IFT, what do you think?

[Veneficus]

It is no surprise to anyone who has ever been involved in the IFT side of EMS that it is a completely different animal from emergency 911, 999, or whatever you dial for an ambulance for an acute medical emergency.

I don't have an official stat, but I am willing to bet a majority of EMS providers work with IFT, whether it is part of a 911 service or not.

There is nothing in the US EMS curriculum that addresses this large segment of the EMS community in terms of education, training, or skills.

Now we all know that any attempt to add hours or information to EMS education is met with absolute opposition.

So here is the questions,

Should IFT require a seperate education(class) from EMT?

Should it be a add on course similar to CCT?

What do you think should be part of this refinement?

Anything else you think would contribute to this discussion?

 

[HotelCo]

A few classes I think should be required before doing IFT:

Hospital Politics 101

RN Drama 312

Dealing With Overly-Involved Family Members 435


..But seriously, it depends what kind of IFT you're doing. If you're doing dialysis runs/take granny to the big hospital because she has a UTI, then no, EMT is fine (and on some of these patients, can be overkill).

If you're doing ACTUAL (unstable) IFT, then more training is a must.

 

[JPINFV]

It should be a seperate service completely. No lights, no sirens, limited emergency equipment on board. I say limited because the majority of the emergency equipment is simply not needed. How many interfacility patients not going to the emergency department need the OB kit? Trauma bandages? Backboard and splinting supplies? The trauma bandage?

I think that, ideally, non-emergent interfacility work should be done by non-EMS providers that are actually trained in treating patients suffering from chronic diseases. Anything going to the emergency room gets an emergency ambulance staffed with paramedics. By splitting it like this you go from a large segment of EMS providers who are trained in treating emergency conditions who are actually transporting non-emergent patients while at the same time removing a large segment of EMS providers where the employers are fighting to keep training requirments low. After all, why care if your EMT can do additional interventions if none of the pateints ever indicate that intervention?

 

[abckidsmom]

From the perspective of ambulance service operation, IFTs (in their many forms) are imperative to the bottom line. 911 doesn't pay the bills, and I can't imagine a system where 911 did pay the bills. Most municipalities do not have the wherewithal to fully fund an EMS system, thus the typical (but not universal) suckiness of the FD-based EMS.

I think that EMT is adequate, but like CPR and ACLS, there should be an every-other-year course to certify you in billing-ese, hospital relations, etc, to help providers navigate the IFT paperwork and system. Learning the specific roles of the people you interact with on the floors, in the dialysis units, etc can go a long way to figuring out why the RN won't do whatever it is you expect her to do.

From the hospital's perspective, a little education for the nurses who make the tranport decisions for their patients would be great. They often just don't understand what the different modes of transportation even are.

 

[Aerin-Sol]

It should be a seperate service completely. No lights, no sirens, limited emergency equipment on board. I say limited because the majority of the emergency equipment is simply not needed. How many interfacility patients not going to the emergency department need the OB kit? Trauma bandages? Backboard and splinting supplies? The trauma bandage?

I disagree, because there is not a strict division between 911 calls and non-emergency IFTs in my city. Many nursing homes/clinics/outpatient facilities call my private IFT service for emergency calls. This past week I worked with a paramedic and we had 3 emergency calls: 1 chest pain/SOA clinic -> ER, 1 active MI clinic -> ER, and 1 call that was dispatched as suspected stroke (but wasn't). In addition, my service does all of the special events/stand-bys for sporting events, which result in occasional emergency calls, and I personally have used a ladder splint and lots of bandages (Australian Football Conference) and know other EMT-Bs who have used backboards and trauma bandages (BMX competition). If there was a clear division between non-emergency IFT and everything else EMS does, I'd agree with you, but there's not, at least in my city.

 

[firetender]

As part of EMT and Paramedic curricula should be a class on

"The Economics of IFT's"

In it, the existing system of EMS should be discussed, including an examination of how the income flow works and how it actually DOES support the delivery of advanced care in your neighborhood.

Then, as your PhD dissertation, you can make a formula for analyzing each system, determining ALTERNATES to financially supporting EMS through IFT's, design and alternative form of service that is truly non-emergency AND cost-effective for the patient and/or insurer. Then, you can find funding sources for an experiment or two. Then, open up a company that solves the problem and make some money for a damn change!

 

[JPINFV]

I believe you are misunderstanding the division. Regardless of the origin, if the patient is going to the emergnecy department, they should be attended by paramedics who are familiar with treating patients suffering from emergencies. As such, the clinic to ED would be treated and transported by paramedics through the emergency system. However, you don't need a paramedic, or even an EMT, for the vast majority of non-emergent transports, in large part because the demands of the job in no way matches the capabilities and training of EMTs and paramedics short of having a van that carries a gurney with a staff of two people.

In my time working IFT, I've only transported one pregnant patient who wasn't even in prelabor. However patients with COPD, renal failure, a-fib, MRSA, and other common chronic diseases and infections every day. Why is it acceptable that the time spend covering deliveries dwarfs the almost non-existant combined coverage of COPD, renal failure, a-fib, and MRSA?

Standby and non-emergent transport are completely different things, hence the BMX and Australian Football events are not pertinent to the discussion. What does a dialysis transport, doctor's office transport, or hospital discharge have in common with event standby short of the aformentioned 2 dudes with a gurney and a van?

 

[medicRob]

In my humble opinion, IFT should have its own section in EMT school. Back when I was in EMT-IV school, my program was separated into 2 semesters.. Semester 1 was trauma, semester 2 was medical.

It would be nice if the program could be extended allowing for IFT to be added in as its own section, or at least throw in IFT as a separate section under medical.

 

[terrible one]

I believe IFT should be completely separte. Private business, leave emergency to a municpality (third service, county, department of health, etc..)

 

[18G]

I think IFT is best served by EMS but would be better served if additional education was directed at transporting patients inter-facility.

I'll use myself as an example, I started working for an ALS service (FD) that does IFT from a rural medical center to actual hospitals with more capabilities. The hospital sends their IV pumps yet there is no formal in-service training whatsoever on the IV pumps. Granted, the pumps and drips are already set but the Medic needs to know how to troubleshoot the pump, clear errors, etc. I at least took the effort to talk to the nursing staff in the ED and got a quick "review" of the pumps and asked for the number to the medical centers education dept.

This is just one example of where specialized IFT training would be helpful. In my program at least, we got zero experience or exposure to IV pumps.

 

[medicRob]

I think IFT is best served by EMS but would be better served if additional education was directed at transporting patients inter-facility.

I'll use myself as an example, I started working for an ALS service (FD) that does IFT from a rural medical center to actual hospitals with more capabilities. The hospital sends their IV pumps yet there is no formal in-service training whatsoever on the IV pumps. Granted, the pumps and drips are already set but the Medic needs to know how to troubleshoot the pump, clear errors, etc. I at least took the effort to talk to the nursing staff in the ED and got a quick "review" of the pumps and asked for the number to the medical centers education dept.

This is just one example of where specialized IFT training would be helpful. In my program at least, we got zero experience or exposure to IV pumps.

Not downing your program or anything, but didn't your paramedic program train you on the use of various IV Pumps in school? Ours trained us and required the skill to be checked off on the "Home Health" section of our check off sheet.

 

[firecoins]

It should be a seperate service completely. No lights, no sirens, limited emergency equipment on board.

We do emergencies on the IFT side. Kind of need those. We have had patients detouriate. Need the the lights and sirens when these occur.

How many interfacility patients not going to the emergency department need the OB kit? Trauma bandages? Backboard and splinting supplies? The trauma bandage?

we have transfered pregnant women. And nursign facilities have called us for falls.

 

[usalsfyre]

I think IFT is best served by EMS but would be better served if additional education was directed at transporting patients inter-facility.

I'll use myself as an example, I started working for an ALS service (FD) that does IFT from a rural medical center to actual hospitals with more capabilities. The hospital sends their IV pumps yet there is no formal in-service training whatsoever on the IV pumps. Granted, the pumps and drips are already set but the Medic needs to know how to troubleshoot the pump, clear errors, etc. I at least took the effort to talk to the nursing staff in the ED and got a quick "review" of the pumps and asked for the number to the medical centers education dept.

This is just one example of where specialized IFT training would be helpful. In my program at least, we got zero experience or exposure to IV pumps.

No offense, but there's no way in flaming hades I'm putting unfamiliar equipment and medications I'm not comfortable titrating in my truck without someone there who is. Doing so is setting yourself up for failure in a big way.

 

[usalsfyre]

We do emergencies on the IFT side. Kind of need those. We have had patients detouriate. Need the the lights and sirens when these occur.


we have transfered pregnant women. And nursign facilities have called us for falls.

The point is if you find an emergent condition on arrival, turf the call to someone who can handle it.

 

[usalsfyre]

I'm in favor of scrapping the current system. EMTs are improperly prepared to do the largest part of their job. Restructure the ciriculum to include chronic diseases, propper pt movement, ect.

 

[JPINFV]

We do emergencies on the IFT side. Kind of need those. We have had patients detouriate. Need the the lights and sirens when these occur.

...and wheel chair vans have had patients deteriorate on board. Should we start equipping wheel chair vans with lights and sirens?

we have transfered pregnant women. And nursign facilities have called us for falls.

Either you take your falls and pregnant women in (pre)labor and fall patients to dialysis clinics instead of the hospital, or you missed the part where I pointed out that if the patient was headed to the emergency room that the designated EMS service, not the contracted IFT service, would provide transport.


How many patients at risk for immanent delivery has your service's EMTs transported?

How many patients with a-fib has your service's EMTs transported?

How many patients with CHF has your service's EMTs transported?

How many patients in renal failure has your service's EMTs transported?


Why is the first covered in much greater detail than the last three? Does the patient population of the general public (which is what emergency services are primarily concerned with) match the patient population of the standard non-emergent transfer service?

Does the non-emergent transfer service really have to take the patients from facilities to the emergency room, or could those transports be funneled into the local EMS system? If an emergency in a clinic, doctor's office, or SNF requires a lights and sirens response shouldn't it always be through the local EMS system?

 

[Aerin-Sol]

I believe you are misunderstanding the division. Regardless of the origin, if the patient is going to the emergnecy department, they should be attended by paramedics who are familiar with treating patients suffering from emergencies. As such, the clinic to ED would be treated and transported by paramedics through the emergency system. However, you don't need a paramedic, or even an EMT, for the vast majority of non-emergent transports, in large part because the demands of the job in no way matches the capabilities and training of EMTs and paramedics short of having a van that carries a gurney with a staff of two people.

In my time working IFT, I've only transported one pregnant patient who wasn't even in prelabor. However patients with COPD, renal failure, a-fib, MRSA, and other common chronic diseases and infections every day. Why is it acceptable that the time spend covering deliveries dwarfs the almost non-existant combined coverage of COPD, renal failure, a-fib, and MRSA?

I agree with you on all of this, and found that my EMT training left me with poor expectations of what my job would actually be like and poor preparation for working it; however, there is no clear-cut "emergency system" and "non-emergency system" in my area. In addition to the scenarios that I offered, the 911 service often passes calls to my service when they are overwhelmed, or if they need a bariatric truck (they don't have one). Perhaps you're arguing that ideally there would be a clear-cut division? I don't see that working practically in my area.

Standby and non-emergent transport are completely different things, hence the BMX and Australian Football events are not pertinent to the discussion. What does a dialysis transport, doctor's office transport, or hospital discharge have in common with event standby short of the aformentioned 2 dudes with a gurney and a van?

I understand they are separate events with separate required skillsets, but in my area, they are handled by the same service. Do you think that over-taxed public emergency services should handle standby events? That IFT services without emergency equipment should handle them? Or that a third group with a third type of training should cover them?

 

[thegreypilgrim]

I'm somewhat undecided on this. I tend to lean toward what JP advocated in making IFT and Emergency completely separate deals. I would prefer if hospitals just handled their IFT issues internally, and maintained ambulances staffed by otherwise non-EMS professionals (RNs, RTs, etc.) while operating on an non-profit basis (cut out all the bottom-feeding racketeering private ambulance services). Any ambulance request originating a non-acute care hospital where the destination is an ED (i.e. clinic to ED, SNF to ED, etc.) gets a standard EMS ambulance with two medics (although a Code 2/No Lights/Sirens response could be appropriate).

Like JP said the two are just entirely different skill sets, perspectives, and contexts with little to no congruence. Therefore, it makes sense to match people with the corresponding education/training to each service. In my opinion, having EMS cross over with IFT is poor decision making. It's akin to crossing EMS with the Fire Dept. or PD or whatever other "dual-function" system you want to devise. You inevitably end up with a disproportionate amount of people trained for XYZ doing ABC resulting in reduced ability to perform XYZ should the need ever arise and never having properly learned how to do ABC to begin with.

I've been an IFT medic for almost 2 years now due to a paucity of emergency jobs in my region, and I can tell you it has absolutely diminished my functional utility in emergent situations.

It has hurt my ability to conduct a thorough, systematic, and concise assessment in acute ahistoric situations. It has hurt my delegation abilities. It has hurt my ability to rapidly generate a differential and reason clinically in acute settings. It has hurt my "scene presence" and leadership abilities. It has hurt my ability to respond cohesively with professionals from other agencies (medical or otherwise).

Even though I haven't really been back in those situations, I know there has been a significant drop off in those skills/abilities I once had simply by virtue of not having been a part of it for almost 2 years (despite continued study, further education, etc. there's something about "doing it" that plays a huge role in your performance). I'm at the point now where I question whether or not I can ever go back to being able to function in emergency contexts as I ought to - indeed the prospect of getting a 911 job seems slimmer and slimmer given the length of my absence from that work (ambulance companies around here don't really care [and probably don't understand] about world events such as the ongoing financial crisis and how that affects job prospects).

So, from that perspective, I think it would be better to just keep them separate. On the other hand I'm all about EMS expanding into new areas and I think it would be interesting to add a post-graduate "Critical Care Paramedic" credential (a LEGITIMATE one - not like the 80-something-hour CCEMT-P course put on by UMBC) which would allow us to participate in legitimate, medically necessary IFTs alongside CCRNs. No more silly insurance repatriations that carry no real medical necessity. Basically a ground ambulance version of the flight service configuration of FP-C/CFRN would be interesting.

 

[DrParasite]

My personal opinion is that most IFTs are a waste of an EMT's time. Especially from hospital to SNF or home. Not that they don't need to get done, but most time the patient is so stable that you don't need an EMT, but rather a couple strong guys just to help with moving from hospital bed to cot, then from cot to end destination. A bunch of professional furniture movers might be better suited for the job.

The fact that in some parts of the country a PARAMEDIC is doing IFTs totally blows my mind. If I was a paramedic (two year degree, 4 year degree, whatever) and I was stuck on an IFT unit, I would either kill myself due to boredom, or look to move to another state where I would be doing the emergencies that I was trained for. But that's just my opinion, and your opinion may vary.

Now, for the potentially unstable IFTs (from a location to an ER), send two EMTs. depending on the nature, send two paramedics. treat it as an emergency.

Send the appropriate unit to handle the call. if the patient has lines that need to be kept running, ALS all the way. maybe CCT with a nurse. if they are unstable, ALS the transfer.

but going from home to a routine doctor's appointment doesn't require a paramedic. doesn't even require an EMT, unless the patient is potentially unstable. then have the EMT for the "just in case" scenario, and the EMT can call for the paramedics if the patient does indeed crash.

But following the line of thinking that an EMT is needed for IFTs, then I would agree that there is a difference between an IFT EMT and a 911 EMT, and the training should focus on IFT, while the 911 EMT should focus on emergencies, and their supplemental training should focus on that area of work.

 

[the_negro_puppy]

While I work for acute emergencies 000/911/999 I do my fair share of IFT's.

Many of these are patients flown in from remote and regional areas to our state capital for care in major hospitals. Our protocols state we have to have a nurse or doctor escort if the patient is receiving any infusions of drugs that we dont/cant use, is on a ventilator etc


I find it a good break from the acute side so I dont mind it. However there's no way i could do just IFTs for a living.