Paramedic Inter Facility Transfer Training Section 1 PIFT Overview

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Paramedic Inter Facility Transfer
TrainingSection 1 PIFT Overview
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• Paramedic
• Inter
• Facility
• Transfer

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Interfacility Transfer

• Interfacility transfer means the transfer of a
  patient from one health care facility (hospital,
  rehab, nursing home, etc.) to another.

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Interfacility Transfer

• Interfacility transfers are done every day within
  the normal scope of practice as defined by Maine
  EMS rules

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Interfacility Transfer

• Examples
• EMT-B transfers a patient with a saline lock
• EMT-P transfers a patient on a Fentanyl drip

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Interfacility Transfer

• If the normal scope of practice is not exceeded,
  then no further assistance or special
  circumstance is needed
• As long as the patient is otherwise stable

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Interfacility Transfer

• Occasionally, the needs of the patient exceed the
  capabilities and scope of practice of the EMS
  provider
• - Examples
• A stable patient on an Amiodarone drip
• A 26 week pregnant female in active labor

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Interfacility Transfer

• Under normal circumstances these patients would
  require hospital staff to accompany the crew in
  transport

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Interfacility Transfer

• The RN would be part of the team, but hold
  ultimate responsibility for administering and
  monitoring the non-EMS medications, devices and
  treatments.

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PIFT Program

• Developed in 1990s to address concerns of
  hospitals
• Hospitals concerned with having to send staff on
  inter facility transfers
• They believed stable patients who had medications
  running that were outside the normal standard of
  care could be transported by paramedics alone

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PIFT Program

• MDPB determined that there are many situations
  where properly trained paramedics can safely
  transport patients who are receiving medications
  that are outside the identified paramedic
  standard of care.

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PIFT Training

• Expanded the paramedic standard of care in the
  interfacility setting only.
• Allowed paramedics in specific circumstances to
  control and administer a new list of medications
  and monitor and troubleshoot a variety of patient
  care devices.

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PIFT Training

• The trouble is the list kept expanding

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PIFT Training

• In 2006 the MDPB updated the program to make it
  more universal.
• Medication classifications instead of a list
• The sticking point has always been patient
  stability.

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Current PIFT Parameters

• Paramedics who have completed the inter facility
  transport program may (in a PIFT Setting)
• Transport medications established by the normal
  standard of care
• And transport the following additional
  classifications of medications

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PIFT Medication Classifications

• Anticoagulants
• Anticonvulsants
• Antidiabetics
• Antidysrhythmics
• Antihypertensives (including ACE inhibitors,
  Calcium Channel Blockers, Diuretics, Alpha
  Blockers and Beta Blockers)
• Anti-Infectives
• Antipsychotics
• Cardiac Glycosides
• Corticosteroids
• Drotrecogin

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PIFT Medication Classifications

• Gastrointestinal Agents (including H2 Blockers,
  PPIs, anti-emetics, and Somatostatin or its
  analogues)
• IV Fluids, Electrolytes (including Dextran,
  Albumin, and Hetastarch)
• Narcotics (including all routes except epidural)
• Over-the-Counter (OTC) medications
• Parenteral Nutrition and Vitamins
• Platelet Aggregation Inhibitors (including
  IIb/IIIa Inhibitors)
• Respiratory Medications (Beta Agonists,
  Anticholinergics, Mucolytics and Steroids)
• Sedatives (Benzodiazepines, Barbiturates)
• Vasoactive Agents (Antihypertensives,
  Pressors/sympathomimetics)

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PIFT Medication Classifications

• Paramedics may actually be administering some of
  these medications as required by the patient
  condition and allowed by physician order and
  training.
• Paramedics may transport patients with central
  lines as long as the medications running are
  contained on this list.

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The MDPB defined very specific limitations for
PIFT transfers
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PIFT Limitations

• PIFT Transfers are limited to PIFT trained
  paramedics
• In order to be eligible to participate in a PIFT
  transfer, the provider must be a paramedic who
  has attended a new, updated PIFT training.

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PIFT Limitations

• Expanded protocols are limited to the
  interfacility transfer setting
• Interfacility transfer setting means the transfer
  of a patient from one health care facility
  (hospital) to another.
• PIFT trained paramedics are not allowed to use
  expanded protocols in any setting other than a
  PIFT transfer.

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PIFT Limitations

• Services must also be permitted through MEMS as a
  PIFT Service
• More on this later

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Stability
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Stability

• To be eligible for a PIFT transfer, a patient
  must be stable.

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Stability

• A patient is considered stable when there is
  no foreseeable likelihood of material
  deterioration in the condition of the patient as
  a result of or during the transport.

Maine EMS Medical Directions and Practice Board
2006
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Stability

• Assessment of stability will require
• Hemodynamic and neurologic signs which have
  demonstrated no deterioration from the acute
  presentation of the patient, or are within
  acceptable limits of variation on existing
  therapy and.

Maine EMS Medical Directions and Practice Board
2006
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Stability

• may be reasonably predicted to remain so during
  the transport without the need for further
  adjustments to such therapy

Maine EMS Medical Directions and Practice Board
2006
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Stability

• The pathophysiology of the patients acute
  condition is known to favorably respond to the
  therapeutic interventions which have been
  undertaken at the sending hospital

Maine EMS Medical Directions and Practice Board
2006
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Stability

• Patient reports and detailed physician orders are
  critical components of a stability decision

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Stability

• The PIFT paramedic must have
• A detailed understanding of the patient history
  as it relates to this current treatment plan
• Additional relevant patient history
• Physician instructions for managing patient
  change during transport.

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The final decision on whether the patient can be
transported under the PIFT program will be made
by the transporting paramedic
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There are many inter facility transfers that will
not be eligible for PIFT and therefore must
utilize hospital staff
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Non-PIFT Situations

• Patients who are not stable according to the
  definition listed previously.
• Patients who are on medications or equipment that
  is not included in the PIFT program.
• Situations where the paramedic is not comfortable
  transporting without additional hospital
  personnel

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Bottom Line
A safe and effective inter facility transport
requires the use of adequately trained personnel
utilizing appropriate equipment for the
management of the patient
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PIFT Transfers
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Pre-Trip Check

• Prior to picking up the patient the transferring
  paramedic receives a report
• Patient conditions
• Medications running
• Required equipment

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Pre-Trip Check

• Paramedic conducts a pre-trip inventory
• Appropriate equipment
• Gas levels
• Resources

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Pre-Trip Check

• Paramedic reviews operation of any required
  equipment to ensure proper familiarity with
  operation.

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Pre-Trip Check

• Paramedic reviews unfamiliar medications
• Mechanism of action
• Indications
• Contraindications
• Precautions
• Side Effects/Untoward effects
• Potential complications

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Patient Deterioration
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Patient Deterioration

• Patient must be regularly re-assessed in order to
  identify changes in patient condition as soon as
  possible.

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Patient Deterioration

• Paramedics must be acutely aware of specific
  physician orders and the medications that are
  being administered

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Patient Deterioration

• What are the orders?
• What medications need to be given to prevent
  deterioration?
• Are there medications to be given in the event of
  deterioration?

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Patient Deterioration

• If changes in the patient are dramatic, the
  paramedic should attempt to contact medical
  control
• 1st choice Sending physician/facility
• 2nd choice Receiving physician/facility
• 3rd choice Diversion/3rd party physician

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Patient Deterioration

• In extreme circumstances, the paramedic may
  consider discontinuing the medication and utilize
  existing MEMS protocols to manage the patient.

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Patient Deterioration

• The transporting crew should also consider
  diverting to the closest hospital with an
  emergency department for assistance.

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Report to Receiving Facility

• The Paramedic is a key part of the patient care
  team and must take responsibility for continuing
  the communication link that passes critical
  patient information between caregivers.

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Report to Receiving Facility

• Information that should be passed along to the
  receiving facility include
• History received from the sending facility
• Assessment findings during transport
• Patient general condition
• Treatments administered and/or altered during
  transport
• Patient response to treatments or changes.

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Summary

• PIFT enables paramedics to broaden their scope of
  practice during interfacilty transfers
• Not all interfacility transfers will qualify for
  PIFT
• PIFT has rigid parameters including a stability
  assessment
• Appropriate transport decisions must be made
• Good judgment is an ongoing requirement