Acting in Time: Transport Nurses optimising critically ill patients for transfer to a regional ECMO centre. A Grounded Theory Study
Regionalisation and centralisation of Intensive Care Units, coupled with demographic changes, have resulted in an increased demand for inter-hospital transport. The Conventional ventilatory support vs Extracorporeal membrane oxygenation for Severe Adult Respiratory Failure Trial (CESAR), validated the use of ECMO in the UK for critically ill adults. The H1N1 Influenza A epidemic in 2009, led to four more adult ECMO centres being designated, and more recently the World Health Organisation (WHO, 2020), recommended ECMO for eligible patients in the COVID-19 pandemic. A critical incident occurred while I was undertaking the transport of a critically ill adult, which led to the unplanned use of mobile ECMO, still in its infancy. Seeking answers to the questions raised from this incident a research proposal was formed in order to investigate what could be learnt from the actions of transport nurses in promoting stability and preventing deterioration of patient acuity during the transport process. A grounded theory approach was used to try and understand the processes and strategies that experienced transport nurses used in optimising their patients’ stability and generate a substantive theory in explaining their timely actions. Under a pragmatic paradigm, this grounded theory study utilised the methods of Retrospective Medical Records Review and Interviews. Quantitative random sampling of 50 patients retrieved to a regional ECMO centre, allowed the collection of vital physiological variables staged over three time points. Data analysis showed that two out of the eight variables demonstrated a statistical significance in deterioration. Qualitative unstructured interviews from six transport nurses revealed a variety of activities, proactive and reactive, cognitive and physical, with overwhelming attention to time constraints, employed to benefit the patient. An explanatory theory was identified. Acting in Time encapsulated extant theory from the Secure Base Model (SBM) in fostering studies, and the Actor-Network Theory (ANT), from sociological literature. Acting in Time made overt the core virtues, practices, and skills of the transport nurse in aiming to reduce the risks associated will transport of the critically ill adult while striving to maintain patient stability. The study identified a growing need for centralisation, coordination, standardisation, audit, education and training for all those involved in transporting critically ill patients to a regional ECMO centre. It recommends that dedicated regional transport centres should be implemented for the transport of the adult critical care patient. A centralised database should be created for the import of data from the regional transport teams. Education for all nurses, not just transport nurses, needs to be available to deliver high quality care at any point of patient retrieval. A curriculum for transport education for nurses is outlined. This research reinforces and adds to the Intensive Care Society and Faculty of Intensive Care Medicine (ICS & FICM, 2019), and standards of education for nurses enhanced.
- PhD