Ambulance Model Project

Friday, January 8, 2010

Editor's Note:This„bonus content to the November 2009 JEMS article,„"Sentimental Journey"„includes a downloadable sample program cover sheet. Download it at the bottom of this page.

The program is a collaborative effort between hospice organizations and EMS transport services to provide special trips to requested destinations for in-house and home hospice patients.„Each patient can have one or three family members accompany them on the ambulance or wheelchair van. Trips on the average can last anywhere between 2-5 hours.„Time of the trip can be during the day or evening, but not after the hours of 11:00 PM.

Patient Screening

The parameters for the patients who can participate in this program are as follows, but exceptions can be made upon consult.

1. Eligibility for this program will be determined on a case-by case basis.
2. The clinical manager or charge nurse will determine if the patient is appropriate both emotionally and physically for the transportation service.„Guidance of the patient_s physician will be requested, if necessary.
3. Psycho-social aspects of the family and patient will be screened for appropriateness for the transportation program.
4. Patients who have other resources for trips should use these resources, enabling the ambulance service and hospice to use this service for patients who otherwise would not be able to benefit from such a trip due to the lack of transportation resources, complex disease process, and/or mobility limitations.
5. Patients who require oxygen therapy might have trip limitations due to the limited amount of oxygen in the portable tanks.„Additional tanks as back-up must be calculated based on liters per minute use.
6. If there is no family member or friend available and the patient requires assistance with medications during the trip, eligibility of the patient depends on the patient_s capability to administer his or her own medication. An ALS EMS provider may be cleared to administer certain medications not normally cleared by their Medical Director, but by the patient_s personal physician.„A separate protocol for pain management medication administration by specifically trained EMS providers should be considered.
7. Patient_s trip destinations may be limited to the county or counties covered by the ambulance services jurisdiction.
8. EMS providers must be trained in I-med administration and maintenance if continuous IV therapy is required for the patient.
9. Patients who are at risk of imminently dying should not participate along with acute patients due to the regulatory requirements for patient care and the documentation care.„Exceptions may be made, but will require the presence of a hospice nurse during the trip.

Screening for this program can originate from the Facility Team meeting or from any team member.„„ Recommendations would come from the Facility Team Meeting to the Clinical Manager of the unit.

Referral Process

Any staff member can recommend a patient for this service.„„ During the Facility Team Meeting, the members will apply the screening parameters to the request to ensure the patient is appropriate for the program

1. The ambulance service will provide a schedule of available trip times.
2. The Clinical Manager or their designee will confer with the EMS„„„„ Sentimental Journey Program Director to inform him or her of the request.
3. The EMS Program Director will confirm if the time requested is available and will approve the destination.„„ The ambulance service will provide the vehicles.„„ Some destinations may be appropriate for vehicle use.
4. After the EMS Program Director_s approval of the trip, the Clinical Manager will offer the times to the patient and their family.
5. The EMS Program Director schedule the EMS providers.
6. The transporting EMS crew will call the particular charge nurse to obtain the client specific information, such as the Physician_s orders, DNR order, and all other pertinent information regarding the patient.

Pre-trip Process

Coordination of the following services is required prior to the trip:

1. The length of the trip according to the time limit of available 02„depending on the required LPM.
2. Assistive mobility equipment required for the trip, i.e., walkers,„wheelchair, bariatric, etc.
3. Anticipated requirements for additional medications for agitation, nausea, increased pain, seizures, etc.
4. Selection of a family member or friend who will accompany the patient in the ambulance.„„ Considerations for this decision will include if the family member/friend can assist in the care of the patient and/or their ability to administer the patient_s medications.
5. If the patient has no requirement for administering medications and has no family or friend to accompany him/her, a referral to the Director of Volunteers will be made.„„ Preferably, the amount of time needed to coordinate the volunteer services in one week.

Medication Protocol

The arrangements for managing the medications during the trip will vary from patient-to-patient. Every effort will be made to administer medication prior to the scheduled trip. If the patient requires medication during the trip, the Charge Nurse will determine whether the patient can administer their own medications.„„ If this is possible, arrangements will be made to send medications with the patient. If the patient is incapable of administering the medications, a family member or friend who is willing to be responsible for the medication administration, will be requested to accompany the patient on the trip.

Patients without a family member or friend to accompany them on the trip„should be able to administer their own medications. Every effort will be made to schedule the trip between the medication dosage times.

EMS crew members may administer patient medication if cleared through their Medical Director or the Patient_s Physician.

Transportation for patients who are on IVs for pain control or hydration will be arranged on a case-by-case basis.„Attempts will be made to schedule patients during the time when the treatment is not being administered.„A patient who requires a continuous IV which must be monitored by a hospice nurse will be required to travel with the patient.

If the patient requires oxygen, the Charge Nurse will arrange for a portable tank(s) to accompany the patient.„The patient can use the 02 available in the ambulance during the trip to preserve the 02 in the portable tank(s) for the patients visit outside the ambulance.

Trip Day Process

On the date of the trip, the EMS crew will call the Charge Nurse to confirm the patient_s capability of making the trip.

The Clinical Manager is responsible for the following task:

1. Instructing the patient_s family to arrive at the facility 15 to 30 minutes prior to the departure time of the trip.„„ This time will be utilized to instruct the family regarding any special needs of the patient such as medication administration, dietary requirements, 02 therapy, or discussions regarding the well being of the patient.
2. Asking the patient and family/friend where they would prefer the EMS crew be during the visit.„„ For example, should the EMS crew wait in the ambulance or would the patient or family like crew to accompany them during the visit.

The Charge Nurse_s Responsibilities are as follows:

1. Copies of the Hospice Treatment Plan Worksheet, any physician orders changing this treatment plan, an original DNR, and any other needed information regarding the patient.
2. If administration for medication is required during the trip, arranging the preparation for the medication to be sent on the trip with the patient, family member, friend, and/or EMS crew.
3. Making arrangements for portable 02 tanks to accompany patients who require 02.
4. Informing the CNAs and volunteers of the trip and request their assistance with dressing the patient beore the scheduled time.

Paperwork Required for the trip

The following documents are required for the trip and must be given to the EMS crew prior to departure:

1. Hospice Treatment Plan Worksheet
2. Physician orders
3. Original DNR order
4. Any other needed information regarding the care of the patient

Emergency Procedures

If the patient becomes acutely ill during the trip, the EMS crew must return to the facility.„„ The following suggestions will assist the EMS crew in determining if there is an acute situation. This is not an all-inclusive list but suggestions of some acute situations. Imminent death, dynamic respiratory distress, seizures, sudden onset of increased and uncontrolled pain, uncontrolled nausea/vomiting, coma, fractures, and/or hemorrhage would necessitate immediate return to the hospice facility. The EMS crew will notify the facility of the acute situation through their dispatcher.

If the patient dies during the trip, the EMS crew will follow procedure listed below:

1. Determine if the patient is dead.
2. Inform the accompanying family member.
3. Inform the facility Charge Nurse through their dispatcher.
4. Return to the facility
5. Bring the body to the patient_s room without covering the patient_s face unless the family request covering the face.

Program Evaluation

The program evaluation effort will focus on two groups:„„ the external customers, patient and/or family, and internal customers, EMS staff and hospice staff. The Clinical Manager of the facility will interview the internal customers to evaluate effectiveness of the program, how well the program functions, and are there any changes needed.„„ This evaluation should be done every month.„With the information gathered at these interviews, program improvements can be implemented more rapidly.

Program Development will interview the patients or their families to evaluate external customers.„This will be done every 3 months

Hospice training for EMS transport crews

Sentimental Journey EMS crews will receive basic hospice volunteer training before working with this program.„A basic familiarity with the hospice mission statement/ philosophy along with patient care team functions - including the nursing team, the physician team, the supportive services team, the spiritual care team and the volunteer services team, and the public relations team will be taught.„Not all classes will be necessary as EMS crews already have pre-existing training in some areas, i.e., patient lifting, certain medical procedures, etc.

Sentimental Journey is considered a complimentary therapy program to assist hospice and palliative care facilities in providing their patients with the very best care for those living with life-limiting illness.„„ Medical research has demonstrated that complimentary programs such as Sentimental Journey can be instrumental in relieving stress, decreasing pain, and adding quality to one_s remaining days.

From a personal standpoint, I have seen EMS personnel gain a greater insight and compassion towards the terminally ill.

This program helps remind us of why we entered EMS and can help add a greater sense of accomplishment and pride in our profession.

I promise you an experience of a lifetime

Let the journey begin'

Steve Berry

Co-founder