Non Emergency Transport (NET) What you need to know! START This ePresentation will take you approximately 25 minutes to complete.

Non Emergency Transport (NET) What you need to know! START This ePresentation will take you approximately 25 minutes to complete

This training package is intended to guide physicians through key information about patient transport that will help you to: a.improve response times of EMS when emergency transfer is needed b.ensure best practice decisions are made for the safety of your patient during transport. Page 1 of 27 Next > < Prev

Learning Objectives By the end of this learning session you will have met the following learning objectives: You will know… Physician accountabilities for patient transport Key decisions for patient transport between hospitals Locating and using the decision algorithm and user guide for Patient Transport Scope of practice for NET attendants and EMS paramedics Why paramedics should NOT be used as escorts Page 1 of 27 Next > < Prev

How does this affect you? EMS is under pressure to respond to emergency calls and is having to further withdraw from providing non-emergency hospital transfer services South West LHIN Hospitals have hired Voyageur as the NET for the region This means that health care workers must make important decisions when patient transport is needed These decisions/actions are guided by a standardized algorithm and include but are not limited to: Selecting either EMS or Voyageur Determining the appropriate escort Choosing a vehicle; i.e. stretcher, wheelchair or taxi when Voyageur is used Preparing the patient for transport Page 2 of 27 Next > < Prev

Physician Accountabiliti es As the sending physician you are the MRP until the patient arrives, hand off is completed and care is assumed at the receiving site regardless if the patient is transferred with EMS or via Voyageur. Accountabilities are: Be familiar with the Ambulance Act Be familiar with the scope of practice of Paramedics Be familiar with the skills of Voyageur attendants Be familiar with the patient transport algorithm for both medical and mental health patients. Ensure written orders for transport allow for decisions based on the algorithm Support the care team in transport decisions as required. …continued Page 3 of 27 Next > < Prev

Physician Accountabiliti es Support the care team and /or Voyageur attendants in the event of an anticipated death (DNRC) or unexpected death during transport. This includes proper identification and notification of Coroner cases. For more information see the Physician Reference Guide. Add LINK Participate in disclosure and support the care team in the reporting of adverse events that occur during transportation. Observe ‘patient self pay” policy requirements. Page 4 of 27 Next > < Prev

The decision algorithm It is standard across the region. It walks you through key steps for making transport and escort decisions for your patients, both medical and mental health populations. It gives you tips on how to obtain a quick response from EMS when your patient needs emergency transport. If properly followed, this guide assures you have done due diligence when making transport decisions and arrangements. Page 5 of 27 Next > < Prev add link to algorithm

Decision 1?Decision 2?Decision 3? Page 6 of 27 The patient’s nurse may require your assistance from time to time. Click on Decision 1 box to reveal the question for the first decision you will have to make.

Does this transfer require an ambulance or NET (e.g. Voyageur)? Decision 2 Decision 3 Page 6 of 27 Click on Decision 2 box to reveal the question for the second decision you will have to make.

Does this transfer require an ambulance or NET (e.g. Voyageur)? Does this patient require an escort? And if so, what kind? Decision 3 Page 6 of 27 Click on Decision 3 box to reveal the question for the third decision you will have to make.

Does this transfer require an ambulance or NET? Does this patient require an escort? If so, what kind? What type of NET vehicle does the patient need? Page 6 of 27 Next > < Prev Click Next to continue.

The Ambulance Act states that -"ambulance" means a conveyance used or intended to be used for the transportation of persons who: a) have suffered a trauma or an acute onset of illness either of which could endanger their life, limb or function or b) have been judged by a physician or a health care provider designated by a physician to be in an unstable medical condition AND require while being transported, the care of a physician, nurse, other health care provider, emergency medical attendant or paramedic, AND require the use of a stretcher; Decision 1 Does this transfer require an ambulance or NET (e.g. Voyageur)? Next > < Prev Page 7 of 27

First decision to be made - Does the patient meet the criteria of the ambulance act? If Yes - the patient requires an ambulance with an appropriate hospital escort If No, the patient may go via Non Emergency Transport (NET - Voyageur) with or without an escort depending on care needs Decision 1 Does this transfer require an ambulance or NET (e.g. Voyageur)? Next > < Prev Page 8 of 27

Decision 1 EMS or NET (Voyageur) Case Examples The following case examples have been designed to illustrate common situations. They are not intended to cover every situation you may come across These case examples focus on the Decision 1 (EMS or NET decision). We recognize that escort decisions are often done simultaneously however for learning purposes they will be managed in two separate sections in this module. A picture of the Decision 1 element of the algorithm has been provided for illustration. Before proceeding we recommend you have a copy of the algorithm to work with. For a full view of the algorithm click here. Page 9 of 27 Next > < Prev Remove this box before publishing…. Edit hyperlink to where decision algorithm is available

A patient is needing transport to a higher level of care, their vitals continue to be of concern and they are at high risk of decompensating. Decision 1 Case Example 1 EMS NET (e.g. Voyageur) < Prev Page 10 of 27 Does this patient require EMS or NET?

Decision 1 Case Example 1 EMS NET Submit Page 10 of 27 A patient is needing transport to a higher level of care, their vitals continue to be of concern and they are at high risk of decompensating. Does this patient require EMS or NET?

Decision 1 Case Example 1 Answer: This patient needs EMS Unstable vitals and needing a higher level of care would qualify this a transfer by Ambulance. This qualifies as an emergency transfer. Refer to the yellow caution box on the algorithm. Next > < Prev Page 10 of 27 A patient is needing transport to a higher level of care, their vitals continue to be of concern and they are at high risk of decompensating. Does this patient require EMS or NET?

Decision 1 Case Example 1 Next > < Prev Page 10 of 27 Answer: This patient needs EMS Unstable vitals and needing a higher level of care would qualify this a transfer by Ambulance. This qualifies as an emergency transfer. Refer to the yellow caution box on the algorithm. A patient is needing transport to a higher level of care, their vitals continue to be of concern and they are at high risk of decompensating. Does this patient require EMS or NET?

Decision 1 Case Example 2 EMS NET < Prev Page 11 of 27 A patient needs to be immediately transferred to a higher level of care for an urgent CT scan. Vitals have been within normal range. Risk of decompensating is low. What type of vehicle would you choose?

Decision 1 Case Example 2 EMS NET Page 11 of 27 Submit A patient needs to be immediately transferred to a higher level of care for an urgent CT scan. Vitals have been within normal range. Risk of decompensating is low. What type of vehicle would you choose?

Decision 1 Case Example 2 Answer: NET is the correct choice The patient does not qualify for EMS as the patient is not critically ill - life or limb is not threatened and does not need emergency transport. Next > < Prev Page 11 of 27 A patient needs to be immediately transferred to a higher level of care for an urgent CT scan. Vitals have been within normal range. Risk of decompensating is low. What type of vehicle would you choose?

Decision 1 Case Example 3 EMS NET (e.g. Voyageur) < Prev Page 12 of 27 A patient is needing transfer to a higher level of care for emergency surgery. The accepting facility is waiting for the patient to arrive and is planning immediate surgical intervention. The patient's vitals are stable however the patient is at high risk of losing life limb or function, or high risk of deteriorating. What type of transport do you ask for?

Decision 1 Case Example 3 EMS NET Submit Page 12 of 27 A patient is needing transfer to a higher level of care for emergency surgery. The accepting facility is waiting for the patient to arrive and is planning immediate surgical intervention. The patient's vitals are stable however the patient is at high risk of losing life limb or function, or high risk of deteriorating. What type of transport do you ask for?

Decision 1 Case Example 3 Answer: EMS is the correct choice Although the patient is stable they are at high risk and a surgical team is waiting for them for emergency surgery. This qualifies as an emergency transfer. Refer to the yellow caution box on the algorithm. Next > < Prev Page 12 of 27 A patient is needing transfer to a higher level of care for emergency surgery. The accepting facility is waiting for the patient to arrive and is planning immediate surgical intervention. The patient's vitals are stable however the patient is at high risk of losing life limb or function, or high risk of deteriorating. What type of transport do you ask for?

Answer: EMS is the correct choice Although the patient is stable they are at high risk and a surgical team is waiting for them for emergency surgery. This qualifies as an emergency transfer. Refer to the yellow caution box on the algorithm. Decision 1 Case Example 3 Next > < Prev Page 12 of 27 A patient is needing transfer to a higher level of care for emergency surgery. The accepting facility is waiting for the patient to arrive and is planning immediate surgical intervention. The patient's vitals are stable however the patient is at high risk of losing life limb or function, or high risk of deteriorating. What type of transport do you ask for?

Decision 1 Case Example 4 EMS NET (e.g. Voyageur) < Prev Page 13 of 27 A patient needs transfer to a higher level of care for urgent surgery the next day. The patient's condition is stable however they require a higher level of care within the next 23 to 48 hrs. What type of transport do you ask for?

Decision 1 Case Example 4 EMS NET (e.g. Voyageur) Page 13 of 27 Submit A patient needs transfer to a higher level of care for urgent surgery the next day. The patient's conditions is stable however they require a higher level of care within the next 23 to 48 hrs. What type of transport do you ask for?

Decision 1 Case Example 4 Answer: NET is the correct choice The patient is not critical or requiring emergency interventions. They do NOT require EMS. However, due to their requirement for "a higher level of care" an escort may be considered. Next > < Prev Page 13 of 27 A patient needs transfer to a higher level of care for urgent surgery the next day. The patient's conditions is stable however they require a higher level of care within the next 23 to 48 hrs. What type of transport do you ask for?

Decision 1 Case Example 4 Answer: NET is the correct choice The patient is not critical or requiring emergency interventions. They do NOT require EMS. However, due to their requirement for "a higher level of care" that an escort may be considered. Next > < Prev Page 13 of 27 A patient needs transfer to a higher level of care for urgent surgery the next day. The patient's conditions is stable however they require a higher level of care within the next 23 to 48 hrs. What type of transport do you ask for?

Decision 1 Case Example 5 EMS NET (e.g. Voyageur) < Prev Page 14 of 27 A Mental Health (MH) patient requires transport to a higher level of care facility for MH treatment. The patient has no medical condition - however the patient is on a Form 1, the patient is combative and of risk to themselves Would you select EMS or NET?

Decision 1 Case Example 5 EMS NET (e.g. Voyageur) Page 14 of 27 Submit A Mental Health (MH) patient requires transport to a higher level of care facility for MH treatment. The patient has no medical condition - however the patient is on a Form 1, the patient is combative and of risk to themselves Would you select EMS or NET?

Decision 1 Case Example 5 Answer: NET is the correct choice The patient does not have an unstable medical condition and thus is not considered under the Ambulance Act as needing an ambulance. NET (e.g. Voyageur) with the appropriate escort will be able to move this patient safely and quickly. Note: all patients formed under the Mental Health Act must have an appropriate escort. More details available later in this module. Next > < Prev Page 14 of 27 A Mental Health (MH) patient requires transport to a higher level of care facility for MH treatment. The patient has no medical condition - however the patient is on a Form 1, the patient is combative and of risk to themselves Would you select EMS or NET?

Decision 1 Case Example 6 Yes No < Prev Page 15 of 27 A patient requires transport to another hospital for the next part of their care. The patient is on IV meds that cannot be discontinued. The patient is stable. You do not have an Regulated Health Professional escort readily available to go with the patient. Should you call EMS to take this patient?

Decision 1 Case Example 6 Yes No Page 15 of 27 Submit A patient requires transport to another hospital for the next part of their care. The patient is on IV meds that cannot be discontinued. The patient is stable. You do not have an Regulated Health Professional escort readily available to go with the patient. Should you call EMS to take this patient?

Decision 1 Case Example 6 Answer: NO is the correct choice Ambulance criteria are unmet and Paramedics/EMS is not an appropriate alternative when the patient does not require emergency transport. The hospital must provide an appropriate Regulated Health Professional escort to support this transfer. Next > < Prev Page 15 of 27 A patient requires transport to another hospital for the next part of their care. The patient is on IV meds that cannot be discontinued. The patient is stable. You do not have an Regulated Health Professional escort readily available to go with the patient. Should you call EMS to take this patient?

Decision 1 Case Example 6 Answer: Next > < Prev Page 15 of 27 A patient requires transport to another hospital for the next part of their care. The patient is on IV meds that cannot be discontinued. The patient is stable. You do not have an Regulated Health Professional escort readily available to go with the patient. Should you call EMS to take this patient? NO is the correct choice Ambulance criteria are unmet and Paramedics/EMS is not an appropriate alternative when the patient does not require emergency transport. The hospital must provide an appropriate Regulated Health Professional escort to support this transfer.

Decision 1 Case Example 7 EMS without Regulated Health Professional NET with Regulated Health Professional EMS with Regulated Health Professional < Prev Page 16 of 27 A patient requires emergency transport to a higher level of care. Vitals are unstable and patient has a high risk of decompensating. The patient is on IV meds and is intubated. Would you select EMS or NET?

Decision 1 Case Example 7 Page 16 of 27 Submit EMS without Regulated Health Professional NET with Regulated Health Professional EMS with Regulated Health Professional A patient requires emergency transport to a higher level of care. Vitals are unstable and patient has a high risk of decompensating. The patient is on IV meds and is intubated. Would you select EMS or NET?

Decision 1 Case Example 7 Answer: Next > < Prev Page 16 of 27 A patient requires emergency transport to a higher level of care. Vitals are unstable and patient has a high risk of decompensating. The patient is on IV meds and is intubated. Would you select EMS or NET? EMS with a Regulated Health Professional is the correct choice The hospital needs to send an escort. This patient requires EMS and your hospital is required to provide an appropriately trained Regulated Health Professional to be responsible for the patient until handoff at the receiving site. The paramedics will assist the escort but all care decisions will be determined by the hospital escort and MRP.

Decision 1 Case Example 7 Answer: EMS with a Regulated Health Professional is the correct choice The hospital needs to send an escort. This patient requires EMS and your hospital is required to provide an appropriately trained Regulated Health Professional to be responsible for the patient until handoff at the receiving site. The paramedics will assist the escort but all care decisions will be determined by the hospital escort and MRP. Next > < Prev Page 16 of 27 A patient requires emergency transport to a higher level of care. Vitals are unstable and patient has a high risk of decompensating. The patient is on IV meds and is intubated. Would you select EMS or NET?

Decision 1 Case Example 8 Call Voyageur and ignore the order Review the Algorithm with the physician to determine if ambulance criteria are met Call EMS as per order < Prev Page 17 of 27 The physician has written an order “transport by ambulance”. The patient does not meet the criteria for an ambulance and the nurse recognizes that to honour the order may cause a transfer delay. Which of the following actions should the nurse take?

Decision 1 Case Example 8 Page 17 of 27 Submit Call Voyageur and ignore the order Review the Algorithm with the physician to determine if ambulance criteria are met Call EMS as per order The physician has written an order “transport by ambulance”. The patient does not meet the criteria for an ambulance and the nurse recognizes that to honour the order may cause a transfer delay. Which of the following actions should the nurse take?

Decision 1 Case Example 8 Answer: Next > < Prev Page 17 of 27 Review the Algorithm with the physician to determine if ambulance criteria are met is the correct choice. EMS is withdrawing service for non-emergency transports in order to better meet demand for emergency transports. If the patient does not meet the criteria for an emergency ambulance transport, the transfer will be delayed. The physician may wish to consider writing the order to read "arrange transport as per the transport algorithm". The physician has written an order “transport by ambulance”. The patient does not meet the criteria for an ambulance and the nurse recognizes that to honour the order may cause a transfer delay. Which of the following actions should the nurse take?

Decision 2 Escort Selection? Before learning about Decision 2 -Escort selection, it is important that you first understand Voyageur training (stretcher/wheelchair attendant) and the scope of practice for Paramedics. Next > < Prev Page 18 of 27

Decision 2 Escort Selection? Voyageur Attendant scope of practice Stretcher Services Stretcher vehicles are staffed with two attendants Attendants are trained in First Responder (can provide CPR, basic airway management, O2 maintenance, and vital sign monitoring) Attendants are also trained in Non Violent Crisis Intervention, Activities of Daily Living (ADL) and gentle persuasion Next > < Prev Page 19 of 27

Decision 2 Escort Selection? EMS Paramedics are not to be used as escorts for patients who have been admitted to hospital or to an ED. Here's why: The MRP for a patient admitted to hospital is the hospital physician and the care team Paramedics may not assume care for a patient admitted to a hospital or an emergency department Paramedics receive their directions from a Regional Base Hospital physician and are not able to accept or carry out orders from a non Base Hospital physician unless that physician assumes full care and accompanies the patient. For more details please see the user guide located on your hospital intranet site. Page 20 of 27 Next > < Prev

Decision 2 Does your patient require an escort? Your patient assessment needs to consider the care needs of the patient during the entire time away. If care needs are anticipated, the escort must have the knowledge and skill to carry out all care needs as required. Page 21 of 27 Next > < Prev

Decision 2 Escort Selection Case examples The following case examples have been designed to illustrate some situations. The are not intended to cover every situation you may come across. For a better understanding of escort decisions please reference the User Guide section - Patient Transportation Assessment, Documentation and Escorts. Link to guide needs to go here Page 22 of 27 Next > < Prev

Decision 2 Case Example 1 Follow CMPC guidelines for transfers or referral Ensure the RHP escort is supported with appropriate orders and direction during the transport and any anticipated time away until hand off Write an order ‘arrange for transport as per decision algorithm’ < Prev Page 23 of 27 A patient is stable and transferring to another hospital. The patient is on IV medication - The decision algorithm supports using Voyageur with a RHP escort. Your responsibility is to: Be available to support the RHP or voyageur attendant during the transport for adverse event should one occur during transport All of the above

Submit Decision 2 Case Example 1 Follow CMPC guidelines for transfers or referral Ensure the RHP escort is supported with appropriate orders and direction during the transport and any anticipated time away until hand off Write an order ‘arrange for transport as per decision algorithm’ Page 23 of 27 A patient is stable and transferring to another hospital. The patient is on IV medication - The decision algorithm supports using Voyageur with a RHP escort. Your responsibility is to: Be available to support the RHP or voyageur attendant during the transport for adverse event should one occur during transport All of the above

Next > < Prev Answer: Decision 2 Case Example 1 Page 23 of 27 A patient is stable and transferring to another hospital. The patient is on IV medication - The decision algorithm supports using Voyageur with a RHP escort. Your responsibility is to: All the above is the correct choice. As the MRP you are responsible for the patient during the entire time the patient is away from the facility up to the time the patient is accepted at the receiving site. This includes ensuring orders for transport align with the transport algorithm and that care orders are completed to support all required care during transport. Finally you or a physician delegate must be available to the transport team ( escort, attendant/ paramedic) should an adverse event occur during the time away.

Next > < Prev Answer: All the above is the correct choice. As the MRP you are responsible for the patient during the entire time the patient is away from the facility up to the time the patient is accepted at the receiving site. This includes ensuring orders for transport align with the transport algorithm and that care orders are completed to support all required care during transport. Finally you or a physician delegate must be available to the transport team ( escort, attendant/ paramedic) should an adverse event occur during the time away. Decision 2 Case Example 1 Page 23 of 27 A patient is stable and transferring to another hospital. The patient is on IV medication - The decision algorithm supports using Voyageur with a RHP escort. Your responsibility is to:

Decision 2 Case Example 2 Voyageur without an escort Voyageur with appropriate orders for restraint and an appropriate escort EMS < Prev Page 24 of 27 A patient is formed under the mental health act and requires transfer to a Schedule 1 hospital. The patient is combative. What does the algorithm suggest is the most appropriate transport for transferring this patient?

of 27 Submit Decision 2 Case Example 2 Voyageur without an escort Voyageur with appropriate orders for restraint and an appropriate escort EMS A patient is formed under the mental health act and requires transfer to a Schedule 1 hospital. The patient is combative. What does the algorithm suggest is the most appropriate transport for transferring this patient?

Answer: Voyageur with appropriate orders for restraint and an appropriate escort is the correct choice. In this case the patient is not medically compromised and does not meet ambulance criteria. Voyageur is appropriate and because the patient is formed an appropriate escort must accompany the patient. Patient and staff safety is an important consideration with a combative/ unpredictable patient, thus the physician must ensure appropriate restraint is ordered. Consider delaying the transfer until all safety requirements are in place including appropriate escort availability. Next > Page 24 of 27 Decision 2 Case Example 2 A patient is formed under the mental health act and requires transfer to a Schedule 1 hospital. The patient is combative. What does the algorithm suggest is the most appropriate transport for transferring this patient? < Prev

Next > < Prev Page 24 of 27 Answer: Voyageur with appropriate orders for restraint and an appropriate escort is the correct choice. In this case the patient is not medically compromised and does not meet ambulance criteria. Voyageur is appropriate and because the patient is formed an appropriate escort must accompany the patient. Patient and staff safety is an important consideration with a combative/ unpredictable patient, thus the physician must ensure appropriate restraint is ordered. Consider delaying the transfer until all safety requirements are in place including appropriate escort availability. Decision 2 Case Example 2 A patient is formed under the mental health act and requires transfer to a Schedule 1 hospital. The patient is combative. What does the algorithm suggest is the most appropriate transport for transferring this patient?

The recommended language for a transport order is - “ transport as per the patient transport decision algorithm”. It is best not to limit the transport options by specifying the mode of transport. To do so may result in delayed transfers and /or inappropriate use of a transport type. Ensure staff carrying out the order have all the necessary information to assist with the decisions required by the algorithm. This includes information about the reasonable likelihood of the patient status changing, the type of intervention required during transport e.g. IV meds must continue. Writing Orders for Transport Page 25 of 27 Next > < Prev

On occasion patients may die during transport. In the case where it is an anticipated death and there is a DNRC form, the MRP will be called for direction by Voyageur as to the disposition of the body. As MRP you are required to make arrangements to certify the death. In the case where the death is unexpected or the death is anticipated but falls under the coroner act, as MRP you are required to give instruction to transportation attendants/paramedics and you are required to contact the Coroner. If this is a coroner case, the vehicle will need to stop and the scene protected until the coroner arrives. Your responsibility is to ensure you are aware of the guidelines as well as ensuring complete and accurate documentation of DNR and DNRC wishes in the patients health record. Link Patient Death During Transport Page 26 of 27 Next > < Prev

Questions? If you have any questions, please consult the Physicians User’s Guide and the Decision Algorithm. Links are provided below. You may also consult with your hospital unit leader. AlgorithmPhysicians User Guide Add hyperlinks & graphic then remove this box prior to publishing Page 27 of 27 Next > < Prev

Subject Matter Experts: Ann Toman, London Health Sciences Centre Strategy & Project Leadership Regional Clinical Standards Committee ePresentation Developer Cindy Pandke, St. Joseph's Health Care London Organizational Development and Learning Services Photopgraphs Presentermedia.com Articulate Storyline © 2013 SW LHIN Hospitals Reproduction and distribution of this document in whole or in part is prohibited without the expresses permission of the publisher c/o St. Joseph's Health Care London 518- 646-6100 x65441 Acknowledgements Exit Module

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Non Emergency Transport (NET) What you need to know! START This ePresentation will take you approximately 25 minutes to complete.

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