If you would like the NH Medical Control Board to consider a scope of practice questions that hasn't yet been answered, please download the Clinical Practice Inquiry Form and

• e-mail: vicki.blanchard@dos.nh.gov, or
• fax: (603)271-4567, or
• mail: NH Bureau of EMS
  Advanced Life Support
  33 Hazen Drive
  Concord, NH 03305

The ALS Coordinator, Vicki Blanchard, will review your questions and determine whether additional information is needed. If additional research is required, the ALS Coordinator will review and send a recommendation to the Interfacility Transport Subcommittee of the Medical Control Board for its decision.

The IFT Subcommittee will determine an answer by consensus and post that decision in a timely manner on the NH Bureau of EMS homepage. There will be, at a minimum, a thirty (30) day public comment period for interested person to respond. The Medical Control Board will confirm the final answer at its next meeting. The Board will not reverse a decision without presentation of facts that have changed and/or there is scientific data to convince the Board of a decision reversal. The Board will post all decisions here, in the NH Bureau PIFT & CCT Clinical Advisory Website.

Please check the "PIFT & CCT Clinical Practice Advisory" section below for Board actions. The Board meets the 3rd Thursday of every other month.

An advisory opinion adopted by NH Medical Control Board, in its official capacity, is an interpretation of what the law requires. Facility/agency policies may restrict practice further in its setting and/or require additional expectations related to competency, validation, training, and supervision to assure safety of their client population and/or decrease risks.

The Paramedic Interfacility Transfer (PIFT) prerequisite packet can be found at www.nhoodle.nh.gov.

October 2013 Clinical Advisories

Question: Can BLS transfer a patient with an Incisional Wound Infusion Pump?
Answer: The Incisional Wound Infusion Pump provides a continuous infusion of a localized analgesia to a surgical incision. The infusion is preset and does not require any interventions for EMS. A BLS crew may transfer a patient with an Incisional Wound Infusion Pump.

September 2012 Clinical Advisories

Question: Is it within the PIFT paramedic's scope of practice to transport a stable long-term ventilated patient?
Answer: Yes, a PIFT paramedic may transport a stable long-term ventilated patient to or from a medical facility, long term care facility, and/or home, provided the patient is stable and the transport is not of an acute nature and the paramedic is familiar with the patient's ventilator and able to operate it.

November 2011 Clinical Advisories

Question: Recently I was requested to transport a patient with an antibiotic running into a central line. I received orders to swap the line over to normal saline after the completion of the infusion. Should PIFT paramedics be swapping tubing over on central lines?
Answer: The correct thing to do in this situation is to ask the sending facility to piggy back the antibiotic onto the saline prior to transport. Changing tubing on central lines should be done using sterile techniques. Creating and maintaining a sterile environment in the back of a moving ambulance is extremely difficult. Should your transfer involve the management of infusions through central lines, the PIFT paramedic should work with sending staff, prior to transport, to alleviate any need to manipulate the line while transporting.

August 2011 Clinical Advisories

Question: What are the options for a non-PIFT EMS unit when a request comes in to do a paramedic level interfacility transfer?
Answer: In the case where a sending hospital is requesting an EMS unit that is not PIFT qualified to transfer a patient at the paramedic level, the unit can assist with the transfer if the hospital is willing to send a member of the hospital staff, such as a nurse. The hospital staff will be responsible for the patient during the transport. The EMS Unit will be responsible for sending two licensed EMS providers.

From the Interfacility Transfer Protocol 7.0:
"As a measure of last resort, in cases where CCT paramedics are unavailable AND delay in transfer would have a significant negative impact on patient outcome, other transport arrangements may be initiated provided that:
1. The sending facility makes an exhaustive effort to send additional personnel.
2. The NH Bureau of EMS and Unit EMS Medical Director are notified within 48 hours and appropriated TEMSIS and IFT documentation is completed by the EMS Unit and the sending physician/institution.
3. All interventions are within the scope of practice of the transporting paramedic and vehicle."

June 2011 Clinical Advisories

Question: Does a non-CCT level crew have to include a respiratory care practitioner when transporting a ventilated patient with advanced or complex vent settings, for example, pressure control or PEEP>10?
Answer: Yes. If the patient is on mechanical ventilation in the critical care setting, then it is the standard of care for the patient to remain on such during transport. It is necessary for a respiratory care practitioner to accompany the patient during transport in order to attend to the complexities of patient care as well as the ventilator equipment.

Question: Is a PIFT crew allowed to remove a ventilator from a vented patient and then manually ventilate during transport?
Answer: No. The role of the PIFT crew is to maintain the same standard of care during transport that the patient was receiving when the request for transfer was initially made. Manually ventilating a patient during an inter-facility transfer raises a concern regarding a loss of PEEP as well as the inability to maintain the following:

• consistent tidal volume
• consistent respiratory rate
• appropriate airway pressures
• proper FIO2

April 2011 Clinical Advisories

Question: Can a PIFT paramedic transport a patient on BiPAP?
Answer: Yes, as long as the PIFT paramedic has proficiency in managing the device.

Question: Is it within the PIFT scope of practice to transport a stable patient on SIMV with pressure support, or pressure support only without additional personnel?
Answer: Yes, provided that PEEP is <10 (which would be considered a relatively basic setting) and the patient was going to a long term facility (thus implying stability) or to home (likewise stable). Such a situation would be considered a PIFT level transfer, but would not require additional personnel to accompany the patient.

Question: Can a PIFT paramedic transport a ST elevation myocardial infarction (STEMI) patient being transported from a hospital to a facility that is capable of percutaneous coronary intervention (PCI)?
Answer: A patient experiencing a STEMI, who is on such medical treatments as a nitroglycerin infusion, a heparin infusion, and a glycoprotein inhibitor infusion, and who is not experiencing significant complications, such as cardiogenic shock, would be considered a stable patient with medium risk for deterioration and may be transported by a PIFT provider.

Question: Can a PIFT service exempt administrative staff who are paramedics, but who will not participate in interfacility transport from the mandatory PIFT credentialing?
Answer: Yes, services in which the paramedic who is the administrator, who may respond to 91 calls but will never participate in either IFT or have clinical oversight to PIFT providers, may be exempt from the PIFT requirement.