Major Topic #2: Meeting Patient Needs

The overriding principle for all aspects of IFT is matching patient needs with adequate provider knowledge and skills, equipment and an infrastructure that provides seamless patient flow during transport. Any judgment should err on the side of caution in providing care at the level likely to be needed or potentially needed during IFT.

Interfacility transfer requires a unique set of skills distinct from the training of most hospital-based or prehospital providers. It is essential that personnel used to provide care during interfacility transfer be properly trained, familiar with the demands of providing care during ground or air transport, legally authorized to perform these skills, and prepared to handle the variety of patient contingencies that may arise during transport. Additional education will be needed to prepare all traditional providers for interfacility care, whether hospital or prehospital-based, but the specific focus of this additional education may vary depending on the provider’s existing knowledge and skill base.

The discussion about provider education should start with a review of the questions to be asked:

• What are the specific needs of the patient?
• What types of practitioners are working in the field?
• What are the skills and knowledge levels these practitioners need for IFT?
• What type of training is required?
• What type of continuing education is necessary to assure knowledge and skills?

Since a variety of practitioners could be involved in interfacility transfer (paramedics, EMTs, nurses, physicians, respiratory specialists, etc.), attention should be focused on the knowledge, skills, and abilities required to match patient needs, as well as characteristics of effective education and training. Operational procedures and protocols must comply with State and local requirements as well as medical oversight.

Regardless of entry-level knowledge, skills, and abilities, there are basic transport skills and knowledge that anyone involved in IFT should possess:

Basic Knowledge and Skills:
Any health care professional providing care during IFT should demonstrate knowledge and skills related to:

• radio and communication technology;
• transport physiology;
• safety operations to include the vehicle (ambulance and/or aircraft) the patient, equipment, and all care providers on board;
• transport equipment;
• documentation;
• transport logistics;
• transfer protocol(s);
• patient records;
• physician orders;
• patient “packaging” for safety and accessibility;
• medical oversight; and
• evaluation of level of care needed by patient during transport.

Providers conducting interfacility transfers for patients in the “stable with low risk of deterioration” and “stable with medium risk of deterioration” should demonstrate knowledge, skills, and demonstrated abilities that include:

Advanced Knowledge and Skills:

• basic transport skills;
• IV insertion, monitoring and maintenance; including maintenance of central venous and intraosseous lines;
• all forms of medication administration;
• pharmacology at the DOT EMT- Paramedic National Standard Curriculum level;
• advanced airway management;
• ECG monitoring; and
• defibrillation, cardioversion, and transcutaneous pacing.

Providers involved in interfacility transfer of unstable, critically ill, or injured patients should have the ability to continuously monitor and assess the patient’s condition and to intervene appropriately. At a minimum, this would require skill and knowledge in the areas of:

Critical Care Knowledge and Skills:

• advanced airway management;
• ventilator management;
• all forms of medication administration;
• pharmacology at the DOT EMT- Paramedic National Standard Curriculum level, plus advanced knowledge of vasoactive and antiarrhythmic drugs; and
• circulatory management and support.

Specialty Care Transport, as defined by the Centers for Medicare &
Medicaid Services¹
Specialty care transport (SCT) is interfacility transportation of a critically injured or ill beneficiary by a ground ambulance vehicle, including the provision of medically necessary supplies and services, at a level of service beyond the scope of the EMT-Paramedic. SCT is necessary when a beneficiary’s condition requires ongoing care that must be furnished by one or more health professionals in an appropriate specialty area, for example, emergency or critical care nursing, emergency medicine, respiratory care, cardiovascular care, or a paramedic with additional training.

General IFT Provider Education Guidelines
Existing resources that establish minimum guidelines on provider education can be incorporated into education standards and guidelines. Desirable characteristics for provider education programs may include:

• Training and education that provide the knowledge and skills enabling providers to monitor and provide necessary care to maintain the stability of the patients’ condition. This includes a working knowledge base and critical thinking ability related to the likely and potential complications associated with specific disease and injury processes, as well as complications associated with specific interventions.
  
  
• Sufficient clinical and field experience enabling providers to deal with varying levels of patient acuity.
  
  
• Initial and continuing education and training that is both didactic and hands-on, and of a sufficient time period to allow provider to demonstrate adequate knowledge and skills.
  
  
• Knowledge of assessment and intervention techniques specific to the provision of care required during IFT.
  
  
• Additional minimum requirements determined by the specific patient population being transported by providers.
  
  
• Continuing education requirements based upon data collected as part of a quality improvement/management program. Quality improvement data can include such information as frequency of specific clinical presentations, low-frequency/high-criticality interventions, patient outcomes, and issues related to concurrent and retrospective quality improvement.

References
1. Program Memorandum Intermediaries/Carriers. Transmittal AB-02/130. Subject: Definitions of Ambulance Services. September 27, 2002. Department of Health & Human Services. Centers for Medicare and Medicaid Services. Washington, DC.