IFT's how do you handle them

rhan101277

rhan101277

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Yesterday I had my first transfers where I was responsible for their care. Even though it was just moving patients from place to place I took it as a big responsibility.

I assessed their LOC and did vitals on them every 15 minutes. One man I had to take about 1.5 hr. away. I checked his vitals five times, I think he was getting a little aggravated. This is how I am supposed to do it though, some people say they do it every 30 minutes, for people you are just moving from Dr.'s appt to nursing home etc. I like having a track record of vitals so I can have it to see if anything is going on. I also listen to lung sounds and heart sounds a couple times.

If they are AO, I will ask them about allergies, past history, current medical illness, medications etc. if I am taking them from nursing home to hospital for a checkup or whatnot. Some pts. come to me and they are not are alert but they can't talk etc. I try to talk to them ask them how they are doing and they shake their head they are ok etc.

How do you do yours?
 
Honestly Rhan, you are going to upset your patients if you check their vitals every 15 minutes on a stable IFT. Unless they are going somewhere for urgent or emergent medical services they cannot get at their sending facility (like SNF to ER, or hospital with no surgical capabilities to one with, etc), than you do not need to be up on them. I personally take a set at the sending facility, interview them in route, and take a last one at the destination.

Than again, they have no right to be upset. If they just took a taxi like they should have and did not abuse the Medicare and healthcare industries by using an ambulance when they did not need one, they would not have to worry about getting their vital sings taken.
 
Did you also go through the paperwork that went with the patient? Most emergency calls and discharges that I've transported has included a history and physical which is a great source for history and allergies. In addition there should be a medications administration record (MAR) with those patients. I wouldn't imagine that most SNF patients know their three pages worth of mediciations off the top of their head.

For dialysis transports, a face sheet can be your best friend since they normally include a limited histroy ("admiting dx" and "secondary dx"), allergies, demographic, and insurance data. Just make sure to leave it with the dialysis clinic so that the return crew has access to it.

Taking vital signs every 15 minutes is good, but if you're on a long transport and the patient is starting to get aggrevated, then you can always increase the time to, say, q20 minutes. If the patient refuse vital signs, then they refuse and just document that ("V/S monitored, BP UTO due to patient refusal").

Stable interfacility patients are great practice. These patients, while stable, are always sick in their own, multisystem way. In addition, you'll be taking multiple sets of V/S while the unit is moving, which will give you the ability to nail down taking a B/P with road noise as well as taking a proper history.
 
Oh rhan! Aren't IFTs great? I LOVE doing IFTs as you have a great chance to work on your assement and learn about some really neat procedures and diseases and the like that you really wouldn't get exposed to doing 911. If you're doing an A/B trip to take a patient to a procedure, sometimes they'll let you watch!

Keep in mind, your patient has probably had their vitals taken a thousand times already that day, so they are likely to get annoyed. Don't take it personally, they're just tired of having their arm squeezed or wrist held! I always grabbed a face sheet, flipped through the chart (and stole a sticker due to the requirement of my former company to have the patient's ID number located somewhere on the paper after someone took the wrong patient.) and got a PTA and an on scene set of vitals. Normally the transfers weren't long enough to get more than one enroute set, but if they were longer transports, I gauged the patient's behavior. If they were up and talking it's "Hey! I know I just took this like 20 minutes ago, but I'm gonna get another set of vitals, okay?" While grabbing the cuff. If they wanted to sleep, and I'd already taken a set myself, eh, I'd let them sleep and take a last set when we arrived. I also tried to confirm their history and allergies that I got from the chart with them in case it didn't include everything (and sometimes it doesn't!)

Talk to the patients about what they got, or what they've had done, if they're up to it. You'll learn so much!

Than again, they have no right to be upset. If they just took a taxi like they should have and did not abuse the Medicare and healthcare industries by using an ambulance when they did not need one, they would not have to worry about getting their vital sings taken.
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At least around here, IFTs are usually arranged by the nurse or discharge planner. The patients don't really have a choice how they want to get home or get to the hospital, cut 'em some slack!
 
Around here, a patient whines about how to get home in an ER, a nurse will call an ambulance as her own little taxi service.

Now, however, I can demand that a MD sign a prescription of sorts for ambulance transportation since medicare is just not paying out on those sketchy calls anymore. Not a lot of self respecting doctors will sign a paper that says the patient would be placed in unacceptable danger using another form of transportation.

I am not sure how getting vital signs in stable patients is great practice. You should already know how to do that :glare:. I am going to be honest, IFTs have given me nothing, and I get no credit with schools or other companies for my time on an IFT ambulance.
 
I did look at the face sheet, it didn't have much information. I found out about the asthma myself. There was some stuff from the hospital in a manila envelope, I thought that might be something I didn't need to look at. Anyhow thanks for the input so far.
 
Always look at the stuff in the manila envelope. Also, if your company has large envelopes and you have time, move all of the documents from the hospital envelope to your company's envelope (advertising for the company makes your company happy).
 
daedalus said:
I am not sure how getting vital signs in stable patients is great practice.
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How many schools require their students to take V/S in a moving vehicle forcing the students to deal with road noises and bumps?
 
JPINFV said:
How many schools require their students to take V/S in a moving vehicle forcing the students to deal with road noises and bumps?
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In my experiences, vital signs are rarely taken in the truck manually. If you get on a real 911 rig in ventura or LA county it just doesn't happen.

Most decent medics demand a manuel blood pressure on scene, which I will as well when I become a paramedic. Since this is when an impression of the patient and a treatment plan is formed, you need an accurate BP. A good assessment also includes feeling the pulse with your own hands, placing that stethoscope on the body, etc. After that, when transporting, its more important to monitor for changes. Thats when EKG, pulse oximetry, and NIBP are completely acceptable as tools to monitor your patient, along with looking at your patient with your own eyes. Since all 911 transports around here are under 10 minutes, there is no logical reason to get a additional set of manuel blood pressures etc on most calls.

I was taught how to take vital signs in a moving noisy environment in class. I do not need any more practice. Lets see IFTs as they are. IFTs.
 
JPINFV said:
How many schools require their students to take V/S in a moving vehicle forcing the students to deal with road noises and bumps?
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I know of one in SoCal. There could be others....

As far as IFTs, if the patient is getting aggravated at the repeated blood pressures, they get wider and wider apart. If they flat refuse, that is documented. Always read the stuff in the envelope.
 
daedalus said:
. Thats when EKG, pulse oximetry, and NIBP are completely acceptable as tools to monitor your patient, along with looking at your patient with your own eyes. Since all 911 transports around here are under 10 minutes, there is no logical reason to get a additional set of manuel blood pressures etc on most calls.

I was taught how to take vital signs in a moving noisy environment in class. I do not need any more practice. Lets see IFTs as they are. IFTs.
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May I put forth that most EMT-Bs don't have NiBP, pulse oximetry (which should be used to measure pulse anyways since the pulse rate is more to verify that the reading is correct), or ECG available to them? May I also put forth that if you are working on an IFT that you might as well get what you can out of it, even if it isn't necessarily the best place to be? May I finally put forth that not everyplace has a transport time of less than 15 minutes? Don't get me wrong, I'm not against V/S, say, q20 or 30 minutes. It's not like the act of moving the patient from the hospital (where V/S might be q___hours instead of minutes) to the ambulance all of a sudden makes the patient unstable. Similarly, I don't believe that the patient is going to similarly crash just because the V/S were taken at 20 instead of 15. That said, I'm not going to advise a new EMT-B to go against their training until they are comfortable with monitoring their patient with their eyes and ears instead of their tools to get numbers that they are comparing against ranges for normal healthy people.
 
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JP... you mean "Shouldn't"... correct? Please don't tell me you think the Pulse Ox is the best toy on a BLS ambulance since the MAST Pants!

Anyway - To the OP: Check your local protocols, and your companies documentation standards. Where I work 911... the minimum is 2 sets of vital signs per call, and we don't have a strict time limit... some places have a q5 unstable, q15 stable documentation standard... so you could get jammed up if you don't document it that way - and don't you DARE falsify documents by fudging the times/inventing numbers - that is asking for trouble.
 
Jon said:
JP... you mean "Shouldn't"... correct? Please don't tell me you think the Pulse Ox is the best toy on a BLS ambulance since the MAST Pants!
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Doh. Yes, I meant "shouldn't."
 
While the IFT's aren't the most exciting, and hell, vitals every 15 minutes can be frustrating for the frequent flyer pt as well as you convincing them, the important thing is that they're required (at least here) every 15 min by our state agency. Documenting "pt refused" on nearly every tx could raise eyebrows towards ya.

I know nothing about you, but what I do know is that you love EMS (the post where you said you took time off your fulltime job to volly at EMS job). It'd be a shame to see you get jammed up because of well meaning (hell truthful) advice. Get vitals as frequently as mandated but take into equal consideration your pts needs.

Ex: Took an IFT ways back as a EMT where a relatively young pt had (among many other things) breast ca that matastecized (sp?) to the point where her chest and arms were necrotic. She was in such a miserable state that she was being taken from home hospice to a full-time hospice facility because of the open wounds and emotional devastation of family. Moving her to the stretcher was horrendous, every bump she moaned or cried out.
Anyways, she had the bilat necrosis on her extremities and was frankly miserably ending her existence... and because of that, I refused to take a BP even once. Sorry for the long explanation... that IFT will just always stay with me.
 
vquintessence said:
Anyways, she had the bilat necrosis on her extremities and was frankly miserably ending her existence... and because of that, I refused to take a BP even once. Sorry for the long explanation... that IFT will just always stay with me.
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Sounds like excellent clinical judgment to me. If she is going to hospice and vitals tank, so what?

But back to the OP: that is what automated bp cuffs are for :)
 
The only V/S I have a hard time getting in a moving truck is lung sounds. Then again, none of my patients so far have had major SOB issues, so maybe when I get someone with serious wheezes/crackles, I'll catch that despite the truck noise. I was worried about doing manual BPs on the move, but it turned out to be pretty easy (I practiced on myself a few times while accompanying a sleeping patient before doing it on a patient). I've never done it with lights and sirens on, though, that would definitely be a challenge. But I do normally use the machine, I just do manual BP when the machine #s seem suspicious, to double-check.


Our PCRs have 5 spots for vitals, I generally make sure I have at least 2 sets of vitals done on a stable transfer. If it's a longer transfer, I will do 3 or 4, which means getting vitals every 45 mins or so. If you have them hooked up to the machine, it shouldn't take you long (or bother the patient too much). Pulse ox and heart rate will show up on the monitor without you having to bother the PT. BP cuff gotta inflate, but you can leave that up to the machine. Resps can usually be observed without bothering the PT. We don't normally take temp and only take BGL 1x unless the PT is a diabetic. I only do pupils once in a medical where there's no possibility of stroke or other neuro issues. So it turns out that the patient doesn't need to be poked and prodded an awful lot for you to gather the vitals required for your PCR.


That said, I once only did 1 set of vitals on a 2.5-hour stable transfer because it was a 3 AM call and the PT had not slept for something like 40 hours straight. He was dozing off and I didn't wanna bother him (he got visibly annoyed when I did vitals on him, even though he cooperated). I got crap for that one. The other day my partner was attending to an epileptic child who also had a fever and was very upset. He was crying for about 2 hours straight, then finally fell asleep, and my partner woke him up to take his BP, after which he proceeded to cry and scream for another hour....I would've definitely NOT done vitals in that situation unless the child seemed to be getting worse.
 
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We don't have auto cuffs on any of our trucks, if we did I am sure only medics could use them. I take down all of my assessment stuff on a paper patient care report sheet and then put them on the computer, that way I get the times right and all the info on there. I see most that have been working there a while just write in on their glove and then put it in the computer. I think I am going to get in the habit of using that paper report and transferring it makes me feel better and lets me know I am being as accurate as I can.
 
I also wanted to know I took of my full-time job, to work at my paid EMT job. It doesn't pay much, I could probably make the same flipping some burgers. This job has much more to offer than the burger job though and I really enjoy it.
 
vquintessence said:
Ex: Took an IFT ways back as a EMT where a relatively young pt had (among many other things) breast ca that matastecized (sp?) to the point where her chest and arms were necrotic. She was in such a miserable state that she was being taken from home hospice to a full-time hospice facility because of the open wounds and emotional devastation of family. Moving her to the stretcher was horrendous, every bump she moaned or cried out.
Anyways, she had the bilat necrosis on her extremities and was frankly miserably ending her existence... and because of that, I refused to take a BP even once. Sorry for the long explanation... that IFT will just always stay with me.
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When reading a chart for comfort care or hospice patients, one might notice that "No vitals" is part of the order set. We do not even check an SpO2 on these patients in the hospital. They are made comfortable by pharmacological means according to visual assessment.

However, there are different types of hospice and different order sets depending on the state and patient's wishes.
 
daedalus said:
In my experiences, vital signs are rarely taken in the truck manually. If you get on a real 911 rig in ventura or LA county it just doesn't happen.

Most decent medics demand a manuel blood pressure on scene, which I will as well when I become a paramedic. Since this is when an impression of the patient and a treatment plan is formed, you need an accurate BP. A good assessment also includes feeling the pulse with your own hands, placing that stethoscope on the body, etc. After that, when transporting, its more important to monitor for changes. Thats when EKG, pulse oximetry, and NIBP are completely acceptable as tools to monitor your patient, along with looking at your patient with your own eyes. Since all 911 transports around here are under 10 minutes, there is no logical reason to get a additional set of manuel blood pressures etc on most calls.

I was taught how to take vital signs in a moving noisy environment in class. I do not need any more practice. Lets see IFTs as they are. IFTs.
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I don't trust automatic b/p cuffs for emergencys. I like to hear what the B/p sounds like. and if you had a pt with a b/p in the toilet it could 10 mins to get a b/p. If you do it manual, it shouldn't take more than a min. plus I tend to find people that I guess are in afib by taking a blood pressure. I am 10 for 10. Not that afib is a big deal.
As for transfers. VS at sending facility, one b/p in route and maybe one at destination, for stable pts only. more for unstable pt's. D/c usally only get one set unless transport is more than a half hour.
 
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