Effective: 10-31-24
Supersedes: 11-01-20
Purpose: To describe the assessment, management and equipment use for Brewster ALS interfacility transports.
Policy: The following guidelines are to be used during IFT by Brewster ALS.
Procedure:
Prior to Brewster ALS arrival
1. Dispatch will obtain the necessary information needed for ALS activation to the facility. Any patient transports with significant medical concerns or logistical considerations will have the input from the shift supervisor assigned to that area.
· Patient age
· Equipment needed
· Names of any active medications running
· Diagnoses
· Is the patient stable?
2. In some interfacility transports, more detailed information should be obtained prior to ALS arrival at the patient; examples are found in specific protocols. Brewster dispatch should employ case-by-case judgment in this area. In some cases, the clinical personnel or supervisors should be contacted to obtain further patient information if needed.
3. The specific patient destination – including hospital and department and accepting MD where possible – should be clarified. The Hospital destination should be appropriate for the care needed to treat the illness or injury of the patient.
Brewster Preparation for Transfer
1. Operational considerations for interfacility transports.
1.1. Brewster Advanced EMTs and Paramedics should bring all of the needed ALS equipment and supplies into the sending facility for patient transition and monitoring.
1.2. Paramedics and Advanced EMTs should receive complete report from staff caring for patient.
1.3. Paramedics and Advanced EMTs should interact with sending staff to provide appropriate stabilization and preparation for transport.
2. The gathering of information and patient assessment should take place contemporaneously with the transition of equipment to minimize time delays within the facility.
3. Medical stabilization should proceed along the lines of the applicable Statewide Treatment Protocols/ACLS/BLS/PALS guidelines.
3.1. All team members should maintain appropriate body substance isolation and universal precautions per OSHA regulations.
3.2. Stabilization for transport should follow the “ABCs” with attention to airway and hemodynamics. A thorough and focused exam should highlight the airway, breathing mechanics, cardiovascular, neurologic, GI/GU, musculoskeletal and psychosocial areas of the patient.
3.3. For trauma patients, wounds and injuries should be assessed and subsequently appropriately dressed and secured.
3.4. Cardiac patients should always have an ECG tracing available for viewing. More critical cardiac patients at risk for symptomatic bradycardia or arrhythmia should have anterior/posterior multifunction pad placement prophylactically to avoid application delays if pacing, cardioversion, or defibrillation is needed.
3.5. Patients should be changed over to Brewster equipment and stretcher.
3.6. Vital signs obtained by Brewster staff:
· ECG Rhythm/HR – including dysrhythmia occurrence and whether HR is intrinsic or paced; a rhythm strip should be attached to the patient care record. (100% compliance)
· BP- A baseline blood pressure should be obtained from the sending facility or Brewster equipment while at the patient’s bedside and repeated throughout transport. (100% compliance)
· RR - An accurate respiratory rate for all patients should be obtained along with any ventilator settings needed for transition to Brewster ventilator. (100% compliance)
· SpO2 - readings should be obtained for all patients requiring ALS transfer. (100% compliance)
· EtCO2 - capnography monitoring will be required for all patients with an artificial airway in place. (when required)
· Pain scales - (0-10) will be obtained for all responsive patients. (when required)
· Warm blankets should be placed for preservation of body temperature.
3.7. Maintenance of normothermia is especially important in trauma patients. Brewster Paramedics and Advanced EMTs should discuss and agree upon a medical care plan for transport, considering contingencies applicable to the patient’s diagnosis. Any concerns by Brewster ALS in regards to care being provided at referring facilities, should be discussed with the St Elizabeth’s Medical Center medical control physicians for continued medical direction.
Criteria for St Elizabeth’s Medical Control Contact Regarding Interfacility Transports
For services which utilize St. Elizabeth’s as their affiliate medical control hospital, EMS will contact on-line medical control at St E’s for guidance regarding the following types of interfacility transfers prior to transporting the patient:
· Patient is Intubated, Vented, or on NIPPV
· Patient is Sedated or Given Sedation Medications in ED
· Any Blood Products Running
· Any Vasoactive medications Infusing (to lower or elevate blood pressure)
· Three or more IV medications running (consider critical care)
· Xigris or Thrombolytics are infusing.
· Abnormal Vital Signs:
o Hypo- or Hypertension (SBP<90 or >200, Diastolic BP>110)
o Brady- or Tachy-cardia (<40, >120)
o Hypoxia (SpO2<90%)
· Any Time Paramedic or AEMT has a question regarding:
o Medication
o Procedure or Device
o Hemodynamic or Airway Stability
o Destination appropriateness
· Aortic Dissection and Vitals are initially or become outside of goal
o Goal HR Range: 60-80, Goal SBP 90-100)
· If the patient’s care may exceed scope of practice
· Need for critical care transport (See critical care indications)
· Hemorrhagic stroke or received thrombolytics and Vitals are or become outside of goal
o Goal HR: >60, Goal BP range: 140/80-180/105
· Receiving Post-Arrest Hypothermia and Temperature is or becomes outside of goal
o Goal Temp range: 32C-36C, 89.6F-96.8F
Interfacility Critical Care Indications
It is the judgement of OLMC if delay of waiting for critical care outweighs its benefit. OLMC should directly discuss these cases with transferring MD.
· Patients with an acute problem who have high possibility of becoming unstable during transfer.
o Potential for airway instability
§ Epiglottitis, retropharyngeal abscess, airway burn, foreign body, etc.
o Intubated Patients with ARDS/Acute Lung Injury (ALI)
o Neonates (< 30 days)
o Children < 8 years old
§ Any intubated pediatric patient
§ Critically ill or injured pediatric patient
· Complicated Devices
o Actively paced patient (Transvenous /Transcutaneous)
o LVAD or IABP
o PA Catheter (although central lines ok to use)
o ICP Monitors / indwelling devices
§ ALS cannot interpret these devices
§ Old VP shunts are OK to transfer
· Strongly consider CCT. Going ALS requires OLMC approval
o More than 3 IV medications running at once
o More than one vasoactive medication infusing (BP lowering or elevating med)
Medical Information
The following patient medical information should be obtained:
1. Age, weight, airway adjuncts used
2. When relevant, ventilator settings
3. Detailed PMH including medication/allergy history
4. HPI – How the patient presented to the facility and their relevant hospital course.
Interventions prior to Brewster ALS arrival should be recorded:
1. Diagnostic/laboratory studies with brief notation of pertinent results
2. Pharmacological interventions and results
3. Procedural interventions and results
Vital signs should be recorded
Materials to be transported to receiving facility
1. Medical records
2. Laboratory results
3. Radiography results and films
4. Tissue/laboratory specimens
5. Forensic evidence
6. Patient belongings
Documentation
1. Obtain a signature on the Medical Necessity form
2. Obtain a consent signature from the patient, or when not possible due to patient condition from a family member or facility representative
3. Obtain a copy of the registration sheet from sending facilities.
4. Complete Brewster PCR
Transfer of Care
1. Airway monitoring during the transfer is imperative.
2. Continuous evaluation of the airway should take place during the transfer
3. Frequency of obtaining vital signs should be based on the patient’s condition. Any patients presenting hemodynamically unstable or on Vasopressors should have vital signs obtained automatically every 3-5 minutes. For hemodynamically stable patients automatic vital signs of 5-10 minutes are appropriate.
4. Other areas of patient care, such as issues of pharmacology or intravenous volume replacement, should be pursued as indicated by the specific clinical situation.
5. During transport, ongoing monitoring of equipment should be performed to assure correct functioning. Equipment sensitive to battery depletion should be plugged in and charged during the transport.
6. Patient expects and arrival time updates can be called in via cell phone or C-med radios
Brewster ALS arrival at receiving facility
1. Upon arrival at the receiving department, Paramedics or AEMTs will give verbal report to medical personnel assuming care of the patient, documenting the name of the appropriate receiving physician on the PCR.
2. Any medical records, imaging, and patient belongings should be transferred to the receiving staff.
3. The electronic Brewster PCR should be completed as soon as practicable during the same shift in accordance with “Patient Care Report Documentation”