Deutschman & Neligan, 2010). Considering that the patient’s level of consciousness progressively declines and there is not much enough time to land the air craft, a rapid intubation may be performed by the most experienced member of the response team (Deutschman & Neligan, 2010). In addition, vomited blood volume of 500-1,000 millilitres can be indicative of shock (Follin, 2004). Monitoring of vital signs is necessary and must be routinely done (Follin, 2004). The team must be prepared to transfuse blood if continuous hematemesis is observed. Shock must be prevented from advancing. Furthermore, the signs and symptoms manifested by the patient must be utilized to identify the most probable cause of the bleeding. Identifying the cause of the bleeding will significantly help in eliminating it. It is by identification of the cause that the problem is solved. The team must decide whether to do intubation or to wait until they arrive in the destination. It is significant to weigh the benefits and risk of performing in-flight intubation of the patient. Managing the patient’s airway, assessment of the signs and anticipation of complications must be done simultaneously. The team must be on full alert and informed, including the pilot. In identifying the cause, noting the characteristics of the vomited blood may help identify its origin (Munden, 2006). The factor mostly considered is the patient’s chronic illness of renal failure. The chronic condition can be the basis for diagnosis of other symptoms. This way, the root of the problem may be addressed. In patients with chronic illnesses, additional symptoms are either in co-existence with the condition, or they can be complications of the disease. In some cases, hematemesis accompanied by flatulence, dysphagia and aspiration can be indicative of a mild gastro-oesophageal reflux disease (Munden, 2006). If the blood is coffee-ground or bright red and was exerted in large amount, esophageal varices can be suspected (Munden, 2006). The patient’s age, chronic renal problem and existing COPD are all contributing factors that make hematemesis a highly likely phenomenon (Munden, 2006). In this case, it is safe to assess that the patient’s hematemesis is brought about by oesophageal varices rather than to dismiss it off as a simple case of GERD. A complete assessment must be made and other symptoms must be noted. Medications to control bleeding may be given but careful consideration of the patient’s chronic illness must be taken into account. A complete list of patient’s medications and previous treatment procedures will aid in deciding the choice for emergency medications. Such careful consideration will help eliminate antagonistic effects and reduce drug interactions between current and emergency medications. References Deutschman, C. & Neligan, P. (2010). Evidence-based Practice of Critical Care. Philadelphia, PA: Saunders. Follin, S. (2004). Rapid Assessment: A Flowchart Guide to Evaluating Signs and Symptoms. Philadelphia, PA: Lippincott Williams & Wilkins. Greaves, I., Hodgetts, T., Porter, K. & Woollard, M. (2006). Emergency Care: A Textbook for Paramedics. Philadelphia, PA: Elsevier. Holleran, R. (2009). ASTNA Patient Transport: Principles and Practice. (4th Ed.). St. Louis, MO: Mosby. Munden, J. (2006). Professional Guide to Assessment. Philadelphia, PA: Lippincott Williams & Wilkins. Read More