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SWAT nursing: A unique specialty
What does SWAT stand for?
At the University of Michigan Health System (UMHS), SWAT stands for a Specialized Workforce for Acute Transport. We are a dedicated transport team whose mission is to provide safe, respectful, and expert short-term care and treatment to patients and families during intrahospital transport to diagnostic and procedural areas and during bedside procedures.
We serve a diverse population of critically ill patients across the age continuum, representing many different cultures. In any one day, we may transport a 1.4-kg (3-lb) infant with necrotizing enterocolitis or a 225-kg (496-lb) medical intensive care unit (ICU) patient with sepsis, or sedate a child with leukemia. We receive more than 6,000 requests and employ 17.1 nursing full-time equivalents (FTEs) and 9 paramedic FTEs.
A review of the literature and anecdotal stories reveals the inefficiency and danger inherent in intrahospital critical care transport. Adverse changes seen in patients transported both emergently and electively include neurological deterioration, dislodgment of tubes or lines, loss of definitive airway, patient discomfort related to transport and procedural positioning, unstable arrhythmias, and I.V. fluid or medication events. Too often, patients are left unattended for up to 30 minutes or under the care of nonnursing personnel at a testing site waiting for the procedure to begin.
The SWAT team was established to address these problems by providing a high functioning system designed to care for critically ill patients while in transport. Started as a pilot program in 1998, SWAT began life with two experienced critical care nurses under the leadership of the critical care transport/flight manager. At that time, we provided coverage to the six adult ICUs.
Data collected during the 1-year pilot program proved the efficacy of this program. Coverage was then expanded to include the pediatric and neonatal ICUs, and the program was made permanent.
We continued to improve our efficiency and service. We improved safety by ensuring the appropriate level of monitoring. As our expertise grew, the SWAT service was able to coordinate and execute transport to diagnostic procedural areas more quickly and more safely. This translated into significant cost savings by reducing time spent in the imaging and interventional areas.
Nursing satisfaction in the SWAT service areas increased because of reduced overtime and stress related to being off the unit. Collaboration between the procedural/diagnostic staff, nurses, and physicians increased, which translated to more seamless patient care and safety.
In 2008, we added paramedics to the SWAT team. This innovative move helped meet the need to provide an additional level of care during transport for high-risk non-ICU patients, including patients requiring telemetry, patients on suicide or fall precautions, stable patients requiring long-term mechanical ventilation, and patients receiving vasoactive I.V. medications that have not been titrated within the last 24 hours.
Sedation and analgesia
Hospitals strive for efficiency in resource utilization and nurse staffing while maintaining a focus on patient safety. It has been challenging to ensure safe and effective sedation and analgesia for patients in the acute-care setting and at the bedside while ensuring compliance with standards from The Joint Commission. In response, SWAT began providing sedation and analgesia in 2000.
Gaps in patient safety brought about changes in the nursing clinical practice, with strict guidelines for the use of sedation and analgesia in diagnostic, therapeutic, and minor surgical procedures in nonintubated patients at UMHS. While the diagnostic and procedural areas had nurses who provided moderate sedation and analgesia, procedures occurring at the bedside were at risk for being performed without appropriate levels of sedation and analgesia or by practitioners with little experience in this area. The time demands often exceeded what a busy staff nurse, caring for several patients, could provide.
We addressed these issues through SWAT, which provides expert short-term sedation and analgesia. Quality assurance data reflected a decrease in adverse events and increased compliance with TJC standards. We saw improvement in patient, nurse, and physician satisfaction, and noted increased usage and requests for SWAT to sedate the patient at the bedside for painful procedures. Our patients felt empowered to request moderate sedation, and our nurses felt less stress related to the workload that sedation involved.
What does it take to be on the SWAT team?
Requirements for SWAT registered nurses include 5 years of critical care experience in both the adult and pediatric ICUs, emergency department, or Survival Flight (or similar flight nursing experience.) Nurses are required to be certified in ACLS (Advanced Cardiac Life Support), PALS (Pediatric Advanced Life Support), and NRP (Neonatal Resuscitation Program) and complete an additional educational course in sedation and analgesia provided by the anesthesia department. Communication skills are essential in this position. SWAT nurses serve as liaisons to each nursing and procedural area.
SWAT paramedics have previous prehospital experience, and are also ACLS, PALS, and NRP certified.
The orientation for both groups includes in-depth training in all patient, diagnostic, and procedural areas. Nurses and paramedics maintain competency in airway management by working with the anesthesia department in the procedural area biannually. Respiratory therapy staff give annual reviews on ventilator management. Educational coordinators familiar with various devices, such as ventricular assist devices, intra-aortic balloon pumps, pacemakers, intracranial pressure monitoring devices, and magnetic resonance imaging incubators, provide education to SWAT staff as needed.
SWAT staff are scheduled to accommodate a 930-bed facility, with seven to 10 nurses between 7 A.M. and 11 P.M. during the weekday, and two to four nurses on Saturday. Nurse staffing levels fluctuate throughout the day based on the volume of requests. SWAT uses two paramedics from 6 A.M. to 6 P.M. and one paramedic on the weekends and off-shift. We generally schedule seven to 10 staff on a weekday and two to four staff on a weekend day.
We are currently expanding our team to provide limited coverage to the emergency department, and to provide SWAT coverage 24 hours a day, 7 days a week.
The Michigan Difference
The SWAT team continues to evolve as necessity demands. We maintain a database of all requests, using the data to adjust staffing levels and hours of operation. Customer service, safety, education, and clinical excellence are the pillars of our service. These are the qualities that will enable us to meet the future needs of our patients and the UMHS.