Helpful Resources
Table 8.3 illustrates an application of the QI process from a single transport program's QI program. It is not meant to be applicable in its entirety to each transport service. From the transport program's annual goals, key performance measures are identified as the first step in the QI monitoring process.
Next, specific indicators and the data collection methods are noted in the action plan. The threshold for evaluation is agreed on. Results are noted and147
Table 8.3: Samples of Area-Specific Indicators*
| Category | Performance Measure | Rationale | Dimensions of Performance | Specific Indicators | Method for Data Collection | Multidisciplinary Component | Assessment | Threshold |
| Patient care | Pain | • High risk • High volume • Problem prone | • Efficacy • Appropriateness • Availability • Timeliness • Effectiveness • Continuity- • Efficiency • Respect and caring • Safety | • Assessment noted on transport record—presence or absence of pain • If present, pain relief measure implemented and assessment of effectiveness documented • Use of pain scale | Review of transport record | No | Monthly | 95% |
| Patient care | Safety | • High risk • High volume • Problem prone | • Efficacy • Appropriateness • Availability • Timeliness • Effectiveness • Continuity • Efficiency • Respect and caring • Safety | • ID bands • Ambulance incident reports • Daily emergency equipment checks: storeroom check, defibrillator check, narcotic log check • Bimonthly: equipment bag check • Seatbelt and specific restraint use • Equipment secured to stretcher or incubator in vehicle | • Review of occurrence reports • Review of occurrence reports • Week-long survey • Review of occurrence reports • Review of checklists • Review of checklists • Week-long survey • Week-long survey | • Risk Management • Medical director • Ambulance personnel • RN • RT | Monthly | 100% |
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Table 8.3: Samples of Area-Specific Indicators*, continued border=0>
| Category | Performance Measure | Rationale | Dimensions of Performance | Specific Indicators | Method for Data Collection | Multidisciplinary Component | Assessment | Threshold |
| Patient care | Sedation | • High risk • High volume • Problem prone | • Efficacy • Appropriateness • Availability • Timeliness • Effectiveness • Continuity • Efficacy • Respect and caring • Safety | Documentation to include: • Presedation assessment of ABCs • Response to medication • VS monitoring in progress • Complications | Transport record review | • RN • Medical director | Monthly | 90% |
| Patient care | Vascular access | • High risk • High volume • Problem prone | • Efficacy • Appropriateness • Availability • Timeliness • Effectiveness • Continuity • Efficiency • Respect and caring • Safety | Monitor: • Umbilical artery catheters • Placement documented per CXR • Assessment of pulses and perfusion distal to the line • Well secured to abdomen • Easily aspirates and flushes • Good arterial waveform per monitor • Umbilical venous catheters • Placement documented per CXR • Well secured to abdomen • IVF only (no meds) if tip below the diaphragm IV or arterial line • Document assessment of site • Easily flushes (waveform blood return) | Review of transport record | • RN • Medical director | Monthly | 90% |
| Documentation | • Phone call record • Transport record | • High risk • High volume • Problem prone | • Efficacy • Appropriateness • Availability • Timeliness • Effectiveness • Continuity • Efficiency • Respect and caring • Safety | • Forms completed: • Signature of RN present • If care suggestions given, individual receiving orders indicated • Time of interventions documented • VS on all patients documented a minimum of every 15 min • Patient response to interventions documented • ETT present Y/N • ETT placement noted on x-ray and documented • End-tidal co2 monitoring used for intubated patients (optional for neonates) | Review of transport record | No | Monthly | 90% |
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Table 8.3: Samples of Area-Specific Indicators*, continued
| Category | Performance Measure | Rationale | Dimensions of Performance | Specific Indicators | Method for Data Collection | Multidisciplinary Component | Assessment | Threshold |
| Education | • Mandatory yearly review | • High risk • High volume | • Efficacy • Problem prone • Appropriateness • Availability • Timeliness • Effectiveness • Continuity • Efficiency • Respect and caring • Safety | • Staff completion of yearly fire, safety, infection control, and critical clinical skills • All transport team staff will attend yearly ambulance safety, helicopter safety, helipad fire safety, and altitude physiology classes. • Staff will maintain current provider status in CPR, PALS, NRP, and ACLS. TNCC will be required by end 2002. Audit of ATLS encouraged. • Staff will attend animal lab and demonstrate umbilical catheterization, needle aspiration of the chest and chest tube insertion (RNs), and intubation (RNs and RTs) a minimum of 3 times per year. • RNs will obtain airway management experience in surgery at Westchester or on the main campus a minimum of 4 times a year (intubations on humans). • Completion of mandatory clinical education competencies, including child abuse, restraint policy, blood products administration, and agespecific competencies | Tracked in unit | No | Quarterly | 100% |
| Satisfaction | • Staff • Patient and family • Referring hospital personnel | • High risk • High volume • Problem prone | • Staff completion of yearly survey • Review of parent satisfaction survey • Referring hospitals to complete transport team service questionnaire | • Tally responses to referring hospital questionnaires. • Press Ganey patient satisfaction survey; report given by CNE | | | • Yearly • Monthly • Quarterly | NA |
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Table 8.3: Samples of Area-Specific Indicators*, continued
| Category | Performance Measure | Rationale | Dimensions of Performance | Specific Indicators | Method for Data Collection | Multidisciplinary Component | Assessment | Threshold |
| Patient care | Transport Review indicators | • High risk • High volume • Problem prone | • Efficacy • Appropriateness • Availability • Timeliness • Effectiveness • Continuity • Efficiency • Respect and caring • Safety | • Multidisciplinary case review of transported patients. Patients whose cases will be reviewed include those with whom the following situations occurred during transport: death on transport; death within 24 hours of admission; unexpected need for the PICU; unexpected need for the PICU within 24 hours of admission or backup bed not previously arranged; arrest; time at referring hospital: neonate, >90 min, or pediatric, >60 min; extubation; hypoxemia: saturation to weather, maintenance, and patient condition | Review of statistical reports | No | Monthly | 90% |
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Table 8.3: Samples of Area-Specific Indicators*, continued
| Category | Performance Measure | Rationale | Dimensions of Performance | Specific Indicators | Method for Data Collection | Multidisciplinary Component | Assessment | Threshold |
| Operations | Utilization appropriateness | • High risk • High volume • Problem prone | • Efficacy • Appropriateness • Availability • Timeliness • Effectiveness • Continuity • Efficiency • Respect and caring • Safety | • Patients transferred to CMH ED by the transport service appropriately triaged before transfer to transport team vs ALS • Medical need appropriate-ness of patients transferred to CMH by the transport service without IVs or oxygen, not transferred from a critical care service, scheduled transports, or interfacility to a lower level of care | Chart review of patients discharged from ED after transport; use of pre established criteria will help determine appropriate use of transport service | No | Monthly | 90% |
* Example of Children's Memorial specific indicators.
Reproduced with permission: Craig LaRusso, RN, Transport Team, Children's Memorial Hospital, Chicago, IL. QUALITY IMPROVEMENT
ID indicates identification; RN, registered nurse; RT, respiratory therapist; ABCs, airway, breathing, circulation; VS, vital signs; CXR, chest x-ray; IVF, intravenous fluids; IV, intravenous;
ETT, endotracheal tube; CO2, carbon dioxide; CPR, cardiopulmonary resuscitation; PALS, Pediatric Advanced Life Support; NRP, Neonatal Resuscitation Program; ACLS, Advanced Cardiac Life Support; TNCC, Trauma Nursing Core Course; ATLS, Advanced Trauma Life Support; CNE, chief nurse executive; NA, not applicable; PICU, pediatric intensive care unit; ECMO, extracorporeal membrane oxygenation; CHD, congenital heart disease; PGE, prostaglandin E; NO, nitric oxide; CMH, Children's Memorial Hospital; ED, emergency department;
ALS, Advanced Life Support.
reported when a problem is identified and corrective action is taken with ongoing reevaluation. Overall, the QI process must show evidence of actions taken in identified problem areas and the evaluation of the effectiveness of that action. In addition, reporting the results through the established organizational structure to directly link the transport service with the base facility is vital. Monitoring may focus on a specific period, procedure, or population.