1 A3 IFT Guidelines and Prtcls Table f Cntents: Part A: Minimum Standards fr Interfacility Transfers Part B: Determining the Need fr Critical Care Transprt B1 Pediatric Patients (age 8 years r yunger) B2 Medical Patients Part C: General Prtcls & Standing Orders fr ALS Interfacilty Transfer Care Part D: Interfacility Transfer Checklists Srted by Patient Cnditin/Diagnsis D1 Artic Disectin D2 Bld Transfusin Reactins D3 Cerebrvascular Accident (Pst-tPa) D4 Pst-Arrest Induced Hypthermia D5 Pregnancy-Related D6 ST-Segment Elevatin Mycardial Infarctin (STEMI) Part E: Interfacility Transfer Medicatin Guidelines/Reference E1 General Guidelines fr Medicatin Administratin E2 Apprved Medicatins and Medicatin Classes E3 Medicatins Requiring the Use f an IV Pump E4 Bld Prducts Part F: Interfacility Transfer Equipment Prtcls and Checklists F1 Mechanical Ventilatin F2 IV Pumps F3 Chest Tubes Minimum Standards fr Interfacility Transfers: Staffing, Training Minimum staffing at the Intermediate level requires ne EMT-Basic and ne EMT-Intermediate. Minimum staffing at the Paramedic level requires ne EMT-Paramedic and EMT-Intermediate r EMT- Basic, in accrdance with 105 CMR (C)(2). EMTs prviding patient care during Interfacility Transfers must meet the fllwing requirements as utlined in 105 CMR et al: a) Current certificatin as an EMT in Massachusetts; b) Cmpletin f Department apprved supplemental training that is specific t and cnsistent with levels f certificatin f invlved EMTs and includes a. expanded rles and respnsibilities b. additinal, apprved treatment mdalities, equipment, devices, and technlgies; and c. ambulance service plicies and prcedures regarding ALS Interfacility Transfers c) has maintained current authrizatin t practice pursuant t the Affiliate Hspital Medical Directr s review f clinical cmpetency Guidelines fr apprved ALS Interfacility Transfer training prgrams have been issued separately by the Department. It shall be the respnsibility f the transferring ambulance service t ensure and t verify apprpriate training f its persnnel prviding ALS Interfacility Transfers. This includes ensuring that all its persnnel successfully cmplete refresher training in prviding ALS Interfacility Transfers at least every tw years, and whenever new equipment r medicatin is apprved fr use n interfacility transfer calls. Affiliatin Agreements; Medical Cntrl An ambulance service must be licensed at an ALS level by the Department t prvide ALS care during Interfacility Transfers, and it must maintain an affiliatin agreement, in accrdance with 105 CMR , with a hspital licensed by the Department fr Medical Cntrl, pursuant t 105 CMR f the Hspital Licensure regulatins. Such affiliatin agreements must designate an
2 Affiliate Hspital Medical Directr (105 CMR (A)(2) and 105 CMR (C)), whse medical versight functins are defined in 105 CMR Standards fr Affiliate Hspital Medical Directrs are defined in 105 CMR Cmmunicatins: All cmmunicatins with a Medical Cntrl physician must be recrded. Scpe f Practice: Sectin (A) f the EMS Regulatins states, N ambulance service r agent theref shall transprt a patient between health care facilities wh is receiving medical treatment that is beynd the training and certificatin capabilities f the EMTs staffing the ambulance unless an additinal health care prfessinal with that capability accmpanies the patient... Depending n the individual s cnditin, there may be situatins in which a physician r sme ther specialist s presence might be necessary; such determinatin shall be made by the n-line medical cntrl physician in cnsultatin with the physician at the sending hspital. All invlved in this decisin shuld cnsider whether the benefits f the transfer sufficiently utweigh the risks; a patient s greatest benefit may result frm being transprted by a standard IFT crew t a higher level f hspital care rather than delay fr ther transprt. The scpe f practice fr each EMT level is defined (1) in regulatin (105 CMR , and ), (2) thrugh established training prgrams apprved by the Department, and (3) thrugh the Statewide Treatment Prtcls cnsistent with the Interfacility Transfer Guidelines. The fllwing are patient cnditin classificatins and crrespnding requirements fr EMT persnnel during ambulance transprt: a) Rutine, scheduled transprt; Patient clearly stable fr transprt with n requirement fr airway management and n device in place that is actively running r requires any maintenance r mnitring. Patient may have a device in place, but device must be lcked and clamped, nt require any maintenance and nt be actively running. Such inactive devices may include, but are nt limited t, IVs, nasgastric tubes, feeding tubes, PICC lines and bladder irrigatin. Minimum Staffing: BLS licensed ambulance service; tw EMT-Basics b) Patient clearly stable fr transprt (as abve) wh has a maintenance IV running withut additives; (e.g., cancer patient transprted fr radiatin therapy, with unadulterated crystallid IV slutin running). Minimum Staffing: ALS-Intermediate licensed ambulance service; ne EMT-Intermediate attending t patient care and ne EMT-Basic driving c) Patient with an acute r sub acute prblem, wh is either cmpletely r, at least, t the best f a facility s ability, stabilized; wh has the ptential t becme less stable during transprt. Instrumentatin r medicatin running must be cnsistent with the Interfacility Transfer Guidelines. Minimum Staffing: ALS-Paramedic licensed ambulance service; ne EMT-Paramedic and ne EMT- Intermediate r EMT-Basic, in accrdance with 105 CMR (C)(2). The EMT with the highest level f certificatin must attend t patient care. d) Patient with an acute prblem with high ptential t becme unstable; Critical care patient with any ther instrumentatin r medicatin running that is nt included in the Interfacility Transfer Guidelines. Minimum Staffing: Apprpriate additinal medical persnnel (per 105 CMR (A)) must accmpany the patient during transfer; any level f ambulance service licensure; tw EMT-Basics. The ALS Interfacility Transfer Subcmmittee recmmends that the referring hspital cnsider Critical Care Transprt fr such a patient. In the event that CCT is unavailable, medical persnnel accmpanying the patient must be able t manage all equipment and instrumentatin assciated with the patient s care and prvide advanced resuscitative measures if needed.
3 e) Critical Care Transprts (see 105 CMR , fr regulatry requirements regarding critical care transprt). Under n circumstances shall EMTs functin r be assigned t transfers beynd, r ptentially beynd, the scpe f their training and level f certificatin. The scpe f practice fr all EMTs is limited t the levels f EMT certificatin and training and by licensure level f the ambulance service by which they are emplyed. If (1) a patient s medical cnditin necessitates immediate transprt t anther health care facility and (2) the patient s medical treatment during transprt will exceed the level f licensure f the transferring ambulance service and/r level f certificatin f the transferring ambulance s persnnel, and (3) the transferring facility will nt prvide apprpriate additinal persnnel pursuant t 105 CMR (A), Critical Care Transprt by grund r air shuld be emplyed. The transferring facility may at any time pt t exceed these minimum requirements by transferring patients in BLS ambulances with apprpriate medical persnnel as defined in (A) r by Critical Care Grund r Air Transprt. Quality Assurance/Quality Imprvement a) Ambulance services prviding ALS Interfacility Transfers shall be required t have quality assurance/quality imprvement plicies specific t ALS Interfacility Transfers in cnjunctin with bth their affiliate hspital medical directrs and their ambulance service medical directrs, if any, and include at a minimum: a. review f apprpriateness f transfers, denials, and cnfrmance with EMTALA regulatins; b. review f critical skills (e.g., intubatins, cardiac arrest management, IV therapy), and ther measures f system functin as deemed apprpriate by the Department; c. steps fr system imprvement and individual remediatin, available fr Department review, f cases fund t be deficient in critical interventins b) Ambulance services shall reprt t the Department and the Affiliate Hspital Medical Directr any vilatins f 105 CMR , this Administrative Requirement and/r prevailing treatment prtcls as they relate t ALS Interfacility Transfers. c) EMT skill maintenance and didactic knwledge will be cntinually assessed and apprpriate measures taken t ensure quality f patient care by affiliate hspital medical directrs and by ambulance service medical directrs, if any. Patient ALS Transfer Prcedure Once an ALS Interfacility Transfer has been deemed apprpriate by the transferring ambulance service (see Scpe f Practice abve), paramedic staff, upn arrival at the transferring facility, will: receive a reprt frm the staff f the transferring facility; assess the patient; and in cases where the patient s care during the transfer exceeds the standing-rder scpe f practice as defined by the current versin f the Statewide Treatment Prtcls fr an EMT- Paramedic r the patient is unstable r is likely t becme unstable as defined previusly (see Scpe f Practice abve) will prvide a cncise, cmplete and accurate patient reprt t an On-Line Medical Cntrl physician, accrding t the EMS service s and the Affiliate Hspital s plicies and prcedures. When EMTs have a cncern regarding the safety f the patient being transferred, the EMT-Paramedic will cntact an On-Line Medical Cntrl physician fr guidance. The reprt shuld include, at a minimum, the fllwing infrmatin: Names f transferring and receiving facilities; Patient s diagnsis;
4 Reasn(s) fr transfer; Brief histry f present illness and any interventin(s) which has ccurred t date; Pertinent physical findings; Vital signs; Current medicatins and IV infusins; Presence f r need fr additinal medical persnnel; Anticipated prblems during transprt, if any; Anticipated transprt time; and Staffing cnfiguratin f the transprting ambulance NOTE: Cmplete cpies f all pertinent medical recrds, including X-Rays, CT Scans, cnsultative ntes and ECGs, as available, must accmpany the patient t the receiving facility. When necessary, the Medical Cntrl Physician and paramedic will discuss with the transferring physician the rders fr maintenance f existing and/r additin f new therapies accrding t the needs f the patient, within the scpe f existing treatment prtcls and EMT scpe f practice. The Medical Cntrl Physician will be respnsible fr all actins/interventins initiated by the EMS persnnel during transprt unless the referring physician accmpanies the patient. If the transferring physician is unavailable, r the patient is unstable, the Medical Cntrl Physician may recmmend t the transferring facility additinal therapies prir t the transfer f the patient in the interest f patient safety and quality care. In sme situatins, cnsistent with the intent f EMTALA, the transfer f a patient nt stabilized fr transprt may be preferable t keeping that patient at a facility incapable f prviding stabilizing care. If the transferring facility cannt prvide apprpriate medical care r apprpriately trained and experienced persnnel t accmpany the patient, alternative means f transfer, including Critical Care Transprt, must be utilized. The use f a lcal Emergency Ambulance Service is strngly discuraged in such a situatin. All such respnses must be reprted by the ambulance service t the Department s Divisin f Health Care Quality and the Affiliate Hspital Medical Directr fr review. It is primarily the respnsibility f the referring physician and Medical Cntrl Physician t determine the apprpriate methd f transferring an unstable patient. When a facility sends its wn staff with the patient during transfer (additinal medical persnnel) and the patient s cnditin deterirates en rute, EMS persnnel must cntact the Medical Cntrl Physician fr apprpriate interventin rders and ntify the receiving facility f the change in patient status. If the accmpanying staff is an RN s/he will maintain patient care respnsibility, functining within his/her scpe f practice and under the rders f the transferring physician. The Paramedic and the RN will wrk cllabratively in the prvisin f patient care. If the patient s cnditin deterirates en rute, the Paramedic may assume full respnsibility in cnjunctin with their Medical Cntrl Physician fr care that exceeds the RN s scpe f practice and/r the transferring physician s medical rders. Prir t transfer with an RN, the referring physician must cntact the service s Medical Cntrl Physician and prvide staffing ratinale. If the accmpanying staff includes a physician frm the transferring facility, that physician shall be in charge f patient care. Prir t transfer, the transferring physician accmpanying the patient must cntact the service s Medical Cntrl Physician and crdinate patient care between the physician-incharge and the paramedic practicing within the Statewide Treatment Prtcls. Clear lines f cmmand and respnsibility shall be established prir t transprt.
5 Interstate ALS Interfacility Transfers Interstate transfers are permitted. Paramedics must btain Medical Cntrl thrugh nrmal channels, thrugh the Affiliatin Agreement fr Medical Cntrl f the ambulance service fr whm they are wrking. Apprpriate prvisins fr re-cntacting the Medical Cntrl physician en rute, if necessary, shuld be made prir t departure frm the transferring facility. If a transfer riginates ut f state and n cntact with Medical Cntrl Physician is pssible, the transfer shuld be made at the BLS level nly with apprpriate additinal persnnel prvided by the transferring facility. Part B Determining the need fr CCT The purpse f this sectin is t determine which patients must be transprted by critical care transprt (CCT). Scenaris and circumstances beynd the scpe f practice f the paramedic (including, but nt limited t thse described belw) require CCT. CCT can be furnished by any f the fllwing: Licensed critical care service An advanced life supprt (ALS) vehicle with hspital MD and / r RN n bard. (A respiratry therapist is acceptable in place f MD and / r RN fr ventilatr management nly) Any advanced (ALS) r basic life supprt (BLS) vehicle staffed by a self-cntained and prperly equipped critical care team. If CCT is unavailable AND sending facility staff is unavailable, AND this patient has a cnditin requiring time-sensitive interventin AND it is apprved by MEDICAL CONTROL, this patient may be transferred by any ALS ambulance, prvided that all interventins are within the scpe f practice f the transprting paramedic and vehicle. The MEDICAL CONTROL physician and SENDING PHYSICIAN shuld be in direct cmmunicatin if there are any cncerning issues prir t patient transprt. B1 PEDIATRIC PATIENTS (8 years f age r yunger) Any nenate patient (30 days f age r yunger) requiring transfer t a higher level f care. Any pediatric patient with critical illness r injury. NOTE: On-line MEDICAL CONTROL shuld be invlved in determining whether pediatric patients require critical care. Any pathlgy assciated with the ptential fr imminent upper airway cllapse and / r bstructin (including but nt limited t airway burns, txic inhalatin, epiglttitis, retrpharyngeal abscess, etc.). If any cncerns whether patient falls int this categry, cntact MEDICAL CONTROL. NOTE: On-line MEDICAL CONTROL shuld be invlved in determining whether pediatric patients require critical care Any intubated pediatric patient requiring an interfacility transfer. All cnditins that apply t adult medical patients als require CCT fr the pediatric patient. B2 ADULT MEDICAL PATIENTS Unless apprved by MEDICAL CONTROL, patients requiring mre than three (3) medicatin infusins by IV pump, nt including maintenance fluids must be transprted by CCT. Unless apprved by Medical Cntrl, any patient receiving mre than ne vasactive medicatin infusin must be transprted by CCT. Any patient wh is being actively paced (either transvenus r transcutaneus) must be transprted by CCT. Patients being transferred due t an issue with a ventricular assist device. Patients with an intra-artic balln pump. Any patients with a pulmnary artery catheter. NOTE: Central lines may be transprted by ALS IFT Any patient with an intracranial device requiring active mnitring. NOTE: Except fr chrnic use devices, such as ventriculperitneal shunts, etc. Any pathlgy assciated with the ptential fr imminent upper airway cllapse and / r bstructin (including but nt limited t airway burns, txic inhalatin, epiglttitis,
6 retrpharyngeal abscess, etc.). If any cncerns whether patient falls int this categry, cntact MEDICAL CONTROL. NOTE: If any cncerns abut whether patient falls int this categry, cntact MEDICAL CONTROL. Any patient being artificially ventilated fr ARDS r Acute Lung Injury. Part 2 General Prtcls fr ALS Interfacility Transfer Care Vital signs shuld be btained and dcumented every ten (10) minutes, unless therwise required by prtcl. If clinically indicated, patients will have cntinuus mnitring f electrcardigram (ECG) and / r pulse ximetry (SpO2). All artificially ventilated patients (and all ther patients where it is clinically indicated) will have cntinuus mnitring f wavefrm capngraphy. NOTE: All ALS services Intermediate and Paramedic -- must be equipped with capngraphy by January 1, The recmmended rute fr medicatin infusins in the ALS IFT setting is the peripheral intravenus (IV) line. Intrasseus (IO) lines may als be used. Medicatins may als be administered thrugh any central venus catheter Paramedics may administer medicatin bluses, infusins and fluids thrugh administratin sets cnnected by the sending facility t subcutaneus devices (e.g., Prt-a- Cath) Patients wh are being transferred ALS between facilities shuld have peripheral intravenus (IV) access, if pssible. Paramedics shuld attempt t establish IV access if n attempts have been made at the sending facility. Paramedics are authrized t establish IO access if warranted by the patient s cnditin. All mnitring and therapy will be cntinued until care is transferred t the receiving medical staff. Paramedics may nt accept any medicatins frm the sending facility fr the purpses f blus administratin during transprt. Any patient wh qualifies fr spinal immbilizatin per pre-hspital statewide treatment prtcls wh has nt been cleared by CT scan r apprpriate physician assessment must be fully immbilized fr transprt. If there is identificatin f a clinical cncern f thracic r lumbsacral spine injury, the patient shuld be immbilized with a lng bard and lg rll precautins used at all times. If any cnfusin arises regarding the need fr spinal immbilizatin MEDICAL CONTROL will be cntacted and the MEDICAL CONTROL physician and the SENDING PHYSICIAN shuld be in direct cmmunicatin. Paramedics must be familiar with the treatments and interventins instituted at sending facility. Patient care dcumentatin shuld include, at a minimum: Patient s diagnsis / reasn fr transfer Brief histry f present illness / injury Brief verview f interventins perfrmed by sending facility Pertinent physical examinatin findings and recent vital signs Current medicatins and IV infusins Presence f r need fr additinal medical persnnel Fr all patients being transferred t an emergency department, wh are critically ill, unstable, r have a change in clinical status en rute, EMTs shuld ntify receiving emergency department
7 via CMED prir t arrival. If lcal CMED is unavailable, entry ntes shuld be made by telephne (n a recrded line, if pssible). Paramedics will cntact n-line MEDICAL CONTROL fr: Any interventin(s) that exceed the standing rder scpe f practice as defined by the current versin f the Massachusetts Pre-Hspital Statewide Treatment Prtcls fr an EMT-Paramedic. Any patient that is unstable r is likely t becme unstable. When there is any cncern regarding the safety f the patient being transferred. Any significant patient care related questins r issues prir t transfer r en rute. The MEDICAL CONTROL physician and SENDING PHYSICIAN shuld be in direct cmmunicatin if there are any cncerning issues prir t patient transprt. On ccasin gd medical practice and the needs f patient care may require deviatins frm these prtcls, as n prtcl can anticipate every clinical situatin. In thse circumstances, EMS persnnel deviating frm the prtcls shall nly take such actins as allwed by their training and nly in cnjunctin with their ON-LINE MEDICAL CONTROL PHYSICIAN. Part 3.1- Artic Dissectin It is recmmended that central access and / r tw large bre IV lines are in place prir t transprt. Care during transprt: Administer high-flw supplemental xygen Cntinuus cardiac mnitring Heart rate, bld pressure, neurlgic evaluatins dcumented every 5 10 minutes Target heart rate = bpm Target systlic bld pressure = mm Hg Cntinually assess mentatin. If patient is utside f these parameters, cntact MEDICAL CONTROL. If nt apprved by n-line MEDICAL CONTROL prir t transprt, yu must cntact MEDICAL CONTROL t adjust all medicatin infusins: Adjust antihypertensive medicatins initiated at sending facility (until systlic bld pressure is less than 100 mm Hg and/r MAP is less than 60 mm Hg): If Labetall infusin has been initiated by sending facility, increase by 2 mg / minute every 10 minutes (t a maximum f 8 mg/minute) If Esmll infusin has been initiated by sending facility, increase by 50 mcg / kg / minute every 4 minutes (t a maximum f 300 mcg / kg / minute) If Nitrprusside infusin has been initiated by sending facility, increase by 0.5 mcg / kg / minute every 5 minutes (t a maximum f 4 mcg / kg / minute) Discntinue drip and cntact medical cntrl fr instructins if: Systlic bld pressure < 90 mm Hg, r; Heart rate < 60 bpm If n medicatin infusin has been initiated t cntrl bld pressure and / r heart rate, MEDICAL CONTROL may rder the administratin f metprll 5 mg IV every 5 minutes t a maximum f 15 mg. Part 3.2 Bld Transfusin Reactin Symptms f a Transfusin Reactin during Infusin f Packed RBCs (PRBCs) Acute Hemlytic Reactin
8 Fever, hyptensin, flushing, wheezing, dark and / r red clred urine, zing frm IV sites, jint pain, back pain, chest tightness Nnhemlytic Febrile Reactin Fever, chills, rigrs, vmiting, hyptensin Allergic Reactin Urticaria, hives (usually withut fever r hyptensin) Anaphylactic Reactin Dyspnea, wheezing, anxiety, hyptensin, brnchspasm, abdminal cramps, vmiting, diarrhea Vlume Overlad Dyspnea, hypxia, rales, tachycardia, jugular vein distentin Transfusin-Related Acute Lung Injury ( TRALI ) Dyspnea, hypxia, rales (usually withut fever r signs f pulmnary edema) If Transfusin reactin ccurs: STOP the infusin if any f the abve symptms are discvered! Start infusin f nrmal saline Cntact MEDICAL CONTROL Treat hyptensin and anaphylactic reactin with standing rders (established pre-hspital prtcls) If minr allergic reactin (urticaria / wheezing) administer Benadryl, 50 mg IV If SpO2 is belw 90% r patient experiences wheezing / rales, administer high-flw supplemental xygen If SpO2 is belw 90% and accmpanied by rales, administer Lasix, 40 mg IV Part 3.3 CVA Pst tpa Seizures (either generalized mtr r nncnvulsive) shuld be quickly cntrlled. After assessing airway, breathing, and applying high-flw xygen: Lrazepam, 2-4 mg IV/IO/IM every 2 minutes up t 0.1 mg / kg, r Diazepam, 5 0 mg IV/IO/IM/PR, r Midazlam 2.5-5mg IV/IO/IM/IN MEDICAL CONTROL can authrize administratin f Midazlam fr seizure activity Fr an ischemic CVA, if a tpa (tissue plasmingen activatr) infusin will be cntinued during the transprt, fllw these guidelines: Sending facility staff shuld withdraw excess tpa frm the bttle, s that the bttle will be empty nce the full dse has infused. Example: 100 mg bttle f tpa cntains 100 ml f fluid when recnstituted; if the ttal dse being administered is 70 mg, then the facility shuld remve 30 ml f fluid frm the bttle befre departure. When the pump alarm indicates that the bttle is empty, yu shuld take the fllwing steps t ensure that the drug cntained within the administratin tubing is administered t the patient: Remve the IV tubing frm the tpa bttle and spike a bag f 0.9% NS and restart the infusin; the pump will stp infusing when the preset vlume has been administered. If systlic bld pressure is fund t be greater than 180 mm Hg r diastlic bld pressure is fund t be greater than 105 mm Hg cnsult MEDICAL CONTROL, then: Adjust antihypertensive medicatins initiated at sending facility: If Labetall has been initiated by sending facility;
9 Increase by 2 mg/minute every 10 minutes (t a maximum f 8 mg/minute) until systlic bld pressure is less than 180 mm Hg and/r diastlic bld pressure is less than 105 mm Hg Discntinue drip and cntact medical cntrl fr instructins if the reductin in MAP is greater than 30% f initial BP r SBP < 140 mm Hg, DBP < 80, r heart rate < 60 bpm If Nicardipine has been initiated by sending facility; Increase by 2.5 mg / hur every 5 minutes (t a maximum f 15 mg / hur) until systlic bld pressure is less than 180 mm Hg and/r diastlic bld pressure is less than 105 mm Hg Discntinue drip and cntact medical cntrl fr instructins if the reductin in MAP is greater than 30% f initial BP r SBP < 140 mm Hg, DBP < 80, r heart rate < 60 bpm Fr any acute wrsening f neurlgic cnditin (e.g., acutely wrsening neurlgical deficits, develpment f severe headache, acute hypertensin, vmiting, etc.): If patient is receiving tpa, discntinue the infusin. Cntact MEDICAL CONTROL fr further instructins. Cntact receiving hspital emergency department with an update n patient s cnditin and an estimated time f arrival. Part 3.4 Pst-Arrest Induced Hypthermia (PAIH) If pst-arrest induced hypthermia (PAIH) therapy in prgress at the time f IFT ALS arrival, it shuld be cntinued during the transprt. Pre-transprt temperature shuld be dcumented, and temperature shuld be mnitred with vital signs every five minutes. The temperature target fr pst-arrest induced hypthermia (PAIH) is 32 C 34 C (89 F 93 F). If pre-transprt r inter-transprt temperature is less than r equal t 34 C: Maintain temperature with cld packs placed in the grin, axillae, and n the chest and sides f neck. Discntinue any cld saline infusin. If pre-transprt r inter-transprt temperature is greater than 34 C: Cntinue cling with cld packs placed in the grin, axillae, and n the chest and sides f neck. Cntinue r initiate cld saline infusin, initially chilled and maintained at apprximately 4 C, at 30 ml / kg ver 30 minutes. Cre temperature shuld be mnitred if pssible fr transprt times lnger than 20 minutes. Patients shuld be handled gently (due t risk f arrhythmias). ALS IFT crews will nt discntinue PAIH unless rdered t d s by MEDICAL CONTROL. If patient temperature is less than 31 C, cntact MEDICAL CONTROL and utilize any external warming devices (blankets, etc.) t actively rewarm patient until the temperature is greater than 31 C. If rdered by MEDICAL CONTROL and available, cnsider infusin f 250 ml IV bluses f warmed nrmal saline slutin, until the temperature is greater than 31 C.
10 If hemdynamically significant dysrhythmias r bradycardia f any type develp, r if the patient develps significant bleeding, PAIH shuld be stpped, MEDICAL CONTROL cntacted, and active rewarming pursued. Part 3.5 Pregnancy Related Patients wh are in labr with cncern fr imminent delivery must be accmpanied by sending facility staff. In high-risk situatins, a physician / registered nurse will accmpany the patient fr transprt. If any cnfusin arises regarding the need fr additinal OB staff MEDICAL CONTROL will be cntacted and the MEDICAL CONTROL physician and SENDING PHYSICIAN shuld be in direct cmmunicatin. In additin t the dcumentatin standards listed in the General ALS IFT Care Guidelines, when transprting an bstetrical patient, the fllwing shuld be dcumented: The presence f a fetal heart rate befre and after transfer Estimated date f cnfinement, maternal histry f any cmplicatins Cnditin f membranes, dilatin Gravida / Para Timing and nature f cntractins Fetal Psitin Patients shuld be transprted in a left-lateral psitin r sitting upright, if pssible. Dcument that the fetal heart rate was evaluated prir t transprt and upn arrival. If patient shuld develp eclamptic seizures: After assessing airway, breathing, and applying high-flw xygen Lrazepam, 2-4 mg IV/IO/IM every 2 minutes up t 0.1 mg/kg, r Diazepam, 5 10 mg IV/IO/IM/PR, r Midazlam 2.5-5mg IV/IO/IM/IN MEDICAL CONTROL can authrize administratin f Midazlam and administratin f magnesium sulfate (4 g ver 3 minutes) fr seizures. MEDICAL CONTROL can authrize administratin f Midazlam and administratin f magnesium sulfate (1-4 g ver 3 minutes) fr seizure activity. Part 3.6 ST-Segment Elevatin MI (STEMI) Paramedics shuld be familiar with the care and treatment the patient has received. Cnsider discntinuing r aviding all medicatin infusins (except fr basic IV fluids) t expedite transfer. Receiving facility shuld be cntacted t ensure rapid transfer t cardiac cath lab. Patients shuld receive apprpriate supplemental xygen therapy (minimum f 4 L/min via nasal cannula) All ther interventins per state-wide treatment prtcl, if nt already administered: Aspirin, 325 mg PO If patient cntinues t experience chest discmfrt: Nitrglycerine (if systlic bld pressure is greater than 100 mm Hg), 0.4 mg SL tablet r spray; may be repeated in 5 minute intervals fr a ttal f three (3) dses Mrphine, 2 4 mg slw IV push; r,
11 Fentanyl, 1 mcg / kg slw IV push, t a maximum f 150 mcg Part 4.1 General Guidelines fr Medicatin Administratin The transprt paramedic must be familiar r becme familiar thrugh cnsultatin (i.e., with a drug reference r discussin with hspital staff) n the fllwing attributes f each drug the patient has received prir t and will receive during transprt: The type and name f medicatin being administered. The indicatin and cntraindicatins fr administratin f the medicatin. The crrect dse, rate, and mixture f medicatin. Any titratin indicatins r instructins. Any specific medical cntrl instructins Any patient-specific infrmatin Any adverse effects f the medicatin being administered. The seven rights f medicatin administratin shuld always be cnsidered, even when transprting patients between facilities. Right patient, drug, dse, rute, time, utcme, dcumentatin Paramedics may nt accept any medicatins frm the sending facility fr the purpses f blus administratin during transprt. Part 4.2 Apprved Medicatins and Classes Any f the fllwing medicatins r medicatin classes, nt currently part f the EMT Paramedic Statewide Treatment Prtcls, may be maintained if initiated at the sending facility, and can nly be titrated thrugh specific IFT prtcls and by n-line MEDICAL CONTROL. Aminphylline Analgesics Anticnvulsants Antidtes Antidysrhythmics Antihypertensive agents Anti-infectives (e.g., antibitics, anti-sepsis) Benzdiazepines Bld prducts Chemtherapeutic agents Electrlyte infusins Ptassium, limited t 10 meq / hur Magnesium, maintenance infusin limited t 2 g / hur Glycprtein IIb / IIIa inhibitrs Heparin Insulin infusins Intravenus sterids Mannitl infusins Octretide
12 Paralytics Parenteral nutritin Prtn Pump Inhibitrs Sedatives Standard IV infusin fluids (including 10% Dextrse) Thrmblytic agent Vasdilatrs (including all frms f Nitrglycerin) Vaspressrs Part 4.3 Medicatins Requiring the use f an IV Pump The fllwing medicatins / types f medicatins must be administered by IV pump: Anticagulant Anticnvulsants Antidysrhythmics Antihypertensives Electrlyte Slutins Insulin Paralytics Sedatives Thrmblytics TPN Vasdilatrs Vaspressrs Part 4.4 Bld and / r Bld Prduct Administratin Heating devices, autmatic and rapid infusers are prhibited fr ALS IFT use. Infusin / bldbank dcumentatin shuld be transprted with the patient. Paramedics will nt initiate a bld prduct infusin At least ne additinal IV line shuld be in place Paramedic will nt administer any medicatins thrugh an IV line which is being used t infuse bld r a bld prduct. Ensure the bld and / r bld prducts are infusing at the prescribed rate Mnitr and recrd the patient s vital signs every 5 10 minutes. If any signs and symptms f transfusin reactin, prceed immediately t the TRANSFUSION REACTION PROTOCOL (Part 3.2) Bld prducts shuld be infusing fr at least 20 minutes prir t departure, t reduce the risk f transfusin reactin. The nly exceptin t this is fr administratin f fresh frzen plasma (FFP) fr patients suffering life-threatening intracranial bleeding. When the transfusin has finished: Recrd transfusin end-time and pst-infusin vital signs. Discnnect infusin set tubing frm primary line. Flush primary line with nrmal saline nly. Place any used supplies int a clean bihazard marked cntainer r bag.
13 Deliver all empty transfusin bags and tubing t the receiving facility with the patient. Part 5.1 Mechanical Ventilatin All artificially ventilated patients must be transferred n a ventilatr. All ventilatrs must be able t meet the demands f the patient s cnditin, taking int cnsideratin all settings and features described r stipulated by the sending facility and / r physician. Ventilatrs may nt be full cntrl mde nly and must be capable f meeting the patient s ventilatry needs. Unless the transfer is time sensitive in nature (e.g., STEMI, artic dissectin, acute CVA, unstable trauma, etc.), the fllwing requirements apply t ventilatr use and / r adjustment: Patients must be bserved, by the sending facility, fr a minimum f 20 minutes after any adjustment in ventilatr settings. Patients shuld be n the transprt ventilatr fr 20 minutes prir t departure. On-line MEDICAL CONTROL is required fr any instance when adjustment f the ventilatr settings is needed. Part 5.2 Intravenus Pumps Paramedics wh perate at the ALS IFT level are expected t have a thrugh understanding f the functins and peratins f the infusin pump they will utilize (whether prperty f the ambulance service r sending facility). Paramedics are expected t nt nly cntrl the basic functins f the pump, but als be able t dynamically trublesht pump issues. Prir t transprt, paramedics must be prficient at the fllwing: Hw t turn the pump n and ff. Hw t lad and safely eject the administratin set int pump. The imprtance f having spare tubing. Hw t suspend pump peratin. Hw t adjust the infusin rate, if necessary. Hw t clear air bubbles frm the tubing. Hw t trublesht prblems (e.g., cclusin alarms). Hw the specific service addresses lw battery r pwer issues. It is strngly recmmended that paramedics be trained and practiced n the infusin pump they will be using in the field. Part 5.3 Pleural Chest Tube Mnitring Obtain and dcument the indicatin fr placement f the pleural chest tube. Ensure that the chest tube is secured t the patient, and that the drainage system remains in an upright psitin and belw the level f the patient s chest at all times. Regularly evaluate lung sunds and vital signs.
14 Signs and symptms f a tensin pneumthrax include: Dyspnea, tachypnea, decreased / absent lung sunds n affected side, hyptensin, tachycardia, jugular venus distentin, tracheal deviatin (late sign) Tubes and cnnectins shuld be evaluated fllwing any mvement f the patient t ensure leak-prf peratin and chest tube patency. Check the fllwing initially and after mving the patient: Ensure the dressing remains dry and cclusive. Ensure there are n kinks r dependent lps (e.g., a lp r turn in the tubing that frces the drainage t mve against gravity t reach the cllectin chamber) in the tubing. Amunt f water in the water seal chamber; if the water level appears lw ask a staff member if it requires refilling prir t departure. Mnitr the fllwing items after rutine assessment f patient s vital signs: Drainage (dcument the appearance and amunt f fluid, at the start and at the cnclusin f transprt) Bubbling in the water seal chamber Gentle rise and fall f the water level, which crrespnds with the patient s respiratins is called tidalling and indicates that the system is functining prperly. Trubleshting / prblems Abnrmal bubbling in the water seal chamber Remember, gentle rise and fall f the water level, which crrespnds with the patient s respiratins is called tidalling and indicates that the system is functining prperly. Cntinuus air bubbling cnfirms a cnstant air leak frm a tube cnnectin r frm the patient's chest (e.g., unreslved pneumthrax). Intermittent bubbling cnfirms an intermittent air leak frm the patient's chest. N air bubbling cnfirms n air leak frm the patient's chest and n air leak frm a tube cnnectin. If the entire chest tube is remved frm the chest: Cver with a three-sided dressing and cntact MEDICAL CONTROL. If the chest drainage system tips ver and spills: Cntact MEDICAL CONTROL; yu may be instructed t clamp tube. If the chest drainage system is crushed r brken pen, r the chest drain becmes detached frm the chest tube: Cntact MEDICAL CONTROL immediately, d nt recnnect; yu may be instructed t place the end f the chest tube in a bttle f sterile water t create a seal. Massachusetts Department f Public Health Office f Emergency Medical Services Statewide Treatment Prtcls versin 12.03