To provide a mechanism for EMT-Ps to be permitted to monitor infusions of nitroglycerin and/or heparin during interfacility transfers.

AUTHORITY:

Division 2.5, Health and Safety Code, Sections 1797.220 & 1797.221.

POLICY:

Only those EMT-Ps who have successfully completed training program(s) approved by the S-SV EMS Agency Medical Director on nitroglycerin and heparin infusions will be permitted to monitor them during interfacility transports.

Only those ALS Ambulance providers approved by the S-SV EMS Agency Medical Director will be permitted to provide the service of monitoring nitroglycerin and/ or heparin infusions during interfacility transports.

Patients that are candidates for paramedic transport will have pre-existing heparin and/or nitroglycerin drips in peripheral or central IV lines. Prehospital personnel will not initiate heparin and/or nitroglycerin infusions. The heparin and/or nitroglycerin drip will have been running for at least 30 minutes prior to transport. Patients will have maintained stable vital signs for the previous two (2) hours and will not have more than two medication infusions running exclusive of potassium chloride (KCL).

PROCEDURE:

1. All patients will be maintained on a cardiac monitor and a non-invasive blood pressure monitor.
   
   
2. The paramedic shall receive the transferring orders from the transferring physician prior to leaving the sending hospital, including a telephone number where the transferring physician can be reached during the patient transport. Transferring physicians must be aware of the general scope of practice of EMT-Ps and the transport protocol parameters outlined below. The written order must include the type of solution, dosage and rate of infusion for the IV fluids.
   
   
3. Patients will meet pre-established criteria for hemodynamic stability, as noted by the transferring physician or nurse on the heparin and/or nitroglycerin transferring orders.
   
   
4. If medication administration is interrupted (infiltration, accidental disconnection, malfunctioning pump, etc.), the EMT-P may restart the line as delineated in the transfer orders.
   
   
5. All medication drips will be in the form of an IV piggyback monitored by a mechanical pump familiar to the EMT-P. In cases of pump malfunction that cannot be corrected, the medication drip will be discontinued and the transferring physician and base hospital notified.
   
   
1. NITROGLYCERIN DRIPS:
   
   EMT-Ps are allowed to transport patients on nitroglycerin drips within the following parameters:
   
   
   1. Infusion fluid will be D5W. Medication concentration will be 50mg/250cc.
      
      
   2. Regulation of the drip rate will be within parameters defined by the transferring physician, but in no case will changes be greater than 10mcg/minute increments every 5-10 minutes. In cases of severe hypotension, the medication drip will be discontinued and the transferring physician and base hospital will be notified.
      
      
   3. Discuss with transferring physician concomitant use of analgesics during transport, e.g. IV morphine sulfate.
      
      
   4. Vital signs will be monitored and documented every 10 minutes and immediately if there is any change in patient status.
      
      
2. HEPARIN DRIPS:
   
   EMT-Ps are allowed to transport patients on heparin drips within the following parameters:
   
   
   1. Infusion fluid will be D5W or saline. Medication concentration will be 100u/cc of IV fluid (25,000u/250cc)
      
      
   2. Drip rates will remain constant during transport. No regulation of the rate will be performed except to turn off the infusion completely.
      
      
   3. Drip rates will not exceed 1600U/hour.
      
      
   4. Vital signs will be monitored and documented every 15 minutes.
      
      
3. CONTINUOUS QUALITY IMPROVEMENT (CQI):
   
   All calls will be audited by the provider agency and the transferring hospital. Audits will assess compliance with physician orders and regional protocols, including base hospital contact in emergency situations. Reports will be sent to the EMS Agency as requested.
   
   

Reference No. 341
Subject: Intravenous infusions of heparin &/or nitroglycerin during interfacility transfers: transferring hospital requirements.

Reference No. 441
Subject: Intravenous infusion of heparin &/or nitroglycerin during interfacility transfers: Service provider Requirements and Responsibilities.

Reference No. 442
Subject: Intravenous infusion of heparin &/or nitroglycerin during interfacility transfers: application and approval process.