Welcome Back to BHP Corner
For those who are new to this segment of the EMOttawa Blog, here’s a little refresher. In the Base Hospital Program (BHP) Corner, we aim to review interesting and evolving topics, as they pertain to the prehospital/paramedicine world. Advances, reviews, and changes to Ontario and local practices, you name it, we review it.
Up this week; out of hospital discharge. The concept in which patients may be diverted away from the emergency department to an alternative destination, that is equal or better suited for the patients complaint. Because, not all 911 calls need to result in an ED visit.
Case Study
You and your partner respond to a code 4 for a 35 year old female who has a cough, shortness of breath and is sweaty. When you arrive you are greeted by a well-looking patient in no acute distress. She describes 24 hours of fever, non-productive cough, rhinorrhea and mild shortness of breath. She took a COVID rapid antigen test today and it was positive. She called her primary care provider and the physician wasn’t available. She was advised that if she is short of breath she should go to the hospital. On exam she appears quite well and her vital signs are normal except for a temperature of 38.3 degrees Celsius. You are your partner wonder if she is best-served by going to the hospital.
Today, we are on the cusp of some exciting new improvements to the way paramedics practice; out of hospital discharge.
For years, the requirement was that all 911 calls resulting in a patient encounter mandated a recommendation to go to the hospital. The only patients who were not transported were those who had capacity and made an informed refusal. As we looked critically at this practice, it became apparent that the best disposition for patients after a 911 call isn’t always an urgent trip to the emergency department (ED).
Recent implementation of a COVID-19 directive and palliative care directives have demonstrated that paramedics can safely disposition patients to alternative destinations, even allowing them to stay at home.
The plan is to expand this practice to a broader range of low-acuity patients through new patient care models and prehospital discharge auxiliary directives in the ALS PCS. This is a new practice in the prehospital world and there will be benefits to patients and the system, but there will also be increased risk to patients, and we need to do this safely.
As emergency physicians we have a lot of experience with dispositioning of patients. We have experience in how to do this safely, and we have learned from when things go wrong. This article will share some pearls and pitfalls for out of hospital discharge of patients so that you can learn and perform this skill safely as well.
A New Approach
When considering an alternate pathway for a low-acuity patient, the approach to the call will be different for EMS professionals compared to their usual practice. Traditionally paramedics have been trained to attend the scene, meet the patient, perform a rapid assessment, initiate life-saving treatment, and transport expeditiously to the hospital. This approach works well for life and limb threatening emergencies when the goals of care are aggressive treatment and patient survival.
While we must never discount the possibility that the patient’s signs and symptoms are related to an acute emergency, we know that many patients who generate a 911 call are experiencing a low-acuity problem, and some might be more appropriate for alternate pathways, where their needs are better-served by avoiding an emergency department; here enters the out of hospital discharge.
To gauge if an alternate pathway is appropriate, the paramedic’s approach to the assessment must change. We must dig deeper into the history, taking time to go over the symptoms, the timeline, the progression, the opinions and assessments already sough, diagnoses already made, the treatments, and the trigger for the 911 call. The physical exam must be more detailed. The focus must be on identifying findings that could help with diagnosis, and examining for red flags that could indicate a more sinister problem (remember a prehospital discharge means you might be the only healthcare provider who sees the patient for this problem). Investigations available to the paramedic should be performed, and any investigations performed elsewhere that you or the patient has access to should be reviewed. Collateral information may need to be sought from others.
This approach will clearly take more time at the scene than a typical 911 call.
After a thorough history, physical exam, and review of relevant investigations, what is the working diagnosis? What is the differential diagnosis? What do we know, and what are we certain about? Are we satisfied that there is nothing life or limb threatening that would benefit from an ED visit? Are there serious conditions that the history and physical might suggest that we simply cannot rule out? Would the ED be able to help with this? If not transported to the hospital, what is the follow-up plan and is it reasonable and practical? These are all important questions when considering our recommendation to the patient and our discussion with them about the pros and cons of the options which is essential for informed consent for the plan, and the possibility of out of hospital discharge.
The Clinical Condition
How do we determine if someone might be appropriate for an alternate disposition? The first place to start is with the reason for the call and the symptoms that the patient has or had, or the signs that the caller was noticing that prompted the 911 call. After a thorough history and physical exam, and taking into account any test results that are available, how satisfied are we that the patient is not experiencing a life or limb-threatening condition? Have we thought about the serious things that this could be that would benefit from the added capabilities of an emergency department – a physician assessment, diagnostics, and time for observation in a monitored setting? Are there any red flags? For example, the red flags for low back pain after an injury are leg weakness, diminished reflexes, perineal anesthesia, and fecal or urinary incontinence. These need to be considered and documented.
This is a new way of thinking for paramedics. You are entering the world of uncertainty, where symptoms a patient is experiencing may not have a clear explanation, and it may not be possible to know if they have a life threatening condition or not. Base hospital physicians (BHPs) are always available for consultation. As partners in a joint assessment, you can be our eyes and ears. We might ask you to conduct examinations, and ask further questions, so we can better understand the condition if there are any red flags. vital signs are vital. Resist the temptation to explain way abnormal vital signs as being nothing serious, especially if the cause of the patient’s symptoms isn’t clear. It should be an unusual case where a patient is dispositioned somewhere other than an emergency department if they have a persistently abnormal vital sign.
Conclusion
We are on the cusp of exciting changes. The use of out of hospital discharge of patients is a new practice that will benefit patients, communities and the healthcare system, but it is also a new skill for paramedics and a skill must be learned.
Case Resolution
You perform a thorough history geared towards the complaints and the finding of fever. She has only respiratory tract symptoms and she is not short of breath currently. There is no other focus for the fever on history (no UTI symptoms, abdominal pain or skin rashes). There is no chest pain. She is eating and drinking normally. There is no past medical history except depression and her only medication is Sertraline. She is fully vaccinated against COVID.
On exam, she appears well and is in no distress. Mucous membranes are moist. Her vital signs are normal except for a fever. Neck is supple, chest is clear and the abdomen is soft and non-tender. There is no peripheral edema and you specifically note no leg swelling or other clinical signs of a DVT. Given the shortness of breath you perform a 12-lead ECG which is normal sinus rhythm with no ST changes. You review the COVID rapid antigen test she performed, which is positive. You confirm with her that the reason for the 911 call was at the behest of the doctor’s office due to the shortness of breath and inability to see her today in the office.
You inquire about her social situation. She lives in an apartment that appears well-kept and her fiancé lives with her and will be home shortly. She works full time as a cashier at Metro. You advise her that her signs and symptoms and the positive COVID test are in keeping with COVID-19, and that she appears to be tolerating it quite well. You explain that the mainstay of treatment is symptoms management, with acetaminophen and ibuprofen for fever and myalgias, and fluids to stay hydrated. She has access to all of these.
You offer her the option of transporting her to the hospital, but suggest that it would also be appropriate to be seen at one of the COVID assessment centres if she would like to be seen today. She advises that she would like to be seen by a physician today since her doctor’s office recommended it, but she would be happy to go to the assessment centre.
You call the BHP to discuss the case and everyone is in agreement that an alternate disposition is safe and appropriate. The BHP suggests a dose of acetaminophen and ibuprofen if there are no contraindications per the analgesia directive.
You assist the patient with making the clinic appointment for the assessment centre, and one is available today. Her husband arrives home and he will be able to drive her there. He is in agreement with the plan. You provide the patient and her husband with contact information for the clinic.
She is thankful for your assistance and particularly grateful for the assessment and in the knowledge that her oxygen levels are okay. You advise her to call back if she experiences chest pain, worsening shortness of breath or any other concerns.
You document your assessment, your discussions with the patient, and the follow-up plan, and clear for the next call. You have successfully completed your first out of hospital discharge.
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