Major Topic #6: Operations

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. Major Topics 2 and 4 address multiple considerations in providing optimal patient care. In addition to these, the operational aspects of IFT should be closely managed, to facilitate seamless patient flow during transport. Operations can include crew selection, staffing levels, the vehicle, equipment, communications, and standard operating procedures.

Crew Selection
Interfacility transfer requires a unique set of skills that is distinct from the training of most hospital-based or prehospital providers. To provide adequately for patient needs during IFT, selection of the transport personnel/crew should include a team capable of providing the level of care the patient’s present condition requires; the likely and the potential needs of the patient throughout the transport. In many jurisdictions, prehospital and hospital health care professionals are legally authorized to perform tasks within a specific scope of practice, which may or may not match the clinical needs of the patient or the needs presented by the operational IFT environment.

In IFT program development, it is advisable to determine the knowledge, skills, and abilities necessary for the IFT patient population. Under the medical director’s guidance, recurring referral patterns, patient populations, and frequently used modes of transportation should be assessed to determine necessary qualifications and training. The need for specialty care transports (i.e., neonatal, intra-aortic balloon pump) should be analyzed to make decisions on how to match patient needs with provider knowledge, skills, and abilities.

It is essential that personnel utilized to provide care during interfacility transfers be properly trained, familiar with the unique demands of providing care during ground or air transport, legally authorized to perform the skills, and prepared to handle the variety of patient contingencies. Multiple providers may be qualified to accompany the patient depending on their education, skill level, and legal authority. Additional education, under the guidance of the Medical Director, will be needed to prepare all traditional providers for interfacility patient care, whether hospital or prehospital-based, but the specific focus of this additional education may vary depending on the provider’s existing knowledge base. Medical directors should be involved in training, education, and evaluation of crew knowledge, skills, and abilities, at each level of care, on an ongoing basis.

The crew should be educated and trained to care for the anticipated patient population using anticipated transport mode(s). Training can be provided by the transport agency or other legally recognized entity, but the medical director and transport agency should approve the level of education and training provided. Providers can also receive specialized education and training in specific areas (e.g., neonatal, cardiac, etc) appropriate for the patient population(s) being transported. There may also be a need for the use of other healthcare professionals (e.g., respiratory therapists) during transport. The crew must be able to provide quality care within their scope of practice including the use of transport equipment in the transport environment.

Minimum requirements for staff qualifications
Minimum requirements can be flexible without compromising care. For extensive information on suggestions for provider skills and knowledge, refer to Major Topic #2, Provider Education, which includes suggested knowledge, skills, and abilities related to IFT.

Staffing Levels
The number and right combination of personnel should be addressed in developing an IFT program. Staffing decisions should be determined by clinical patient care needs and operational requirements. Recurring referral patterns, patient populations, and frequently used modes of transportation should be assessed to determine necessary qualifications and training. The highest potential acuity level of the transported patient and the ability of the staff to respond appropriately in the transport environment should be a determinant of crew composition.

Many transfer services use the team concept in developing and deploying IFT. Predetermined staffing patterns with specific qualifications can be developed to match patient need and deployed when patient need is identified. Determination of the appropriate team composition can include consideration of the following:

• the availability of critical care and/or specialty care transport teams within a reasonable proximity;
  
  
• the modes of transportation and/or transport personnel available as options in the particular geographic area;
  
  
• specific circumstances associated with the particular transport situation (e.g. inclement weather, major media event, etc.);
  
  
• anticipated response time of the most appropriate team and/or personnel;
  
  
• established State, local, and individual transfer service standards/requirements;
  
  
• combined level of expertise and specific duties/responsibilities of the individual transporting team members;
  
  
• degree of supervision required by and available to the transporting team members;
  
  
• complexity of the patient’s condition;
  
  
• anticipated degree of progression of the patient’s illness/injury prior to and during transport;
  
  
• technology and/or special equipment to be used during transport; and
  
  
• scope-of-practice of the various team members.

The transport team leader should possess appropriate clinical experience and expertise, as well as the leadership skills necessary to direct the provision of patient care in the IFT environment. Unless a physician is included as one of the transport team members, a physician designated to provide medical direction should be available for consultation. An acceptable exception to this requirement may exist in those circumstances when, under supervision of the designated medical oversight physician, the transport team follows established written policies, protocols, and procedures.

Filling Staffing Needs
Although there may be variation in the minimum requirements and core knowledge, skills, and abilities that the members of the IFT team are required to possess, their combined expertise should provide for accurate patient assessment, formulation of an effective plan of care, implementation of appropriate interventions for the actual and potential patient problems that may be encountered, and evaluation of the patient’s response to the care provided. Education and training specifically related to the characteristics and differences of delivering patient care in the transport environment must be provided prior to any performance of independent transport care activities by any member of the transport team.

The content and extent of required training will be dependent upon the job description and/or the specific set of duties for which the individual team member will be responsible. Qualified people may be hired or training provided for existing staff. Decisions favoring one approach over the other involve the availability of qualified staff, possible pay differentials based on knowledge and skills, providing training to existing staff, and the cost-effectiveness of comparable models.

The Vehicle
Vehicle selection should be driven by the IFT mission profile. State licensing requirements should be met, and the vehicle should be able to accommodate the necessary equipment. Vehicle selection should provide enough room for the patient, caregivers, and potential additional equipment and/or providers. As with any transport, all safety standards should be met. Redundant power, electrical, communication, and lighting systems should be provided.

Equipment
As with crew vehicle selection, determination of equipment should be based upon patient and operational needs. Equipment should comply with all minimum statutory and regulatory requirements, and provide for accurate patient assessment, implementation of appropriate interventions for the actual and potential patient problems that may be encountered, and evaluation of the patient’s response to the care provided. Equipment should also provide all necessary functions to operate safely and accurately within the transport environment. Equipment lists are available from multiple sources. For more information, refer to Appendix B: References & Resources, References of General Interest.

Communication/Linkages Needed
Communication is essential for the safety of the crew and the optimal care of the patient. The crew must be able to communicate with the dispatch/communication center, the receiving facility, the local public safety providers — EMS, fire and police, and on-line medical direction. Communication and data linkage should be available throughout transport. A redundant system should be in place in case the primary communication system fails.

Administrative Protocols/Standard Operating Procedures
A comprehensive IFT service requires administrative protocols to provide seamless patient flow during transport and to deal with challenges IFT may pose. Standard operating procedures are recommended to address such issues as mutual aid, communications, weather, and equipment maintenance and failure. More information on standard operating procedures can be found by referring to the Commission on Accreditation of Ambulance Services (CAAS). Both CAAS and the Commission on Accreditation of Medical Transport Systems offer helpful information as well as the opportunity for accreditation, which may have practical benefits for IFT services. The CAAS Web site can be accessed at: www.caas.org and the CAMTS Web site can be accessed at: www.camts.org.