Transcript NALTE - Doctor Fowler

The Challenge
of Safe Non-transport
Managing Risk while
Optimizing System Efficiency:
The Future is Upon Us!
Jeff Beeson, DO, EMT-P, RN, DABEM
Chris Chiara, LP, BS
Raymond L. Fowler, M.D., FACEP
Who Are
We Really?
The Logic of Non-Transport
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We do it ALL the time
The ACTUAL incidence of error is low
“It’s the tip of the iceberg.” P. Pepe, MD
Can we actually “write down what we do
all the time”?
SCOPE OF THE EPIDEMIC:
PREVIOUS REPORTS
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Hauswald M; 2002: PEC 6(4): 383
Silvestri S et al; 2002: PEC 6(4): 387
Vilke GM et al; 2002: PEC 6(4): 391
Pointer JE et al; 2001:
– Ann Emerg Med 38:268
• Zachariah B et al; 1992:
– Prehosp Disaster Med 7: 359
Hauswald 2002
• Prospective survey in Albuquerque, NM
• 236 patients
– 183 charts reviewed
• 97 patients recommended not to need
ambulance transport
–23 (24%) ended up needing it
• 71 patients recommended not to need ED
–32 (45%) needed it
Hauswald 2002 - 2
• ED diagnoses of those for whom
“alternative transportation” was
recommended included:
– Coma
– Chest pain
– Seizure, adult onset
– Dislocated hip
– Sepsis
- Syncope
- Pyelonephritis
- Liver failure
- Hypoxia
- Severe bleeding
Hauswald 2002 - 3
• ED diagnoses of those for whom non-ED
care was recommended included:
– Active labor
- Multiple drug OD
– Extensive lacerations - Liver failure
– Child abuse
- Fractures
– Assault, multiple injuries
– MVC, multiple injuries - Chest pain
Vilke et al 2002
• Telephone survey of elderly patients who
called 911, then refused transport
• 636 patients
– 121 reached by phone
– 100 participated in the survey
• Average age: 72.2 +/- 6.4 yr.
• CC: 61% medical, 39% trauma
• 40% of non-transports said that they would
have gone to the hospital if a physician had
come to the phone / radio
Non-Transport in EMS
Can EMS Systems be as reliable
as Poison Control Centers
or Pediatric Nurse Call Lines?
Managing Non-Transports
• What do we do about medics who just
DON’T want to see patients?
• If we allow a “No Apparent Life
Threatening Event Policy” to guide nontransport, we are relying on medic:
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Performance
Grace
Charity
Ethics
Paramedic Ethical Behavior
Is this an oxymoron?
Or….is it not?
Paramedic Ethical Behavior
Reversing the question….
Can we depend upon EMS
personnel to act ethically?
Do all medics have ethics?
Paramedic Ethical Behavior
Must /can we create a policy
that does
presume
“paramedic ethical behavior?
Fowler’s War Story
• Began EM in ‘78, two years
before the first ABEM boards
• 20 years as an ER medical
director and >30 years as EMS
medical director
• I have seen all the mistakes,
and they drive my work
http://www.doctorfowler.com/www/lectures/fifteenlawsof
EMS2008.pdf
The Chief Potentials for a Mistake
Assuming you know
the diagnosis
Implying to the patient that you know
the diagnosis
Implying to the patient that it is safe to
remain on-scene based upon your
assessment of the problem
Paint Gun
It’s all about
Patient Assessment
• Primary Survey
• Initiate history taking and ALWAYS DO
IT TO THE BEST OF YOUR ABILITY
• Secondary Survey
• The “Third Survey”
Scene Survey/Mechanism/# pts.
LOC/Airway/Cspine
Respiratory Rate and Labor
Pulses R & Q, N & W
Skin CMT/CRT/External Bleeding
Neck appearance, JVD, Trachea
Chest appearance, BS, HT
Quick survey of abdomen, pelvis,
extremities, and back
Central Cyanosis
We hold these
truths to be
self evident
“All” Paramedics
are
Created Equal
REALLY???
All certified by the state…
All have passed Registry…
including clinical skills
and a written Exam
Therefore
They’re
ALL EQUAL!
The State doesn’t
differentiate
between them!
What about
physicians?
Are THEY all equal?
Licensed by the state…
Passed national
boards…
Residency program…
Board certified…
Everyone knows a
Physician you would not
let treat your dog…
Let alone your family
95% of Training
for
5% of Calls
Level 7
• Base Station Physician
Level 6
• Critical Care Paramedic/Nurse
• Critical Care MICU
Level 5
• Primary Paramedic
• MICU
Level 4
• Lead Secondary Paramedic
• ALS Ambulance
Level 3
• Secondary Paramedic
• ALS-Basic Ambulance
Level 2
• EMT-Intermediate
• ILS Ambulance
Level 1
• EMT-Basic
• BLS Ambulance
Level 7
• Base Station Physician
Level 6
• Critical Care Paramedic/Nurse
• Critical Care MICU
Level 5
• Primary Paramedic
• MICU
Level 4
• Lead Secondary Paramedic
• ALS Ambulance
Level 3
• Secondary Paramedic
• ALS-Basic Ambulance
Level 2
• EMT-Intermediate
• ILS Ambulance
Level 1
• EMT-Basic
• BLS Ambulance
New EMS Model!
• Right Resource
• Right Time
• Right Patient
• Right Outcome
Vicious Cycle…
The vicious cycle of health care for the
underserved……..
Increased EMS Use
Decreased Health Status
Poor follow-up care
Lack of Primary Care
Poor care coordination
Lack of Transportation
Community Health Patients
• No defined source of primary care
– “Navigating the system” issue
• Connect the dots
• EMS becomes primary care
– “My primary care doctor is Dr. XXXX” (an E/D doc!)
• Minor conditions become major syndromes
– Leads to preventable admissions
• Revolving door medicine
– Patient’s hospital shop for meds or psych care
• Or even points of interest
Economic Impact - EMS
• FY 2008/09 Analysis
• Lost Revenue
– 21 “Frequent flyer” patients
• 812 unnecessary responses
• $975,000 charges (mostly uncollectable)
• Ambulance Costs
– 1,218 ambulance Unit Hours Consumed
– Operational Unit Hour Cost = $116.18
– Total Cost = $141,507
Economic Impact - Hospital
• Lost Revenue
– 812 patients by ambulance to emergency
departments
– $2,997,904 emergency department charges billed
• At ~$3,692/visit*
– Minimal Collected
• Costs
– $345,912 Emergency department costs
• Emergency department Visit
– At ~$426*
*2010 Survey of EPAB Hospitals
Resource Impact…
• 4,872 E-D bed hours consumed
• 1,218 ambulance unit hours consumed
– Not available for other calls
• Crowded emergency departments = long
waits
– Ambulance patients + “walk-ins”
• Sicker patients = more hospital admissions
– Typically uncompensated
The Challenge…
• How do we as a community:
– Deliver the right resource, to the right patient at
the right time?
– “Connect the dots” for disenfranchised patients?
– Help people become more healthy
• Personal responsibility
– Save resources
– Save money
Community Health Program
• Identify at-risk patients
– Frequent users reports internally
– Field referrals
– Community partner agency referrals
• Develop a care plan
– Including designating a Medical Home
• Only transported THERE!
• Visit them proactively
– Teach them how to manage their care
Community Health Program
• Alternative dispositions
– Clinic appointment
• Including mental health
– Mobile Mental Health Crisis Team
– Bus Pass
• Tracking use on ePCR
• Compare to transportation authority ride data
– Off bus route?
• Non-Medical Transportation contractor
Homeless Shelter Calls…
• Some people call 9-1-1
– To see if they should have called 9-1-1!
• Trained
criteria met
to access 10-digit # if
– Like the CHP patients
– If “OMEGA” call…
• APP goes alone to the call
• Arrange appropriate resource and transportation
Police Lock-Up Calls
• “Jail-itis” calls
– BGL checks
– Medication checks, et. al.
• Used to tie up ambulances waiting for officer to
transport
– Who would then often release the arrestee
• Rather than have PD sit at the hospital
• APP responds to ALPHA and OMEGA level calls
– If transport needed, officer is called FIRST
– Once on-scene, THEN ambulance called via radio for
transport
CHP Future
• Solo Omega Responses
• Accountable Care Organizations
• Medical Home
– Primary Care Involvement
– Alternative Destinations
• Shared Electronic Medical Record
• In Field Evaluation
• No Transport Follow Up
It is Time for
All of Us to
Stand UP and
Make a
Difference!
Pay for Performance
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Accountable Care Organizations
Medical Home
Work closely with Hospitals/Payers
How do we benefit healthcare
The Future Holds?
• Alternative Responses
– Triage protocol
– Non-ambulance transport
• Alternative Destinations
– Stand Alone/Free Standing
– Primary Care
• Medical Home
• Reimbursement
Pediatric Transports
• How do you safely non-transport a child
• Especially given the variability of patient
presentation
• ….and the difficulty of assessing fine
changes in the “very small”…
• ….and family anxiety
Pediatric Transports
“Can you turn down a pediatric call?”
Dr. Halim Hennes, Medical Director
Department of Emergency Medicine
Children’s Medical Center of Dallas
Medic “at the end of a career”
“Doc, I’m done….this is my last shift, and I
hope I never see another patient again.”
Dallas Area Medic, ca 2010
(…I heard this while I’m planning on 20
more clinical years at Parkland)…
The DFR
Mandatory Transport Protocol
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Thirteen pages
Hundreds of entries
A “historic and growing document”
“Behind every line is a law suit.”
J. Ayres, JD
NALTE
The Management of Patients with
“No Apparent Life-Threatening Emergency”
Over the Course of a Year
• DFR responds to 165,000+ EMS calls
• Approximately 80,000 of those patients
are transported to the ED
• >60% of EMS calls terminate with the
patient remaining on scene
• That translates into approximately 300
non-transports per day, 365 days/year
The Problem
We know not EVERY patient needs
treatment at the ED or needs transport to
the ED by ambulance.
BUT..
During initial training, how many paramedics
are trained in how to SAFELY nontransport a patient?
The Problem
We KNOW how to “GET” a refusal:
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“Riding in the ambulance will cost $_____.”
“Your regular doctor can take care of…”
“The waiting room is pretty full up at the ED.”
“Everything we are checking looks good…”
What policy OR training provides us the scope
of knowledge to offer such advice?
The Problem
Patient refusals / non-transports can:
• HARM HUMAN BEINGS NEEDLESSLY
• Increase liability for medics and providers
• Create a forum in which medics routinely
operate outside their “scope of practice”
More Problems
“Over-transporting” perpetuates:
• ED overcrowding
• Ambulance diversions
• Increased resource utilization hours
• Higher operating costs
In the ED, patient triage before being seen
by a physician is the standard of care.
With all the demands placed on EMS
systems, why is pre-hospital triage not a
commonly accepted practice?
Pre-Hospital Triage Challenges
• Training has not evolved
• Greater liability on the provider’s part
• Errors are more likely to be broadcasted in
a very public forum
NALTE Goal
Improve emergency response capabilities of
DFR EMS & area emergency departments
by utilizing current assets and triaging
non-urgent / stable patients from the
Emergency Response System
Do We Have A Patient?
Definition of “Patient”:
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Any person who has called 911 or has contacted EMS
requesting emergency medical attention for
themselves.
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Any person for who 911 has been summoned because
a third party, who is on location with said person,
believes that person may be sick or injured.
Not a Sick or Injured Person (NASIP):
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Persons for whom emergency medical attention has
been summoned by a third party (who is not on
location) or who does not have DIRECT CONTACT
with said person may be classified as a “Not a Sick or
Injured Person” (NASIP) if examination supports this
conclusion
NASIP Criteria
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Be awake, alert, oriented and cooperative
Can calmly, clearly, and lucidly state that he or she is not ill or
injured and does not wish to be evaluated or treated by EMS
personnel
Be ambulatory without assistance, or is at usual baseline level of
ambulation (can sit in a chair [Wake County Protocols])
Does not exhibit any external signs of recent trauma (for
example: lacerations, abrasions, contusions, domestic violence)
Has not been involved in an event that meets Trauma Level
Criteria
Does not exhibit signs of gross alcohol and/or drug intoxication
(for example: slurred speech, ataxic gait, alcohol on breath)
Be willing to provide his or her name for documentation
purposes
No Patient Exists
• EMS personnel shall document both:
1) That the person(s) on scene meet all criteria for a
NASIP as well as…..
2) The circumstances for which EMS was incorrectly
summoned to the location. Person(s) who do not
meet ALL criteria for a NASIP, shall be considered a
patient and will be treated / evaluated as such.
Does person on scene
meet DFR patient
definition?
No
NASIP
Do person(s) on scene
meet criteria for NASIP?
Yes
Patient Triage
A complete medical evaluation, examination, and
history SHALL be performed on any patient not
fitting NASIP Criteria
Non-urgent / Stable Patient:
Identified Person on
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Age 18 - 64
Systolic BP between 100 - 140
Pulse rate 60 - 100
Respiratory rate 12 - 20
Blood sugar 90 - 180
SpO2 > 94% on room air
Temperature < 101 degrees F
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Lung sounds clear and equal
Scene?
Yes
Does person on scene
meet DFR patient
definition?
Do person(s) on scene
meet criteria for NASIP?
No
Urgent / Non-stable Patient:
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All other patients not meeting Non-urgent / Stable criteria
Yes
Does patient meet
criteria for non-urgent /
stable patient?
Urgent / Non-stable Patients
Identified Person on
Scene?
• Patients classified as an
“Urgent Patient” shall be
transported to an
emergency department
facility capable of treating
the patient’s actual or
potential illness
• Any urgent patient refusing
transport must sign an
Against Medical Advice
(AMA) refusal form
Yes
Does person on scene
meet DFR patient
definition?
Yes
Does patient meet
criteria for non-urgent /
stable patient?
No
Urgent Patient
Patient
refuses
transport
Patient
accepts
transport
Non-urgent / Stable Patients
Triaged into the following dispositions:
• Patient Declines Transport (PDT)patient is treated and released at scene
or chooses not to seek further medical
treatment
• Alternative Transport / Alternative
Destination (AT/AD) - patient seeks
further treatment by means other than
ambulance or at a medical facility other
than an ED
• No Apparent Life Threatening
Emergency (NALTE) - patients that are
triaged out of the EMS system by
medics (based on chief complaint)
*If at any time a patient falls outside the
non-urgent / stable patient criteria, he or
she shall be deemed an urgent patient
and treated as such
Does patient meet
criteria for non-urgent /
stable patient?
Yes
Non-urgent / Stable
Patient
NALTE Chief
Complaint?
No
Patient
requests
transport
Patient
refuses
transport
NALTE
Non-urgent / stable patients presenting with one of the
following chief complaints may be refused transport by
EMS personnel:
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Toothache - chief complaint must be limited to atraumatic tooth pain,
without signs of abscess or infection.
Anxiety (panic) attack - must be confirmed with ETCO2 monitoring and
breathing rate must return WNL for at least 5 minutes before refusing
transport. Patients who present with chest pain not relieved with normal
breathing rate shall be treated under chest pain protocol. Those patients
presenting with any type of chest pain shall have 12-lead ECG
performed.
Nausea / Vomiting - Onset of illness must be less than 12 hours. Patient
shall not have any bloody stool or blood in emesis and TILT test
negative. If accompanied by abdominal pain, complete abdominal exam
shall be performed. If any tenderness, rigidity, or guarding is present,
patient must be transported.
Flu-like symptoms - Onset of illness must be less than 24 hrs. Patients
with nausea and vomiting must also meet criteria for Nausea/Vomiting
NALTE protocol. Patients with underlying respiratory illness (CHF,
asthma, COPD) are not eligible for NALTE refusal.
NALTE
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Minor “fender bender” MVC - Patient must be
ambulatory at the scene prior to EMS arrival and no
other persons in the vehicle have signs & symptoms
of injury. The vehicle in which the patient was
traveling must not have any damage or damage
localized to the front or rear bumper without airbag
deployment. If the patient’s vehicle has any damage
to the body of vehicle, that patient is not eligible for
NALTE refusal. Patients who show signs &
symptoms of intoxication are not eligible under
NALTE refusal. Patients with history of back or neck
injury are not eligible.
Localized trauma (minor injury) - Patient has
localized, superficial injury that does not require
sutures and bleeding can be controlled with simple
dressing. A thorough history shall be performed to
rule out more serious cause of injury (syncope,
hypoglycemia).
Welfare check - Patient has no chief complaint and
has summoned EMS for the sole purpose of
obtaining vital sign check, blood sugar level check, or
welfare checks for persons in police custody.
Patients with any other complaint(s) shall be treated
according to treatment guidelines.
Non-urgent / Stable
Patient
NALTE Chief
Complaint?
Yes
NALTE
No person on scene
who called 911 or for
who 911 was called
Identified Person on
Scene?
Yes
UTL
No
Does person on scene
meet DFR patient
definition?
Do person(s) on scene
meet criteria for NASIP?
Yes
No
NASIP
Yes
Does patient meet
criteria for non-urgent /
stable patient?
Yes
Non-urgent / Stable
Patient
Urgent Patient
NALTE Chief
Complaint?
Yes
No
Patient
refuses
transport
Patient
accepts
transport
AMA
TRAN
No
NALTE
Patient
requests
transport
AT/AD
Patient
refuses
transport
PDT
Potential Dispositions
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UTL= Unable to Locate
NASIP= No sick or injured
PDT= Patient Declines Transport
AT/AD= Alternative Transport / Alternative Destination
TRAN= Transport to ED
AMA= Refused Against Medical Advice
NALTE= No Apparent Life Threatening Emergency
Factors in Safe Non-transport
• TIME = the “X Factor” of patient evaluation
• A “normal” history and physical actually
very little
• What can we do about this?
• Spend a few more minutes on the scene
• More detailed or changing history
• Trending VS / error
• Give the patient the opportunity to say
something else
What Does It Take to Craft a
Safe Non-Transport Protocol?
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Design
Vetting
Community Agreement
Training
QI
Remediation
RECOURSE for bad decision-making
Fowler’s Law of Non-Transport
“It is a SIN to EVER manipulate
someone into making a bad
medical decision based upon your
own needs or intentions.”
Beeson’s Corollary to the
Law of Non-Transport
“It is ALSO a sin to EVER express
an opinion on a subject in which
you are inadequately informed that
can cause YOUR PATIENT – for
whom you are legally, ethically,
and morally responsible – to come
to harm.”
Summary Thoughts
“It isn’t what it isn’t: It’s what it
MIGHT be that will hurt your
patient if you non-transport”: R.F.
“Take yourself out of the equation
and be a patient advocate”: C.C.
“Spend less time refusing transport
and more time finding
alternative transportation”: J.B.
www.rayfowler.com