Titrate Medications for Interfacility Transports

[amyrox]

Currently my organization has a MICU service and CICP medic service along with all the others, but to the point past precadent has allowed advanced care medics to transport without RN several meds some requiring titration. The question being is this the norm? Meds in example : Heparin, Integralin, Diprovan. I function in dual capacity as Nurse/Medic and the changes really don't change my day a whole lot, however some of these trips are being directed towards MICU/RN rather than Medic and Medics that have been doing these trips are getting a little salty because now they are not "good enough". It is not a billing thing due to either way being billed as SCT and max money back. My overhead feels that medics are not functioning in this capacity else where and maybe we should not be. Any thoughts?

[Niftymedi911]

If it's something that's not in my scope (Heparin). I talk to the Doc, have him order a bolus for the remainder of the transfer so I don't have to worry about it. 99% of the time the RN's at the new facility take the drip off anyway. Diprivan is in our crash airway protocol, that's a normal medication down here.

[amyrox]

Wish we had the luxury to discontinue the drips. Our average transfer is 60-90 minutes so meds infusing stay infusing. At the medic end only TPN and blood products fall under mandate for RN so the medics take everything else. Or have been and with positive outcomes to this point. However I am learning that maybe this really isn't the norm and we should maybe not be putting so much faith at the medic level. The clinical admin part of me would like to keep encouraging the medics to take these trips, They are with in scope with the state, but I can't help wonder why other transport companies are not. Maybe a better question would have been how do you decide if MICU or Advanced ALS?

[jjones1418]

This one kinda slipped by me. I just caught it this morning, as I am up for some strange reason at 4:00 am...

I am having trouble seeing your question, as it looks like you're trolling for someone to say that paramedics aren't good enough to take a patient on "titrated drips" as you're calling them.

But as you gave examples....... In my practice, I'm not really going to be "titrating" Heparin or Integrilin, but I could be titrating Diprivan. I also make sure I spell the drug names right when I write them on my chart. Some of us knuckle-dragging paramedics are half-way intelligent and take it as an insult that you "should maybe not be putting so much faith at the medic level."

Before someone starts off with a state-of-the-disunion address about EMS education, and all that, that's a different thread.

After all of that, to answer your original question.... Medics are functioning this way elsewhere, and some of us are doing a decent job at it. If it's not working for your system, rather than take away a medic's ability to take a certain patient, consider education. Maybe have your medical director come in and do an inservice on the common medication infusions that you transport.

And your second question, "how do you decide if MICU or Advanced ALS?"

I'm guessing, although Advanced Advanced Life Support is rather redundant, that this would be a paramedic ambulance and an MICU would be an RN/EMT-P ambulance. My answer is assuming that you're not letting paramedics take the SCT calls anymore... With a response based on this assumption (uh oh), I would have something in writing that had this determined. Maybe a sheet in dispatch that has a checklist...

Send MICU for any patient that has/is on

1) ventilator

2) multiple IV medications infusing

3) blood products hanging

4) TPN hanging

5) You get the idea.....

Put the checklist in dispatch and make it a predetermined assignment.

[ERDoc]

You won't be titrating Heparin or Integrillin in the ambulance. They require PT/INR/PTT to titrate so they will pretty much stay where they are during transport (unless the pt starts exsanguinating). Propofol is pretty easy to titrate. Is the pt waking up? Turn it up (yes, there is more to it, but it is pretty simple). The medics that do the transports should be educated in the particular drugs they are transporting.

[ccmedoc]

The medics that do the transports should be educated in the particular drugs they are transporting.

I agree with this. Being a paramedic does not exclude them from transporting with additional meds hanging, titrating these meds, or initiating additional meds in transport. Educating within the given system and their medication usage would be prudent, but I would assume that they (the medics) were exposed to the additional pharm in their CCT training. A large sector of the CCT market I have been exposed to utilize medic/medic as the rule due to the shortage of suitable transport RN candidates and staffing. Licensure in this instance between medic and RN should not be the determining factor in my opinion as there are qualified and unqualified candidates to be found in both pools...the question is not worth the argument and using medics is more fiscally responsible, sadly enough :roll:

I fail to see the advantage of a floor RN when a adequately educated paramedic is available and working in their environment? could you elaborate?

[VentMedic]

I believe a lot of the team make up should depend on the acuity of the patient and the length of transport.

We have several hospitals within our system and transport may be required throughout the system for specialization. Due to the high acuity of our patients we had to go with establishing transport RNs to accompany our patients because we were finding out when the Paramedics arrived they may have little or no knowledge about certain medications, lines or ventilation. An RN would have to go anyway leaving the ED or ICU short staffed. The hospitals have no control over the skills, knowledge, education, competencies or equipment of the paramedic teams that were showing up to transport. The hospital formulary is also constantly changing as new medications are being added. The ALS transport companies have difficulty getting all of their paramedics inserviced properly on all the new meds.

There is little doubt that a paramedic is capable of learning additional medications and equipment. But, it is gaining experience with the medications and equipment that becomes difficult. Even when it comes to working with various IV pumps, skills and competencies vary greatly. Factor a ventilator into the equation and it can become a very difficult transport. Many don't realize that the switch from the ICU vent to the transport vent may cause a profound decompensation about 15 minutes into transport. A couple of turns of the knobs and you may have to quickly titrate the vasopressors. Then, that titration leads to another ventilation/oxygenation effect which the inexperienced may get caught up in a cycle without understanding how to get out of it without experience. Also, fixation on one particular system is what can also happen that leads to a very bad transport situation. For inter-facility transport, no RN at our hospitals will be considered with less than 5 years of ICU experience. Even the ED RNs can be at a disadvantage if they have not worked ICU and may not be considered for inter-facility transport of an ICU patient.

[ccmedoc]

As VentMedic pointed out, there are always special circumstances that need special teams. In a system that can contract with specific companies for their CCT transports, then the medics can be inserviced appropriately and trained in the ICU. We have rapid response teams in the hospital on call for NICU, Neuro/Trauma transports, and any CCT that requires a continuation of care from the nursing team familiar with the patient in question. I believe the key is a team approach. We use RN/RRT, RN/Medic, RRT/Medic, and Medic/Medic teams almost interchangeably, based on availability and if the patient may indeed benefit from the continuing care of the nurse responsible for care up to the transport. Familiarity with patient condition should not be undervalued. To the question posed initially, flexibility would seem to be the key, and the willingness of all parties to maintain education and training. Most likely comes down to money...it usually does.IMHO

[amyrox]

I thank all of you for your input. It is not often I can pick the brains of those who are not close to the issue and or able to pull emotions out of it, I am finding the initials behind the name does not mean they are more qualified to perform the care, just comes down to educating all of my teams well and reminding them to play nice while in each others sand box.