Directions for using the Pre-transport Stabilization Self-Assessment (PSSAT) Form
This form is public domain and is intended for the improvement of patient care. It may be duplicated without permission of the S.T.A.B.L.E. Program. This form may also be found in the Quality Improvement module of every 5th edition Learner and Instructor Manual.
It only takes approximately five minutes to complete the form for each time period (A, B, or C) that is being assessed. Please note, this form does not substitute for recording the patient care, vital signs, or physical exam in the medical record. Rather, the PSSAT is intended for data collection that will be useful to assess the stabilization care provided to neonates requiring transport or transfer to another unit.
1. Either during pre-transport stabilization care (ideally), or, immediately after the infant is transported, complete the demographic information in the Patient Information section of the form.
2. Under Indications for Referral, select all of the suspected or confirmed diagnoses that apply at the time of referral.
3. Times A, B, and C are used repetitively on the first and second pages of the form. The idea is to record the vital signs, physical exam, and stabilization procedures that were performed:
- At the time the transport team was called (transport was requested) = Time A
- Upon arrival of the transport team in your nursery = Time B
- Upon departure of the transport team = Time C
The transport team should help complete the Time C items, unless the infant is unstable and time does not allow. In that case, if at all possible, ask the team to leave a copy of their stabilization record so you can complete the Time C items.
4. The overall idea is to evaluate stabilization care by looking at three specific time intervals:
- What stabilization actions were taken at the time it was determined the infant was ill?
- What stabilization actions were taken while awaiting the team’s arrival?
- What stabilization actions were completed by the team? The following scenarios are possible:
- The team arrives and stabilization is complete so they do not need to do more than assess the baby, attach the transport equipment and move the baby into the incubator.
- The team arrives quickly and completes the stabilization procedures that you did not have time to complete.
- The team arrives and determines that additional care is needed, and therefore, additional actions are taken (such as intubating the patient, inserting lines, changing an ET tube, administering certain medications, etc.).
- By recording these actions, it is hoped that the nursing and medical leadership team will be able to assess adequacy of pre-transport (or transfer) stabilization care.
If you have trouble filling out the form, or you need additional expertise to answer the questions on the third page of the form, then the transport team should be consulted for assistance. It would not be presumptuous to say that transport teams would love the opportunity to help their community hospitals to improve their ability to provide optimal pre-transport stabilization!
5. Remember to insert the confidential reporting protection number at the bottom of the form so that the form may be used for Quality Improvement review and it will not become a part of the medical record.
See: Confidential report for improvement of hospital facility and patient care – Not part of medical record and not to be used in litigation pursuant to (state)___________ code_______________