Thursday, December 28

Patient - Defined. Wrong, but defined.

I nearly had a stroke the other morning.

As I came into work I was notified that our local EMS Agency, the agency tasked with telling me what I can and can't do as a Paramedic, has added a new sentence into a policy that makes it nearly impossible to believe they know what they are doing anymore.

I've been to the meetings where these policy changes are discussed and most are suggested by an ED doc upset something happened once out of 115,000 calls for service.

 

In our policy that defines what is required to document a patient contact, there were 2 bullet points that gave guidance as to who was a patient, since if you have a patient you must complete a primary and secondary assessment (including ECG and BGL), identify illness or injury, treat said illness or injury and offer transport.

Those two bullet points were:

  1. Anyone who requests medical evaluation. That makes perfect sense to me.  They want us here, we're here.

  2. Anyone who, based on practitioner impression, requires assessment or intervention.  Makes sense again, altered consciousness, folks who need us but can't ask for us by name.


That's all we really needed.  Either they want us or, if they were able to ask for us, they would.

 

Nope, now nestled inbetween sanity is insanity.  A new bullet point is included...

  1. Remains unchanged

  2. Any person for who assistance was summoned by a third party.

  3. Remains unchanged.


Do not adjust your TV sets.  Yes, the new policy states that a patient exists if a third party believes they are in need of assistance.   This means that, LEGALLY, there is a "patient" at every single 911 call regardless of the condition of the person in question.  If you sneeze and someone in a passing Lexus calls 911, I'm required to assess you and get a refusal signature.

We've fallen down more than a few rungs on this one and, so far, I can't get anyone in the agency to reply as to why this was changed.  All I can figure is that they're gearing up to start charging a response fee (Which is almost as stupid as the new definition of patient) and now delays units clearing calls where the caller was wrong (more often than right) which impacts the system.

And all for what?  So we can stay out of service longer to document how the 911 caller is not on scene and the man who sneezed is not giving consent for an unnecessary medical procedure and refuses to sign my form?

 

It's almost 2018 too.

Thursday, December 21

Merry Christmas from #TCS!

The Crossover Show - 136

In this episode, MC and HM celebrate some Christmas. The guys wax philosophic about holiday plans, traditions, and whine about their busy schedules (as they are wont to do) and let you down easy with announcement that episode 136 will be the last of 2017!


This episode is in no way brought to you by Alexa or her human sycophants at MCPD. In related news, MC got him an Alexa and he’s diggin’ it.


Not to worry, friends! HM and MC will be back and stronger than ever in 2018!


BOLO


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Source: the Crossover Show

Friday, December 15

Three Discipline Sponsors – Kosher or Corruption?

The Crossover Show - 135

In this episode, HM and MC discuss Mesa, Arizona, and their plan to advertise on the side of Fire Engines. MC is against it, HM is for it but they uncover a mine field of problems they hope Mesa has thought of ahead of time.


But why stop there? Why not an ad for a tow service on a traffic cop bike?


See? Problems…







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Source: the Crossover Show

Thursday, December 7

Has Video Killed the Radio Star?!

The Crossover Show - 134

They say that video killed the radio star but as far as the guys can tell…it ain’t helping all that much. In this episode of a cop and fireman having a beer and solving the worlds problems they discuss exactly what all the video is supposed to be doing for us. Everyone is taking video…what is it for?


The guys discuss MC showing video of a traffic violation in court, to a judge.

They also discuss a video from Statter 911 where a citizen live streams a fire response (and hilarity ensues)!


Is video even worth it if it isn’t being used properly?


BOLO


The Enemy of the State by Kyle Mills


Artemis by Andy Weir






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Source: the Crossover Show

Sunday, December 3

Dispatch centers tracking the wrong things?

I was contacted recently by one of us internet EMS folks about their new role as supervisor of their dispatch center.  A qualified care giver with a thirst for knowledge from the old CoEMS days, they jumped into the role with both feet and, as too many of us learn in EMS, the admin pool is a lot shallower than we had hoped.

"Hey HM, I was wondering if you had a minute for some feedback on a project. I got the comm center job this week and am shadowing the current supervisor. So far I'm learning the basics OK, but we seem to be focusing on some random stats I would be curious to hear what you think about the stats?"

They go on to list the top 3 focuses of this center:

-Code 2 dispatches that result in code 3 returns

-Call taker processing between 5 minutes and 15 minutes

-Ambulance at hospital times "Wall time"

 

I can't make too much of a stink about those, except that I will.  Some centers look the other way, at least we have our eyes open.

Code 2 calls in this system have a response target of 22 minutes 90% of the time.  Code 3 calls, 12 minutes 90% of the time.  While no one can cite WHY these random numbers are pulled out of thin air (Why does the ambulance in this area have 2 minutes longer to arrive on scene than where I live? - easy answer is the contract they signed) at first glance this is a metric you'd want to take a look at.

Why did a non-emergency call become an emergency transport?

Our friend asked what the outcome was of the dozen calls they were looking at for the month and he was met by blank stares.  Apparently no one thought to find out if the emergency transport was warranted, justified or had an impact on patient condition.  While new research is leaning away from code 3 transports having an impact at all, we still need to take a look.

In 8 of the 13 returns, it involved an elderly fall.  The PCR's didn't have any time sensitive interventions, including pain control.  There was no discernible reason the crews used lights and sirens to transport these non emergent falls, until he interviewed the crews.  They stated feeling compassion for the patients who were found down after an extended period of time and wanted to minimize that discomfort.  When asked why no interventions were performed the crews (mostly) said they were not indicated.

So here we have a dispatch center about to upgrade certain fall calls based simply on the fact that crews chose to use the lights and sirens based on their observations of discomfort, without treating them or showing benefit.

I'd argue they're doing great but need to shift focus to a more concerning population in your data:

Code 3 calls that result in a non transport.

Why was an emergency call generated for a non-emergency situation?  Is it a call taker issue?  A call classification issue?  Could it be similar to the reason crews are transporting certain patients lights and sirens?  Sending crews out fast does not decrease system liability, it increases it.

Could it be a response metric issue?  Simply sending crews out code 3 on short runs to pad the numbers?  Sounds crazy but I've actually heard dispatchers discussing this, in multiple systems in more than 1 country.

 

Issue 2 - call taker processing between 5 and 15 minutes

WHAT?!  Unless there is a language barrier I can't imagine why it would take between 5 and 15 minutes to classify a call.  Look into that!

Issue 3 - Ambulance wall times

Ah, yes.  The hospital problem tracked by EMS.  We hear often that EMS can't truly ease ER workload simply by diverting patients, but oh hells yes we can.  When we have to transport every person who wants it, we seem to stack up at the ER.  Often times we are diverted to the triage desk in the waiting room with the minor injuries and chronic ailments but still have to wait for hospital staff to make space.  In my system we give a radio report with an ETA but they still act surprised when 5 minutes later we arrive and there's no bed.  One hospital in NM long ago had the bed assignment board next to the EMS radio.  As we made our radio report, they'd note it on the board and have a bed waiting.  When we arrived we'd check the board, goto that room and begin patient transfer.  After a few minutes the RN would arrive to take report.  Easy Peasy.  Nowadays we seem to be stuck with a triage nurse at a tiny little assessment computer more interested in the patient's billables than their condition.

Wall times are a hospital problem.  Their inefficiency slows EMS which then has an impact on response times, which then leads to non-compliance which leads to more cars on the road, you see where this is going.

 

So, Mr new dispatch supervisor, my advice to you is to look at everything, from all angles.  Look outside EMS for concepts and solutions.  Read Dan Khaneman, Dan Pink, Freakonomics, become a student of efficiency, productivity and truly strive to understand all the working parts of your system and how they interact with each other.  Sometimes a simple fix far upstream can steer the river.

 

Good luck!

-HM

Friday, December 1

Does your confidence exceed your abilities around the homestead?

The Crossover Show - 133

In this episode, MC and HM discuss how first responder personas and their inherent confidence/arrogance may land them in some proverbial (or possibly literal if we’re talking plumbing) hot water around the house.


What about you? Do any of your work experiences and your relative confidence surrounding them translate into possible problems for you at home?


On a side note, apologies for the lack of show last week! HM was traveling for the holiday and MCPD was rife with the flu. All of them. It was terrible.


BOLO


Sense Home Energy Monitor


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Source: the Crossover Show