Alternative Transport

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Permalink Reply by Skip Kirkwood on November 2, 2009 at 11:36am

Is it any surprise that paramedics don't do this well? Most paramedics have not had a single minute of training in the proper assessment and decision-making for arriving at such a determination.

Pretty much every hospital in the US utilizes the same 5-point triage scoring system at the door of the ED. How about training paramedics to use it? THEN maybe we could evaluate their abilities against an objective standard.

How about "Paramedics are incompetent to drive space shuttles"? That's equally relevant!

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Permalink Reply by Mike Rubin on November 2, 2009 at 11:43am

Skip Kirkwood said:

How about "Paramedics are incompetent to drive space shuttles"? That's equally relevant!

Maybe we just need a paramedic-to-astronaut bridge program :-)

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Permalink Reply by Neil White on November 2, 2009 at 1:53pm

This has been working its way in for a while now, its a double edged sword ensuring that the alternative pathways are in place and as has been said the clinicians have the safety netting/assessment skills to ensure that the alternative pathway is both safe and appropriate for the patient.

Community Paramedic training programmes are on the increase and having completed one myself, the assessment tools are a useful addition to the toolbox but without underpinning knowledge A&P pathology ect, many just listen to chest/bowel sounds use percussion, different ecg's and have no idea what they mean in relation to the patient in front of them... reaching a decision that a person is safe to leave in the community that should really be in hospital

We've been also faced with increased on scene times from alternative pathway calls, you have your initial assessment, additional assessments, consultation with the alternative pathway and then safety netting takes a call which in old school care would take an hour...assess, treat transport now doubles. One call I had involving a vulnerable elderly patient with social care issues lasted 3 1/2 hours before a safe care plan was reached.

The UK government is big on avoiding Emergency Departments, giving advanced trained paramedics, suturing skills, antibiotic prescription rights for UTI's, authority to request xray's ect to keep minor illness/injuries in the community and not in hospital. We are coming to the stage where paramedic's will attempt to have admission rights to clinical decision/medical assessment wards bypassing A&E.

The situation at the moment comprises of the emergency call coming in, being triaged via AMPDS, resource dispatched, single response paramedic or conventional crew, assessment and determines that the patient has a chronic medical condition that does not require acute management of ED intervention. Refers to primary care, crew leaves scene...doctor conducts home visit or telephone triage, decides hospital admission and requests ambulance transfer...second crew attends and transfer to hospital....

Does attempting to arrange alternative pathways eventually delay treatment and cost the service more???

I don't know how much stock to put in decision assisted software programmes, PSIAM ect... but would the taxi programme benefit from a clinician (paramedic, nurse, doctor) performing an initial assessment via telephone of all flu-like calls and then triaging a response appropriately...

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Permalink Reply by Robert Sullivan on November 2, 2009 at 2:47pm

Taxis for the flu are a bandaid on our EMS crisis (which like the thermometer are missing from most ambulances). With study after study showing that the current EMS education/funding/oversight model is unable to safely direct any patients somewhere other than the ED, why does anyone think this will work for the flu?

The Dr. Evil voice in my head says that a busy flu season will finally break our EMS system. We'll be showered with Homeland Security money to furnish offices at our own federal agency. We'll even prepare for an increase in calls during flu season.

Then reality sets in, and I realize I should see someone about the voices in my head.

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Permalink Reply by Marshall on November 2, 2009 at 3:14pm

My question is - does medical necessity equal medical transport? I say no... it doesn't. Primarily from the fact that the definition of "medical necessity" (not CMS definition) is really not clear. Furthermore - what kind of knowledge base do you need to determine "how sick" some one really is? I thought that is what paramedic school was all about? Not just a 'you call we haul' mentality.

The bigger question - are paramedics capable of determining if a patient will suffer greater harm or injury by not being transported by ambulance and are they capable of mitigating the potential for harm or injury? Because this, in my opinion, turns into a slippery slope: if I can't determine if a patient is capable of being transported by POV, then I most certainly am not capable of determining if a patient is stable enough to be transported by BLS, so everyone ought to be transported every time by the highest level of care provided in that area of service.

As far as the abstract goes (thats all I could read), I found the n to be fairly small despite the strength of a prospective study with 9 people were admitted (the abstract doesn't get into detail about the admission details) and no emergent procedures were performed or blood administered. So if we are determining transport by admission criteria - well, we've got a lot more schooling, training, and education ahead of us - I think it's medical school?

If anyone is interested:

Brown, Larwrence H., Hubble, Michael W., et al 'Paramedic Determinations of Medical Necessity: A Meta-Analysis', Prehospital Emergency Care, 13:4,516--527

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Permalink Reply by Neil White on November 2, 2009 at 3:26pm

The money will be spent on artwork for the walls and creating complicated command structures with unnecessary positions....the operations director for the logo needed on the front page of the agenda for the meeting to decide who should be on the committee to discuss the brand of respirator masks to use.

That being said, I think we should avoid opening another swine flu discussion....and rather stick with safe assessment of patients

Is it right nay safe to say, hey you don't need an ambulance... The UK has one of the most complex primary care systems known to man with NHS Direct or as its know to all paramedics NHS ReDirect as almost all calls become ambulance emergencies when there really is no need. The problem is compacted in that we have one of the worst out of hours care systems going, many of the schemes whilst under the guise of the NHS are operated by private companies many of whom bring in foreign doctors (its cheaper).... One of whom undertook a long haul flight landing in the UK an hour before his shift started, done the shift and was negligent in care of 2 patients resulting both in deaths.

So you can understand why the public turn to the ambulance services, there's no need to leave home, its free to call and you see a healthcare professional in most cases in under 15 minutes.

It is expected that the flu will take a particular course in symptoms and would be expected to respond well to over the counter medications, which, I know I will sound stupid saying this, most people try before contacting professional help. It should be clear relatively quickly if the presentation is not the flu, a temperature not responding to paracetamol... chest pain without excessive coughing and so forth...

We have a robust assessment protocol which should be in the remit of all providers which is then linked into the secondary care system. It has 7 red flags any one prompts emergency admission to the ED,

So for adults;
A - Severe respiratory distress, Severe breathlessness, e.g. unable to complete sentences in one breath. Use of accessory muscles, supra-clavicular recession, tracheal tug or feeling of suffocation.
B - Increased respiratory rate measured over at least 30 seconds. Over 30 breaths per minute.
C - Oxygen saturation 92% on pulse oximetry, breathing air or on oxygen (Absence of cyanosis is a poor discriminator for severe illness)
D - Respiratory exhaustion, New abnormal breathing pattern, e.g. alternating fast and slow rate or long pauses between breaths.
E - Evidence of severe clinical dehydration or clinical shock, Systolic blood pressure <90mmHg and/or diastolic blood pressure <60mmHg. Sternal capillary refill time >2 seconds, reduced skin turgor.
F - Altered conscious level New confusion, striking agitation or seizures.
G - Causing other clinical concern to their own GP or clinical team e.g. a rapidly progressive or an unusually prolonged illness.

It is deemed that if the patient has none of the criteria, it is safe to manage in the community. Appropriate discharge advice given...and then I guess a taxi to see their primary care doctor?
Does that seem safe without any additional training, I think so, even the most inexperienced provider can monitor and assess all that is on the list?

Attachments:

• dh_106496.pdf, 1.1 MB

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Permalink Reply by Skip Kirkwood on November 2, 2009 at 3:46pm

So - the AHRQ has a program called Emergency Severity Index - it is used for triage in and by many (most?) hospitals in the US.

Could paramedics be trained to perform this assessment? I suspect so...

http://www.ahrq.gov/research/esi/

The question would then become - can paramedics do it as well as nurses, and if so, can this tool be used to determine the need for ambulance vehicle transport?

Given the proper training, I suspect that we can do much more, much better, than we do currently.

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Permalink Reply by Nathan on November 2, 2009 at 6:42pm

Its the triage system I was trained in. I worked my entire EMT career in an ER and the system is pretty simple. Of course that involves additional training/education time......

Skip Kirkwood said:

So - the AHRQ has a program called Emergency Severity Index - it is used for triage in and by many (most?) hospitals in the US.

Could paramedics be trained to perform this assessment? I suspect so...

http://www.ahrq.gov/research/esi/

The question would then become - can paramedics do it as well as nurses, and if so, can this tool be used to determine the need for ambulance vehicle transport?

Given the proper training, I suspect that we can do much more, much better, than we do currently.

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Permalink Reply by dr-exmedic on November 2, 2009 at 6:56pm

Skip Kirkwood said:

Given the proper training, I suspect that we can do much more, much better, than we do currently.

Suspect? You should be quite certain, seeing as how "determine whether a given pt needs ambulance transport" isn't an NSC objective at any level. ;)

Since there isn't enough A&P in the paramedic curriculum, not enough exposure to less fatal (but nevertheless ED-worthy) complaints, and no mindset to get new medics thinking about transport decisions, it's only natural that we're pretty bad at it. Actually, as much as we should be embarrassed by this, we should at least be proud that we seem to function better than a flipped quarter.

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Permalink Reply by dr-exmedic on November 3, 2009 at 9:26pm

Mike said:

(Incidentally a cosmetologist requires 1600 and I know that barbers were the precursors to surgeons, but I don’t think it would be fair to compare a modern surgeon to a cosmetologist)

Clearly you did not see the blood loss from the last time I got a straight razor shave at the barber. But I digress. :)

I stipulate an EMS provider doesn’t need to decide who requires admission. They need to determine who is emergent and who is not. Not one patient in this abstract demonstrates EMS failed to meet the criteria of determining who needs immediate life saving treatment.

As I'm sure you are well aware, there are plenty of people who could benefit from paramedical care, ED evaluation, and even ambulance transport who do not need immediate life-threatening treatment. But that's a whole 'nother thread.

*sigh* I dog-eared my PEC to blog this study, but at the risk of stealing my own thunder: the story gets a little more complicated when you look at 1) what they did for the study and 2) the pts who needed admission despite EMS alternative transport.

The study critieria: they're too long to list here. They didn't use paramedic judgment to determine taxi transport eligibility, they gave a list of inclusion & exclusion criteria. There were literally 20 types of pts that could not be given alternate transport (including any chest pain, abnormal VS--to include fever >101F by history--any pregnancy complaint, and the catch-all "any patient scenario where the crew's best judgment dictates transport"). The only actual inclusion criteria were 14 bullet points long, and included things like prescription refills, pain on urination, penile discharge, and "toothache without significant swelling." 28 medics participated in the study, but if I gave this list to 28 random people in the phone book, I have no doubt that they would perform almost as well as the medics. How could you not when the list is so programmatic? It's paramedicine for dummies....

According to the study, there were 34,080 pt transports over the study period. Medics approached 104 pts who met study enrollment criteria, 0.3% of all pts transported. This tells you just how restrictive the criteria were--I could grab any sample of 0.3% of an ambulance service's pt's and tell you practically nothing useful.

Of the 9 people who were admitted despite meeting taxi transport criteria, 1 had no EMS run sheet (pretty major problem) but was diagnosed with suicidal ideation; any psych complaint was one of the exclusion criteria. 2 had vomiting as part of the EMS chief complaint; GI complaints were one of the exclusion criteria. 2 had "weakness" as the EMS chief complaint, we can disagree whether that counted as an exclusion criterion but it was certainly not one of the inclusion criteria. So 5 (55.55555%) of the ones that got taxis and were later admitted shouldn't have gotten taxis in the first place.

(Side note: One of the vomiters was diagnosed with peritonitis. One of the weaknesses was diagnosed with suspected jejunal intussusception and taken straight to the OR. One person with "chills, ill feeling" on the EMS run sheet--which is not enough info to determine whether or not the pt met the criteria--was admitted to ICU with hepatic & acute renal failure.)

Removing the folks who were incorrectly classified would make the criteria look better. However, as this was a study not of the criteria but of how the criteria work in the real world, it would also be wrong IMO.

So the net result: paramedics are emininently capable of using an idiotic list to determine what 0.3% of pts don't need to go to the hospital immediately, although they will occasionally go off the reservation and ignore the rules, putting a few people into the delayed-transport category who shouldn't be in it. (I suppose if you correct for the fact that the study paramedics only represented 1/5 of staff, you might be able to replace the 0.3% with a 1.5%.) I don't think the study says anything about the ability of paramedics to make a decision on their own about whether a pt is really sick or not--it's a study about whether medics can correctly check boxes or not.

If anyone is interested: Brown, Larwrence H., Hubble, Michael W., et al 'Paramedic Determinations of Medical Necessity: A Meta-Analysis', Prehospital Emergency Care, 13:4,516--527

This study (from the same issue, natch) is much more interesting, but just as useless, I think. They attempt to meta-analyze various studies of paramedics' ability to predict admission, "need for ED evaluation" as judged against ED docs' opinions, or various other endpoints; several of the studies included EMT-B providers. Incidentally, there was actually a lot less variation among the studies evaluating whether paramedics could predict who didn't need hospital admission (all numbers were given as NPVs) than among the other endpoints. (The relatively high NPV, incidentally, suggests to me not that medics are good at figuring out who is sick, but are pretty good at figuring out who's not sick. As we don't have a PPV we can't make the other determination.)

The best part of the study is its discussion over what constitutes "medically necessary" ambulance transports, noting that when an internist and emergency physician reviewed the same cases, the internist thought 36% were emergencies while the EP thought 90% were.

Final food for thought: a lot of words are spilled about 911 system abuse, but every study I've ever read on the topic has pts arriving by ambulance admitted at twice the rate of walk-ins. (Admission may not be the perfect indicator of illness but I think that admitted pts as a whole are clearly sicker than non-admitted pts.)

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Permalink Reply by Robert Sullivan on November 3, 2009 at 9:51pm

Thanks Dr. Ex, I found it ironic that the PEC issue with these studies came out so close to the Ft. Worth taxi story. Like Skip said, I think we can do better with more training, pilot programs, and oversight. A knee jerk reaction to a busy flu season is likely to fail.

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Permalink Reply by dr-exmedic on November 4, 2009 at 8:57pm

Mike said:

Did he hang the bloody rag outside on the pole to dry? :)

Yes, right next to his apron, which was already stiff with blood. :)

While it sounds terrible based on the dx, I would think if you are seriously considering alternate transport criteria, you are going to have to accept some level of undertriage. At what starting point would you find it realistically acceptable?

I started to make a WAG, but then I realized I should at least put some thought and maybe even some (gasp!) data into it. Then as I was doing calculator work something occurred to me: The biggest problem is first defining, what is an acceptable ambulance transport?, so we really need to start there. As we've already noted, although admission or death rates might be partial proxies for ill pts, neither really tell the whole story. For example, someone having a moderately bad asthma attack is best transported to the ED for their treatment but (if all goes well) will end up neither admitted nor dead. However, since admission or death-within-30-days are such measurable statistics, we'll have to settle on something like that. An average ED has about 3-4% of its pts revisit within 72 hours. Since I clearly can't expect medics to have the clinical acumen of physicians (on average), an acceptable undertriage would be 6-8% return 911 call within 72 hours, or perhaps sending 5% of admissions to alternate pathways (and less than 1% to doctor's visit >24 hours away).

Ultimately, if we are serious about paramedic-initiated alternate transport methods or destinations, our best bet is to have medics who are educated to a certain level, and then the statistics will work themselves out--and if we don't like them, it's time to change the paramedic education some more. As things stand, I don't think I like the idea of EMS-initiated alternatives very much at all--particularly when it comes in the form of yet another cookbook protocol.

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