QUALrrY ASSURANCE

Pediatric, Neonatal, and Maternal Patient Care Addendum to the AAMS/NFNA Resource Document for Air Medical Quality Assurance Programs [] AAMS Quality Assurance/Standards Committee and NFNA Special Interest Group

DURING 1990, THE QUALrrY ASSURANCE (QA) Committee of the Association of Air Medical Services (AAMS), in conjunction with the National Flight Nurses Association (NFNA), gener- ated a resource document for air medical programs to use as a guide in developing their own quality assur- ance programs. The original docu- ment was published in the August 1990 i ssue of The Journal of A i r Medical Transport.

The QA indicators in the original resource document identified broad areas of patient care related to adult and trauma patients, as well as opera- fionai and safety issues. The adden- dum was c r ea t ed to add re s s the specific patient care areas of pedi- atric, neonatal, and maternal air med- ical transports.

The addendum is written in the same format as the original docu- ment. Both documents will eventual- ly be merged into one, which will be

made available through the AAMS office. The document was designed to include indicators and associated thresholds specific to air medical ser- vices . The Qual i ty A s s u r a n c e Committee presents this information to AAMS members as a resource for their quality assurance effort.

The identi{ication of indicators and the sett ing of thresholds is a dynamic process. The following docu- ment is intended to serve as a generic resource. It is the responsibility of indi- vidual air medical services to adapt the indicators~thresholds to local cir- cumstances. Individual p rograms should devise additional indicators with appropriate thresholds that are meaningfu l and re levan t to the patient care being delivered in their respective air medical communities.

Thresholds should be revised on the basis of scientific evidence. The committee welcomes and encourages participation ~om the membership in

the area of research to help validate or change the established thresholds intuitively identified in the document.

Even though the current trend in quality assurance across the nation is moving toward "Quality Improve- ment and Management," indicators and thresholds are still applicable in deve lop ing a p rogram of qual i ty management.

Through quality improvement , problems identified by using quality assurance indicators and thresholds can be solved by looking at why the problems are occurring, rather than by isolating individuals.

The Quality Assurance Committee salutes AAMS and NFNA for their l eadersh ip in deve loping quali ty assurance standards. These have been incorporated in the resource document, where appropriate. When other air medical associations devel- op parallel standards, they may be added in subsequent revisions.

Document Instructions The following resource document addendum for air

medical quality assurance programs is organized accord- ing to standards, indicators, and thresholds. The stan- dards are pub l i shed first, fo l lowed by a s soc i a t ed

indicators that list appropriate threshglds at right. When possible, we have attempted to correlate an available stan- dard with a measurable indicator. We realize that these standards do not always match the indicator.

The Journal of Air Medical Transport • October 1991 51

Quality Assurance Resource

Clinical Standards/ Indicators/Thresholds

NFNA PRACTICE STANDARD III: PLAN OF CARE-- Realistic goals and a prioritized plan of care are based on nurs- ing diagnosis.

Support Standard: The flight nurse shall derive a valid plan to prioritize the patient 's needs based on actual or potential threats.

N F N A PRACTICE S T A N D A R D IV: INTERVENTION- Nursing interventions are performed in a planned sequence to support the patient experiencing either single or multiple sys- tem failure.

Support Standard: The flight nurse shall implement nursing care based on current scientific knowledge and within his/her scope of practice.

B. MEDICATIONS/BLOOD PRODUCTS Pediatric 1. IV fluids and rate

THRESHOLD

a. IV rate appropriate according to PALS standards for fluid bolus and maintenance rates.

Document Addendum

1) Fluid bolus - 20 cc /kg crystaUoid solution, repeated as indicated. 1

2) Maintenance fluid rate adjusted to current disease process:

24 Hour Period 0-10 kg 100 cc/kg 11-20 kg 1000 cc + 50 cc /kg

over 10 kg Over 21 kg 1500 cc + 20 cc /kg

over 20 kg 2'3

b. Documentation and use of IV infusion pump or Buretrol for all pediatric inter- facility transports in order to maintain accurate volumes.

c. Medication dosages in pediatric patients are consistent with pediatric advanced life support (PALS) guidelines.

95%

90%

Neonatal 1. Documentation of administration of prophy-

lactic eye drops, vitamin K, and PKU status by referring facility or flight nurse completed.

90%-95%

95%-99%

2. Amount of blood out in cc's documented. 95% - 99%

C. VENOUS ACCESS Pediatric

1. Intraosseous (IO) insertion a. Unsuccessful 1V attempts prier to

IO insertion documented. b. Number of IO attempts documented. c. Intraosseous location and documenta-

tion appropriate (i.e., -3 cm below the proximal tibial tuberosity; distal 1/3 of femur; or medial malleolus).2(°852)

95%

95% 95%-99%

Neonatal 1. Venous and Arterial Access

a. Documentation will include:

1) IV, umbilical arterial catheter (UAC), 95% - 99% umbilical venous catheter (UVC), and arterial fines secured with tape or suture.

2) Position of UAC and UVC lines by chest and abdominal X-ray.

95%-99%

3) Appropriate IV fluids and rate are 90% - 99% administered according to patient age, weight, diagnosis and type of W line.

D. ONGOING PATIENT ASSESSMENT/INTERVENTION Pediatric 1. Recent temperature (less than 1 hour old) 95%

recorded on pediatric patients up to 10 years old.

2. Pediatric Glasgow Coma Scale used for neurological evaluation of children less than 2 years old when indicated for suspected head injury or alteration in mental status t-ore other medical causes. 2(pv12-13),3(p757)

95%

Neonatal 1. A complete maternal history will be obtained 90%

at the referral hospital by patient interview and/or maternal chart review. a. Maternal age. b. Gravity/parity. c. Rupture membranes

1) Time. 2) Fluid color. 3) SROM'vs. AROM.

d. Previous complications with pregnancy (both past and previous pregnancies).

e. Prenatal care. f. Type of delivery. g. Maternal drugs, smoking, ETOH. h. Blood grouping.

2. Parental permission for transport obtained. 3. Parent teaching in regard to patient condition,

reason for transport, and informatiolLabout receiving hospital provided is documented.

4. Transport isolette for 5 kg or less neonates or infants with acute illness.

5. Vital signs documented a minimum of every 95%

95%-99% 90%-95%

95%-99%

54 The Journal of Air Medical Transport • October 1991

6.

7.

15 to 30 minutes (temperature, pulse, respira- tions, BP, Sa02, if available, or determined by flight program's patient care guidelines/standards, procedures, and protocols). Documentation includes first time void and stool on newborns. Blood cultures obtained and labeled, approp- riately with central or peripheral IV source prior to antibiotic administration.

95%

95%-99%

Pediatric/Neonate 1. Serum Glucose Level

a.

b.

C.

Recent Chemstrip or serum glucose completed (within the last 30 minutes) and documented on all interfacility trans- ported patients less than 3 years old.

Repeat Chemstrips completed every 15 minutes when acute systems suggest hypoglycemia.

Glucose administered in pediatric/neonate patients with Chemstrip or serum glucose levels less than 40 for children less than 3 years old. 3(p1919)

95%

95%

95%

d. Dextrose solution administered to pediatric/neonate patients uP to 10 years old will be no greater than D25W. 1(p53),3(p1919)

95%

2. Initial assessment includes fontanel assessment.

Maternal 1. Fetal heart tones documented every 15

minutes per external monitor and/or doppler.

2. Fetal monitor strip evaluated at least at the referring facility and the following documented:

90%

a. When fetal monitor strip was obtained (i.e., referring facility, during transport, or at receiving facility).

b. Variability. c. Presence or absence of decelerations. d. Description of fetus response to contractions.

3. Recent or initial maternal temperature documented on patients in preterm labor or when ruptured membranes present.

90%

4. During transport, the maternal patient is positioned in either lateral position (preferably left) to avoid supine hypotension in the mother and fetal distress in the infant.

95%

5. In patients with ruptured membranes, a vaginal exam is done by sterile speculum unless patient is in active labor.

. Uterine contraction assessment and documen- tation will include: a. Frequency.

b. Duration. c. Maternal response.

E. TRAUMA CARE

Maternal 1. During transport of the pregnant trauma

patient more than 20 weeks gestation, the backboard/scoop is tilted to the left. Placement of a towel roll under the right or left hip is only done when LS and thoracic spine is cleared radiologically for fractures.

95%

NFNA PRACTICE STANDARD h DATA COLLECTION-- The assessment and collection of patient health data is system- atic and con t inuous . The data is d o c u m e n t e d and communicated to appropriate members of the health care team.

Support Standard: Data collection shall be recorded in a systematic and retrievable manner.

AAMS R O T O R C R A F r STANDARD VII: The quality and appropriateness of patient care provided by air medical services shall be continuously reviewed, evaluated, and assured through the establishment of a quality control mechanism.

Interpretation: A patient record shall be maintained, docu- menting patient care rendered by the air medical personnel and disposition of the patient at the receiving institution and depart- ment on file, for a period of time to include that of the statute of limitations.

F. DOCUMENTATION THRESHOLD Neonatal 1. Copies of most recent X-rays obtained unless 90% - 99%

there is a significant change from previous X-rays.

Neonatal/Maternal 1. Copied chart of maternal and neonatal history

obtained. 90%-99%

Maternal 1. Obtained copies of fetal monitoring strips if

abnormal. 90%

2. Documentation of referring hospital last 90% - 95% vaginal exam (VE) or flight nurse VE includes:

a. Dilatation, b. Effacement. c. Presenting part. d. Abnormalities. e. Sterile technique utilized.

Adul t /Materna l /Neona ta l /Ped ia t r i c 90% 1. Patient care documentation reflects nursing 95% - 99%

assessment, plan, intervention, and evaluation.

Operational Standards/Indicators/Thresholds 95%

J~JHS ROTORCR_~--T STANDARD I ] : The ACMs shall be well-organized, properly directed, and staffed according to the

The Journal of Air Medical Transport • October 1991 55

nature and extent of health care needs anticipated and scope of services offered. AAMS R O T O R C N STANDARD VIII: The air medical ser- vice must strive for full integration into existing emergency medical systems and interhospital transfer networks.

Interpretation: The air medical service must ensure continu- um of care and expedition of treatment of patients using stan- dard protocols whenever possible.

A. TIMELINESS OF CARE Neonatal 1. Emphasis on timeliness of neonatal inter-

facility care is placed on quality of stabilization; therefore, in-house time limits reflect acuity of neonate, procedures done prior to transport, and equipment/drugs used during transport.

THRESHOLD

80% - 90%

AAMS SAFETY G U I D E L I N E IV: The aircraft must have appropriate equipment in order to assure the maximum safety of the air medical personnel and the patient(s).

N F N A A I R C R A F T SAFETY S T A N D A R D I I h PATIENT SAFETY: The flight nurse must assume responsibility for the patient's safety, since the patient has an altered ability to meet this need.

Support Standard: The flight nurse will ensure proper prepa- ration and unloading of the patient for transport.

B. SAFETY Neonatal

1. Neonate will be secured in the isolette with safety belt throughout entire transport.

99%

2. Transport isolette will: 99%

a. Have a minimum of one hour battery supply. b. Have adequate heating capabilities using

electrical or battery power. c. Be secured in the aircraft with FAA approved

restraints during all transports.

Adult/Pediatric/Neonatal/Maternal 1. All patient transports in dedicated, medically 99%

configured rotor-wing or fixed-wing aircraft will have a 500 watt or greater inverter on board for medical equipment (i.e., for isolettes, invasive monitoring, pacers, intra-aortic balloon pumps, suction units, pulse oximeters, infusion pumps, and external fetal monitors).

References 1. Chameides L (Ed): Textbook of Pediatric Advanced Life Support.

American Heart Association, 1988 p 47. 2. Blumer, JL (Ed): A Practical Guide to Pediatric Intensive Care. 3rd

ed, St. Louis, C.V. Mosby, 1990 p 547. 3. Oski FA (Ed): Principles and Practice of Pediatrics. Philadelphia,

J.B. Lippincott Co, 1990 p 58.

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The Journal of Air Medical Transport • October 1991 56