EMS seems to have a “technological imperative” when it comes to our allotted “monkey skills”. The day they put a new toy on your rig is the day you suddenly find a need for it. Venous access is no exception. Now granted, starting IVs is not a new addition to the EMS scope of practice, we’ve been doing that for years. And the ability to start them isn’t the only driving factor. Crews that I’ve spoken to often reference the appreciation of the hospital staff for starting an IV. Other crews reference complaints by the hospital staff that an IV wasn’t started. Call it a healthy mix of availability and peer pressure.
In a 2011 article published in the Journal of Vascular Access (did you know there was one of those?) authors review a cohort of patients transported to a single emergency room and evaluate whether IVs were actually used after they were placed. Here’s the abstract:
J Vasc Access. 2011 Jul-Sep;12(3):193-9. doi: 10.5301/JVA.2010.5967.
Indication and usage of peripheral venous catheters inserted in adult patients during emergency care.
Göransson KE, Johansson E.
Department of Emergency Medicine, Karolinska University Hospital Solna, Stockholm, Sweden. firstname.lastname@example.org
PURPOSE: The aim of this study was to identify the underlying decisions taken regarding the insertion of prehospital peripheral venous catheters in adult patients and, additionally, to ascertain peripheral venous catheter insertion rate and explore prehospital and hospital (within 24 hours of insertion) pharmaceutical treatment via peripheral venous catheters.
METHOD: This cross-sectional study gathered data through a study-specific questionnaire and patient record auditing. We distributed a study-specific questionnaire to be completed by ambulance crews, and carried out patient record auditing for 345 patients (median age 64 years, range 18-97 years) arriving at the emergency department at a Swedish level-1 trauma center in October 2008.
RESULTS: Of 135 patients (39%) arriving at the emergency department with a peripheral venous catheter, 94 (70%) had received the device because the ambulance crews intended to use it for intravenous therapeutics (of which analgesics, intravenous fluids, and psycholeptics were most frequently used). In 30 patients (22%), the prehospital inserted device was not used by the ambulance crews or at hospital within 24 hours. The corresponding rate of unused peripheral venous catheters inserted in patients after arrival at the hospital was 35%.
CONCLUSIONS: We found that the main reason for the ambulance staff to insert a peripheral venous catheter in a prehospital setting was that they intended to use the device. Further, the rate of unused peripheral venous catheters was lower among prehospital peripheral venous catheters than hospital.
The results pretty well speak for themselves. It should be noted that this analysis only took place at one hospital. I also know that compared to my system, 39% of patients receiving an IV is relatively low. The important thing to remember is that an IV is an invasive procedure. Simply starting one because you can or because “someone might use it later” may not be the best thing for your patient. Every IV increases the risk for healthcare-acquired infections.
What about you? Do you routinely start prophylactic IVs? Why or why not? Let me know in the comments.
One of the hallmarks of advanced paramedic programs and really the future of EMS in general is the ability of providers to determine if a patient NEEDS to go to the emergency department. If the goal of such programs is to reduce the utilization of ED resources, field practitioners must be able to safely determine if alternate transport or non transport is appropriate.
Approximately a year ago, the National Association of EMS Physicians (NAEMSP) issued a position statement on this topic and determined that:
• There may be potential for EMS providers to avert unnecessary emergency department
visits by providing a medical assessment to determine whether patients can safely be
managed without emergency transport to an acute care facility.
• While evidence supports determination of necessity of transport to acute care facilities
by EMS providers in certain select situations, in general evidence is currently lacking to
establish that EMS providers can universally make determinations about necessity of
• Prior to adoption of EMS provider initiated non-transport programs, there should be
evidence in the peer-reviewed literature that demonstrates that EMS initiated nontransport for the specific situation is a safe practice.
• A prerequisite to EMS provider decision to not transport requires at minimum:
additional education for the providers, a quality improvement process, and stringent
The entire document can be viewed here (PDF).
I appreciate a few aspect of this position statement. First, the NAEMSP acknowledges that EMS plays a pivotal role in the reduction of utilization of ED resources for non-acute patients. Second, the position paper calls for evidence-based standards and adequate training and oversight when developing such programs. In the current state of EMS, however, there is little incentive to develop non-transport guidelines as there is no reimbursement for patients that are not transported.
In another position paper published at the same time, the NAEMSP addresses issues surrounding reimbursement:
• When callers access 9-1-1 (or a similar emergency call center) requesting emergency
medical response, third party payers—including federal and state programs, their agents,
and private insurers—should provide fair and reasonable reimbursement for those
• Retrospective determination that a transport was not medically necessary should not
result in denial of payment. Payment for 9-1-1 emergency response should be based on
the prudent layperson standard.
• When EMS systems that possess adequate educational, medical direction and quality
improvement resources choose to implement EMS-initiated non-transport policies
(including, but not limited to, treat and release protocols, termination of resuscitation or
on-site care for mass gatherings), third party payers should consider the relative cost
savings associated with providing on-scene care without subsequent transport, and
provide fair and reasonable reimbursement for those services
The entire document can be viewed here (PDF).
Note, in particular, the last bullet point. A system that takes the effort to building an appropriate non-transport program should be reimbursed fairly. Makes good sense to me.
The resource document for both of these position statements can be found here (PDF).
So what do you think? How close are we to researching the ability of paramedics to make a determination not to transport? Are there cases where we can do this already? Does your system get reimbursed for non-transports? Let me know in the comments.
Community health departments have a variety of resources for patients suffering from chronic disease. It may be that you know about some of these resources in your own community. If not, I recommend that you reach out to the Department of Public Health so that you or your agency can compile a list for patients. Doing so can increase the general health of the community but can also connect patients to these resources before they suffer lasting consequences. Often, patient who do not utilize their primary care physician are not adequately screened for diseases like hypertension or diabetes. If these patient utilize the 911 system, EMS practitioners have an opportunity to perform these screenings.
A study out of King County in Washington published earlier this year looked at the ability of EMS to identify patients at risk for uncontrolled hypertension. The study can be found here (PDF).
It is important to note that this was a feasibility study only. The researchers were looking at whether it was possible to develop a program in which first responders identified at risk patients. This study did not look at outcomes or improvement in health. That said, the results were interesting. Survey respondents seemed interested in the program with 82% stating that they would be comfortable having their blood pressure screened at a local fire station. The next obvious step is to implement a program and track a population for changes. Compliance with medication, reduced ED visits and improved overall blood pressure could be outcomes to consider.
Does your agency perform health screenings outside of calls? Do you have a list of health and social resources you can provide on scene? What has the response from patients been? Let me know in the comments.
There is a huge body of evidence that therapeutic hypothermia can improve neurological outcomes in the post-cardiac arrest patient. The questions becomes, how best to cool that patient? Options in the EMS systems I’ve worked in have ranged from ice packs in the groin and axillae to helicopter transport with chilled normal saline and micro-fiber cooling blankets and everything in between. Most ambulances do not have refrigerators or freezers so keeping chilled saline around is difficult…or is it?
In an article published in the American Journal of Emergency Medicine, authors tested the ability to maintain chilled saline with coolers and ice packs. Here’s the abstract:
Am J Emerg Med. 2012 Jan 2. [Epub ahead of print]
A simple method of maintaining chilled saline in the prehospital setting.
Isenberg DL, Pasirstein MJ.
Department of Emergency Medicine, Mercy Catholic Medical Center, Philadelphia PA 19143.
OBJECTIVE: Mild therapeutic hypothermia has been shown to improve neurologic outcomes after sudden cardiac arrest. Therapeutic hypothermia should be started as soon as return of spontaneous circulation occurs. However, saline is difficult to keep chilled in the prehospital environment. We sought to determine whether a cooler and ice packs could keep saline cold under prehospital conditions.
METHODS: In phase 1 of the experiment, two 1000-mL bags of prechilled 0.9% normal saline were placed in a cooler with 3 ice packs. An additional bag of 1000-mL 0.9% normal saline remained outside the cooler as a control. Over 9 consecutive days, we measured the ambient air temperature and the temperature of each bag of saline every 4 hours. In phase 2 of the experiment, the cooler was kept sealed, and the temperature of the saline was measured after 24 hours.
RESULTS: The mean temperatures over 24 hours ranged as follows: ambient temperature, 24°C to 27.2°C; bottom bag, 0.6°C to 3.5°C; top bag, 1.4°C to 5.7°C; and control bag, 9.8°C to 26.8°C. A t test was used to compare the chilled saline against the control bag. Statistical significance (P < .05) was achieved at all times. In phase 2 of the experiment, after 24 hours, 100% of the bottom bags and 93% of the top bags were less than 6°C.
CONCLUSIONS: Our data demonstrate that saline can be kept chilled in ambulances for 24 hours using ice packs and coolers. The estimated cost is less than $50.00 per ambulance. Using coolers and ice packs is an inexpensive way for emergency medical service agencies to initiate prehospital hypothermia.
Since few ambulances are away from a station for greater than 24 hours, this seems like a reasonable method to maintain the ability to provide therapeutic hypothermia in the prehospital environment.
Does your system use therapeutic hypothermia? With what method? Do your vehicles have refrigerators on board? Let me know in the comments.
As we talked about last week, the Glasgow Coma Scale is a useful assessment and triage tool in patients presenting with illness and injury. An article in the Emergency Medicine Journal looks at the ability of Australian paramedic students to correctly determine the GCS of several patients on a video test.
Here’s the abstract from PubMed:
Emerg Med J. 2012 Apr 13. [Epub ahead of print]
Should an alternative to the Glasgow Coma Scale be taught to paramedic students?
Winship C, Williams B, Boyle MJ.
Monash University, Department of Community Emergency Health and Paramedic Practice, Victoria, Australia.
Background The accurate assessment of a patient’s conscious state using the Glasgow Coma Scale (GCS) is an important skill for paramedics as it may determine the patient’s initial and ongoing management. The objective of this study was to determine if undergraduate paramedic students from a large Australian University were able to accurately interpret a variety of conscious states.
Methods A prospective double-blinded observational pilot study requiring students to interpret the conscious state of four adult patients using the GCS by viewing a simulation DVD package.
Results There were 137 students who participated in the study, of whom 65% (n=87) were female students. The results demonstrated that undergraduate paramedic students were unable to accurately interpret a number of patient conscious states with only 20% and 37% of students able to accurately identify the GCS of patients 2 (GCS=12) and 3 (GCS=7). The motor component of the GCS appeared to be the component where the least accurate interpretation occurred, with only 47% of students being able to accurately identify the criteria that patient 3 displayed. Participants were however able to accurately interpret the GCS of both patient 1 (GCS=14) (86%) and patient 4 (GCS=15) (92%).
Conclusion This pilot study demonstrates that undergraduate paramedic students from an Australian university were unable to accurately interpret a patient’s conscious state if their GCS score was <14. These findings have provided academic staff with important information for considering alternative teaching and learning strategies and approaches in conscious state assessment in current paramedic curricula.
Obviously there are some short falls in the performance of the students. I find it interesting, however, that the title of the article discusses finding an alternative to GCS. For better or worse, the Glasgow Coma Scale is a standard measurement. If the students aren’t able to utilize it properly, perhaps a different method of teaching is warranted. If an entirely different assessment technique is taught, those students would just have to learn GCS after getting into the field.
What do you think?
I’ve written before about the CDC Field Triage criteria. There has been a lot of talk since the guidelines were released about whether mechanism of injury is a worthy criteria to use when deciding about whether to trauma activate a patient or not. Though mechanism is questioned, the physiologic criteria are generally accepted as effective criteria. The question is: how effective are they? Is a patient meeting those criteria more likely to die and therefore may have a benefit from going to a trauma center? A study published in Prehospital Emergency Care looks to answer that question for traumatic brain injury (TBI) patients.
Let’s look at the abstract from PubMed:
Prehosp Emerg Care. 2012 May 1. [Epub ahead of print]
A Review of Traumatic Brain Injury Trauma Center Visits Meeting Physiologic Criteria from the American College of Surgeons Committee on Trauma/Centers for Disease Control and Prevention Field Triage Guidelines.
Pearson WS, Ovalle F Jr, Faul M, Sasser SM.
From the Division of Injury Response, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention (WSP, FO, MF, SMS) , Atlanta , Georgia ; Vanderbilt University School of Medicine (FO) , Nashville , Tennessee ; and the Department of Emergency Medicine, Emory University (SMS) , Atlanta , Georgia .
Background. Traumatic brain injury (TBI) represents a serious subset of injuries among persons in the United States, and prehospital care of these injuries can mitigate both the morbidity and the mortality in patients who suffer from these injuries. Guidelines for triage of injured patients have been set forth by the American College of Surgeons Committee on Trauma (ACS-COT) in cooperation with the Centers for Disease Control and Prevention (CDC). These guidelines include physiologic criteria, such as the Glasgow Coma Scale (GCS) score, systolic blood pressure, and respiratory rate, which should be used in determining triage of an injured patient.
Objectives. This study examined the numbers of visits at level I and II trauma centers by patients with a diagnosed TBI to determine the prevalence of those meeting physiologic criteria from the ACS-COT/CDC guidelines and to determine the extent of mortality among this patient population.
Methods. The data for this study were taken from the 2007 National Trauma Data Bank (NTDB) National Sample Program (NSP). This data set is a nationally representative sample of visits to level I and II trauma centers across the United States and is funded by the American College of Surgeons. Estimates of demographic characteristics, physiologic measures, and death were made for this study population using both chi-square analyses and adjusted logistic regression modeling.
Results. The analyses demonstrated that although many people who sustain a TBI and were taken to a level I or II trauma center did not meet the physiologic criteria, those who did meet the physiologic criteria had significantly higher odds of death than those who did not meet the criteria. After controlling for age, gender, race, Injury Severity Score (ISS), and length of stay in the hospital, persons who had a GCS score ≤13 were 17 times more likely to die than TBI patients who had a higher GCS score (odds ratio [OR] 17.4; 95% confidence interval [CI] 10.7-28.3). Other physiologic criteria also demonstrated significant odds of death.
Conclusions. These findings support the validity of the ACS-COT/CDC physiologic criteria in this population and stress the importance of prehospital triage of patients with TBI in the hopes of reducing both the morbidity and the mortality resulting from this injury.
Well would look at that? Physiologic changes, particularly those measured by GCS are linked to increased mortality. I suppose we did know that, but think about the flip side. This means that a patient with a GCS of 14 or 15 is 17 times less likely to die than a patient with a GCS of 13 or less. Maybe we can consider a basic ED for those patients or transporting them without lights and sirens.
What do you think? Does your system use the CDC criteria? What do you do with patients that don’t meet physiologic or anatomic criteria but might meet mechanism criteria? Let me know in the comments.
Image via Flickr
Last week it was reported that a Central Valley, California man was arrested and charged with failing to comply with his tuberculosis treatment. To my knowledge, there aren’t many cases where Public Health can mandate care, but TB is certainly one of them. Interestingly the article stated that county officials had also charged a woman for knowingly giving syphilis to her partner and refusing treatment. The county concludes that legal action is an extension of medical care. A bold, but likely controversial statement. What do you think?
While you ponder the answer to that question, I’ll leave you with a quote from the article:
He failed to self-administer the drugs on one day, telling a nurse he had gone on an alcohol binge and taken methamphetamine and didn’t want to hurt his liver…
Yup, wouldn’t want that medication to harm your liver…