# Is starting an unnecessary IV fraud?



## ExpatMedic0 (Nov 24, 2013)

Here is one for you all. I don't know about you, but I have seen a lot of BS prehospital IV's started in my time for no reason. I once asked a provider why he started IV's on every transport and he replied "because we can." 
Not only does this open the patient up to a higher risk of infections and complications, but its a costly unnecessary procedure. Furthermore, if there is no medical necessity for the IV, depending on your billing system, it could effect the patients ambulance bill or the insurance payment, which I consider fraud. 

Any thoughts?


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## CriticalCareIFT (Nov 24, 2013)

One needs to perform the skill to maintain adequate proficiency for the select few patients who really do require IV access. If you only initiate IV access on very small percentage of patients who truly need it, you may lose the dexterity and precision and the diabetic with BGL of 30mg/dl who is laying on the floor with non perfect vasculature, would be a tough stick or you may not even get access if you seldom perform the procedure.

Peripheral IV access is not central canulation and does not carry such stringent criteria and believe it or not, even central access gets places on patients who do not always need it, because residents need practice and attendings need skill maintenance.

Fact: majority of ALS calls are really BLS, or they can even take the cab. That 10-15% would constitute an ALS call, if we only performed IV access on 10-15% of the time, how would you maintain proficiency? IV access will turn into intubation as we experience it now.


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## medicsb (Nov 24, 2013)

I have heard of at least one instance of a service getting audited and having to justify why certain patients were transported ALS, and many of the transports questioned were ones where only an IV was placed.  I expect this will happen more frequently.

In my experience, medics in "all-ALS" systems are somehow compelled to treat everyone with VOMIT (y'know: vitals, O2, monitor, IV, transport), when vitals and transport are all that is needed.  I imagine at some point an IV and monitor will no longer be considered an ALS intervention and will not generate a higher billing rate.


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## Medic Tim (Nov 24, 2013)

Never really thought about it as we don't have itemized bills. ALS or BLS it doesn't matter. Same flat fee.

I only do IVs on pts I am going to give fluid or meds to. It is common for me to not start one "because the protocol" sad to. This has cut down on my number of IVs but I am still able to do enough to stay proficient.


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## medicsb (Nov 24, 2013)

Medic Tim said:


> Never really thought about it as we don't have itemized bills. ALS or BLS it doesn't matter. Same flat fee.
> 
> I only do IVs on pts I am going to give fluid or meds to. It is common for me to not start one "because the protocol" sad to. This has cut down on my number of IVs but I am still able to do enough to stay proficient.



I'm not an expert on billing by any means.  But in the US there is no itemized billing (though there may be exceptions), but there are pre-defined billing levels based on what was done for the patient.  I believe the it's BLS non-emergency, BLS emergency, ALS-1, ALS-2, and SCT.  And then the service can charge a per-mile rate.  Difference between ALS-1 and 2 is the number of meds administered (≥3 for ALS-2 and IV solution and O2 do not count) and certain procedures (intubation, cardioversion, pacing, etc.).

I did once hear of a service purposely not stocking duoneb, so that they could bill ALS-2 on most COPD and asthma patients, because if they gave the atrovent separately from the albuterol that was 2 meds whereas giving a "duoneb" counted as one med (the third med for the ALS-2 would be solu-medrol).


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## Ewok Jerky (Nov 24, 2013)

ExpatMedic0 said:


> Here is one for you all. I don't know about you, but I have seen a lot of BS prehospital IV's started in my time for no reason. I once asked a provider why he started IV's on every transport and he replied "because we can."
> Not only does this open the patient up to a higher risk of infections and complications, but its a costly unnecessary procedure. Furthermore, if there is no medical necessity for the IV, depending on your billing system, it could effect the patients ambulance bill or the insurance payment, which I consider fraud.
> 
> Any thoughts?



I dont think "because we can" cuts it...but certainly "because I might need it later" can fly given a rational line of thought from presentation and Hx to possible outcomes.


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## Bullets (Nov 24, 2013)

CriticalCareIFT said:


> One needs to perform the skill to maintain adequate proficiency for the select few patients who really do require IV access. If you only initiate IV access on very small percentage of patients who truly need it, you may lose the dexterity and precision and the diabetic with BGL of 30mg/dl who is laying on the floor with non perfect vasculature, would be a tough stick or you may not even get access if you seldom perform the procedure.
> 
> Peripheral IV access is not central canulation and does not carry such stringent criteria and believe it or not, even central access gets places on patients who do not always need it, because residents need practice and attendings need skill maintenance.
> 
> Fact: majority of ALS calls are really BLS, or they can even take the cab. That 10-15% would constitute an ALS call, if we only performed IV access on 10-15% of the time, how would you maintain proficiency? IV access will turn into intubation as we experience it now.



I dont insert pharyngeal airways every day, but based on your reasoning, everyone is getting a NPA now. 

Patient doesnt NEED an NPA, but i need to practice the skill of measuring a correct size.


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## Carlos Danger (Nov 24, 2013)

ExpatMedic0 said:


> Here is one for you all. I don't know about you, but I have seen a lot of BS prehospital IV's started in my time for no reason. I once asked a provider why he started IV's on every transport and he replied "because we can."
> Not only does this open the patient up to a higher risk of infections and complications, but its a costly unnecessary procedure. Furthermore, if there is no medical necessity for the IV, depending on your billing system, it could effect the patients ambulance bill or the insurance payment, which I consider fraud.



That is an excellent point and question.

The last 911 ground job I had, I was frequently scolded for not starting IV's or doing 12-leads. My philosophy was, if I don't plan to give meds or fluids, the patient doesn't need an IV from me. And for that reason, I rarely started them even though many other paramedics would start them on almost everyone. 

Of course, the only reason the company cared was because they could bill at the higher ALS rate if the patient had an IV.



CriticalCareIFT said:


> One needs to perform the skill to maintain adequate proficiency for the select few patients who really do require IV access. If you only initiate IV access on very small percentage of patients who truly need it, you may lose the dexterity and precision and the diabetic with BGL of 30mg/dl who is laying on the floor with non perfect vasculature, would be a tough stick or you may not even get access if you seldom perform the procedure.



"We need to practice" is an extremely poor justification for exposing a patient to unnecessary costs and risk.


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## AeroClinician (Nov 24, 2013)

If the pt. is going to / possibly have blood drawn for labs at the hospital during their course of care. How is vascular access prior to arrival, fraud? It's for an actual purpose. Prehospital vascular access allows blood to be drawn faster. 

Now I know what some are going to say, " they don't use our line becaus it's a "field line" ". I call BS, I couldn't tell you how many times I see RNs draw blood out of my line upon arrival after aspirating a good 10cc of blood first.

A sizable portion of ALS pt.s have the potential to deteriorate, wouldn't you like to have a line already in place if that happens?


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## VFlutter (Nov 24, 2013)

AeroClinician said:


> If the pt. is going to / possibly have blood drawn for labs at the hospital during their course of care. How is vascular access prior to arrival, fraud? It's for an actual purpose. Prehospital vascular access allows blood to be drawn faster.
> 
> Now I know what some are going to say, " they don't use our line becaus it's a "field line" ". I call BS, I couldn't tell you how many times I see RNs draw blood out of my line upon arrival after aspirating a good 10cc of blood first.



It may happen but it is poor practice. We do not draw labs off peripheral IVs. If we absolutely can't get labs we will do an arterial stick. 

I will try to find some studies but I know our hospitals informal evaluation showed that the majority of hemolyzed and rejected lab draws came from the ER where it was standard practice to draw off PIVs.


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## ExpatMedic0 (Nov 24, 2013)

Halothane said:


> That is an excellent point and question.
> 
> The last 911 ground job I had, I was frequently scolded for not starting IV's or doing 12-leads. My philosophy was, if I don't plan to give meds or fluids, the patient doesn't need an IV from me. And for that reason, I rarely started them even though many other paramedics would start them on almost everyone.
> 
> ...



I just learned this, but check this out
http://quitam-lawyer.com/ambulance-fraud.html

Whistle blower rewards are now offered for providers reporting possible fraud.  I believe that probably includes being forced to do an "ALS" procedure that is medically unnecessary just for billing purposes.


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## Summit (Nov 24, 2013)

In answer to OP's question, fraud if unjustifiably unnecessary invasive procedures are billed for period. If providers are providing invasive procedures without reason, that is unprofessional, unethical, and grounds for reprimand or referral to their certifying board's review panel.



CriticalCareIFT said:


> One needs to perform the skill to maintain adequate proficiency for the select few patients who really do require IV access. If you only initiate IV access on very small percentage of patients who truly need it, you may lose the dexterity and precision and the diabetic with BGL of 30mg/dl who is laying on the floor with non perfect vasculature, would be a tough stick or you may not even get access if you seldom perform the procedure.
> 
> Peripheral IV access is not central canulation and does not carry such stringent criteria and believe it or not, even central access gets places on patients who do not always need it, because residents need practice and attendings need skill maintenance.
> 
> Fact: majority of ALS calls are really BLS, or they can even take the cab. That 10-15% would constitute an ALS call, if we only performed IV access on 10-15% of the time, how would you maintain proficiency? IV access will turn into intubation as we experience it now.



I would never perform an unwarranted invasive procedure on a patient because "I need the practice for the people who really need it." That is an outrageously unethical attitude. If that lack of professionalism is rampant in your system, you should be the agent of change. I certainly hope you don't buy into that horsehockey.

I find most of that post entirely ludicrous in both claim and reasoning.


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## VFlutter (Nov 24, 2013)

CriticalCareIFT said:


> even central access gets places on patients who do not always need it, because residents need practice and attendings need skill maintenance.





Summit said:


> I find most of that post entirely ludicrous in both claim and reasoning.



You mean your Intensivist doesn't float Swans on patients, who do not need one, for practice? He must be rusty.


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## truetiger (Nov 24, 2013)

I noticed some of you only start IV's when YOU plan to use them, but what about our hospitals? What percentage of ER patient's get an IV? I'll start an IV on anyone I suspect would get one in the ER. Our ER's are busy and they truly appreciate anything we can do to cut down on their to do list when we arrive. I cringe when I hear providers say that "oh they'll do that when they get to the hospital" or "I was too close to the hospital to perform xxx intervention...) I think its best practice to treat your patient's just as the hospital would, protocols allowing.


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## teedubbyaw (Nov 24, 2013)

Starting then for practice is silly, and starting them because they'll get one in the hospital is NOT a reason to do it.


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## Summit (Nov 24, 2013)

Know your receiving facility. Many EDs will pull every field line as "dirty" unless its critical, and restart it if needed. If that is not the case, and they need one for the ED, sure!


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## Tigger (Nov 24, 2013)

Practicing IV skills on patients that do not need them is not in any way a justifiable reason to start one, especially if it costs the patient more money. That's downright deplorable. 

Most patients I take to our in town Level 4 ED get an IV, but that is at staff request. There's only 1-2 RNs and a tech, so "busy" for them is like three patients. In Colorado IVs can be billed as BLS, so the bill doesn't go up at least. 

Otherwise, it needs to be medically indicated, and not be a "I had time so I did it" type thing. I also don't want to have the patient get stuck more time than needed or ruin a perfectly good site for the hospital to draw labs off of.

Sure I can get a 22 in an elderly man's hand, but when we get downtown 45 minutes later, I doubt they'll be able to draw off of it and that might have been the best site available. Now I've made more work for everyone.


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## Akulahawk (Nov 24, 2013)

If my patient needs vascular access because I _suspect _that I will have to administer medication, I'll start the line. Whether it's a line or a lock depends upon whether my patient needs fluids and if I have the right tubing to do it. My view is that if I'm starting a line on a patient, I have to be able to justify it and "the hospital will start one" won't fly.


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## CriticalCareIFT (Nov 24, 2013)

Please get of your high horses about this noble pursuit of "only if truly required". If you followed this rule you would be performing maybe 1 IV a day or most likely not at all, as majority of ALS calls don't "truly require" IV access. I guess none saw any flaw with this statement "because I might need it later" which translates  to we starting one either way, wether you need it now or not.

And unless you got multi-venous IV training arm at home or at your station there is no way you initiating IV access often enough to maintain adequate proficiency on the poor vasculature patients. 

This is not the ER where I see 8+ patients and most will require specimen collections where you will practice your skill. 

And what is your response when the patient truly requires IV access and you are unable to obtain it due to skill degradation? So you will stab him multiple times and then transport to the ED telling you battle story "It such a hard stick you know, very hard!".

I guess none of you saw residents place central lines during cardiac arrest, because certainly main reason they doing it is out of patient necessity. 

This is a chief reason intubation is highly contested, we don't do it nearly enough, and very few go to the operating theater for practice. Now before some of you hit your keys with furious anger, I do not advocate intubating everyone you come across. However peripheral IV access does not carry the same deleterious effects when appropriately conducted yet crucial for certain calls.


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## ffemt8978 (Nov 24, 2013)




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## Carlos Danger (Nov 24, 2013)

CriticalCareIFT said:


> And unless you got multi-venous IV training arm at home or at your station *there is no way you initiating IV access often enough to maintain adequate proficiency on the poor vasculature patients. *



Do you have any evidence to back up that claim?


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## Tigger (Nov 24, 2013)

CriticalCareIFT said:


> This is a chief reason intubation is highly contested, we don't do it nearly enough, and very few go to the operating theater for practice. Now before some of you hit your keys with furious anger, I do not advocate intubating everyone you come across. However peripheral IV access does not carry the same deleterious effects when appropriately conducted yet crucial for certain calls.



Perhaps it does not have same deleterious effects when done improperly, but it certainly has a deleterious effect on the patient's wallet in most places. Is that not a concern?


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## CriticalCareIFT (Nov 24, 2013)

Bullets said:


> I dont insert pharyngeal airways every day, but based on your reasoning, everyone is getting a NPA now.
> 
> Patient doesnt NEED an NPA, but i need to practice the skill of measuring a correct size.



First I never stated EVERYONE is getting an IV for practice. I would say the populace that truly requires IV access for medication administration/fluid administration is tiny compared to overall call volume. 

Second IV access and Nasal Pharyngeal Airway skills are not at all the same. Have you initiated peripheral IV access on someone in cardiac arrest with non existent vascular tone? Or a diabetic all clenched up on the floor and incontinent? What about heroin user with track marks? Patient with CKD with PICC line in one arm and poor vasculature in the other? Patient that suffered large scale burns and needs IV access for fluids and induction, Dark skin and you are feeling for it? etc. Let see NPA let's measure from patient's nostril to the earlobe and insert.


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## CriticalCareIFT (Nov 24, 2013)

Halothane said:


> Do you have any evidence to back up that claim?



Certainly it's called empirical evidence. Do you have any evidence to disprove my claim?


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## medicdan (Nov 24, 2013)

I don't buy that starting unnecessary IVs is justified for practice. If you truly believe you need more experience, work to schedule yourself with some ED time to get access on patients who do need it, and are sick, or pick up a side job as an IV tech for nursing homes, or a phlebotomist. The answer is not to perform unnecessary procedures.


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## chaz90 (Nov 24, 2013)

CriticalCareIFT said:


> Certainly it's called empirical evidence. Do you have any evidence to disprove my claim?



Not the way the scientific process works. Assertions have to be proven with evidence, not disproven.


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## VFlutter (Nov 24, 2013)

CriticalCareIFT said:


> I guess none of you saw residents place central lines during cardiac arrest, because certainly main reason they doing it is out of patient necessity.



What is your point? Are implying that residents place central lines during codes because they do not have the skills to place a PIV? Don't worry I am sure the Noctor, I mean RN, will already have a line or two before they even get there.

Also, I have seen some wicked phlebitis and hematomas from IV sticks. Not life threatening but certainly not benign.


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## CriticalCareIFT (Nov 24, 2013)

And how many of you protested in medic school when you had to do multiple IV 's on each other for PRACTICE?


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## Medic Tim (Nov 24, 2013)

CriticalCareIFT said:


> And how many of you protested in medic school when you had to do multiple IV 's on each other for PRACTICE?



Most places no longer allow this.


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## VFlutter (Nov 24, 2013)

CriticalCareIFT said:


> And how many of you protested in medic school when you had to do multiple IV 's on each other for PRACTICE?



  Practicing on a willing participant in an academic setting is totally different than patients. Especially patients who are trusting you as a medical professional to treat them and do not know any better. Also most school no longer allow this practice due to liability.

**Edited for niceness :excl:


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## ffemt8978 (Nov 24, 2013)

Play nice or


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## CriticalCareIFT (Nov 24, 2013)

Chase said:


> Practicing on a willing participant in an academic setting is totally different than patients. Especially patients who are trusting you as a medical professional to treat them and do not know any better. Also most school no longer allow this practice due to liability.
> 
> **Edited for niceness :excl:



Again I am not advocating starting IV access on every single person. However if you only initiate IV access on people *you are giving IV medications* to that number will be very small to maintain IV skill proficiency.

Let's say we go with "because I might need it later" approach.

Would you object IV access on these patients?

1- Postictal patient, who is now A&OX3 not seizing on your arrival. Family states has hx of epilepsy and had a seizure 20 minutes ago prior to your arrival. If you start IV on him now what IV medicine are you giving? Do you advocate not starting IV access?

2- Chest pain 8 (1-10), has cardiac history, 12 lead no elevations or depressions looks normal, sinus rhythm. You protocols do not have IV meds to be given for this call.   If you start IV on him now what IV medicine are you giving? Do you advocate not starting IV access.


etc... 


here is a study utilizing nurses

http://www.ncbi.nlm.nih.gov/pubmed/16157191

"A total of 77% of the IV insertions were successful. Nurses who were older, had more years of experience, were certified in a specialty, and rated themselves higher in insertion skill had significantly more successful insertions than their younger and less-experienced and less-skilled counterparts (P < .001)."

So more experience and more iv sticks = more successful insertions.


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## Medic Tim (Nov 24, 2013)

I think some things are being taken a bit to literally here. I don't think anyone specifically mentioned iv meds as the only time thy would start an iv. Like I said earlier . If I am going to use it I will start one. Every once on a while I will start one on a person I know will get one in te hospital.

Pt 1 would most likely not be transported if that is all that happened. We also use an prefer IM benzos over IV. (Rampart study)

P2 would obviously get an iv as most people would follow an acs protocol ( I med being administered and most likely a bag hung)


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## Farmer2DO (Nov 24, 2013)

I have a low threshold for starting IVs in the field. If:

1.) I know the patient is going to need medication: fentanyl, ondansetron, methylprednisolone. These are no brainers.

2.) Fluids. I also have a low threshold for giving fluids. We carry 500 ml bags. If they're vomiting, they get a bag. If they're going to get an IV bolus, they get a bag. If they meet SIRS criteria, they get a bag.

3.) The potential to give meds. Chest pain, treating for ACS. Seizures that have stopped, but you would treat if they seized again. Stroke symptoms. Those all are good patients to have access in before you need it.

4.) There is a VERY HIGH likelihood the patient will get lined and labbed at the ER. These patient usually meet one of my first three criteria. Our ERs routinely draw off the locks, and the patients are grateful for one stick. The nurses are very grateful that it's been done for them. The patient gets a dispo faster, beds turn over quicker. Everyone wins.

Basically, I am able to justify with sound reasoning every IV I put in. But skill proficiency is not one of them. IMHO, if that's the only reason, it's unethical.


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## CriticalCareIFT (Nov 24, 2013)

Based in the discussion here if you initiated IV access and patient is paying for it, and you are not giving any IV meds or IV fluids that the patient currently requires then IV access that was established is not actually being utilized.

I am very liberal with my 12 lead acquisitions and I have done them on patients whose chief complaint was not chest pain (and at times that abdominal pain turned out to be a STEMI). Should we only be doing 12 lead EKG's on patients with chest pain? Yes the patients are paying for them.

Either way if you employ "because I might need it later" or "maintaining your skills" you have started IV access and have not used it for its intended purpose.


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## Farmer2DO (Nov 24, 2013)

Then you didn't understand my post.


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## AeroClinician (Nov 24, 2013)

Farmer2DO said:


> I have a low threshold for starting IVs in the field. If:
> 
> 1.) I know the patient is going to need medication: fentanyl, ondansetron, methylprednisolone. These are no brainers.
> 
> ...




I agree with every bit of this post, and I currently operate this same way. 

This is solid reasonable logic, and properly justifies the necessity of pre-hospital venous access.


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## unleashedfury (Nov 24, 2013)

AeroClinician said:


> If the pt. is going to / possibly have blood drawn for labs at the hospital during their course of care. How is vascular access prior to arrival, fraud? It's for an actual purpose. Prehospital vascular access allows blood to be drawn faster.
> 
> Now I know what some are going to say, " they don't use our line becaus it's a "field line" ". I call BS, I couldn't tell you how many times I see RNs draw blood out of my line upon arrival after aspirating a good 10cc of blood first.
> 
> A sizable portion of ALS pt.s have the potential to deteriorate, wouldn't you like to have a line already in place if that happens?



Most hospitals in my area do not draw from at IV site, due to the fact that it may have already had meds and Saline passed through it may "error the results" they will do a Lab draw. and if they are after an ABG its a no brainer that they are going after an artery and not using the established. And yes if the patient does deteriorate its nice to have a patent IV site established for use



medicdan said:


> I don't buy that starting unnecessary IVs is justified for practice. If you truly believe you need more experience, work to schedule yourself with some ED time to get access on patients who do need it, and are sick, or pick up a side job as an IV tech for nursing homes, or a phlebotomist. The answer is not to perform unnecessary procedures.



Not everyone has this option, around here ER techs are BLS only and IV starts are not part of the protocol for ER techs. Getting ER time is like pulling teeth, even if your medical director is part of the ER. trust me many have tried already to get their profficency up and the hospital gives the long story about why you can't. warranting HIPAA or the Campus policy 



CriticalCareIFT said:


> And how many of you protested in medic school when you had to do multiple IV 's on each other for PRACTICE?



A few students in my class moaned and groaned about this, They wanted to stick everyone else licking their chops. But when it was stick and be stuck the bawled their faces off. 



CriticalCareIFT said:


> Again I am not advocating starting IV access on every single person. However if you only initiate IV access on people *you are giving IV medications* to that number will be very small to maintain IV skill proficiency.
> 
> Let's say we go with "because I might need it later" approach.
> 
> ...



Both patients can warrant IV access. the first since they have a hx of epilepsy, and 1 seizure PTA, establish access and monitor if they have another seizure benzos can go right in that site. 

the second. you are giving NTG, and possibly fentanyl or morphine after the 3rd nitro if pain exsists and blood pressure warrants. So your giving your patients Vasodilators, if their pressure takes a dump, You have IV access to compensate. 

IMHO I believe its going to come down to Local protocol, paramedic experience and general impression of the patient. I know the ED around here gets themselves in a tuff if the patient comes in ALS with no IV access, not even an attempt. The big thing that's pushed as an ALS provider is everyone gets IV O2 and Cardiac monitor. which in a perfect world that's great. Yet its not required. So when you have a borderline call whether or not you want to start IV access, some do just as a safety net. 

comes down to symptoms and complaints. If the patient you are treating complains of nausea vomiting x 2 days. limited PO inputs. hanging an IV bag to combat dehydration maybe push some Zofran if its warranted. 

your respiratory distress patient. give a duo neb. Start an IV maybe some solu Medrol if the the patient can benefit from it. Granite takes 4-6 hours to work but your ahead of the game. 

In Pa I'm not too sure about other states ALS is an all inclusive rate, you pay a flat fee of ALS rate, or BLS rate, plus mileage billed in tenths of a mile. so if your mileage rate is 10.00/mile you take the patient 10.3 miles they pay 103.00 for transport mileage. 


to the poster who stated that ECG monitors are going to become a BLS thing is hogwash. In a round about way if you have Cardiac monitoring a BLS skill, Yes BLS can obtain a strip. but who will interpret it. Pass it along to the ED via Wireless transfer for interpretation Ok fine. now you have to tie up a doc to read ECG strips amongst other duties he will have to perform as a physician. If your stating that EMT basics will learn to interpret ECG's how will they treat any abnormalities? It will also drive the cost of BLS services up since you are now adding another skill that a BLS provider can perform. 

IV access vs no IV access to start a line on somebody because you "need to practice the skill" is unethical, However if based on your experience and you look at your patient and say well he/she could probably benefit from IV access for some Fluids or cause I might just end up giving so and so med. its justifiable, In the end it will be up to the QA manager to read your reports and see if your patient required access. and if so did you justify why?


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## medicsb (Nov 24, 2013)

It IS reasonable to start IVs if you suspect there will be a need for it (e.g. ACS, respiratory failure, etc.) due to patient deterioration.  However, you should not be apply "what if's" to everyone who gets on your ambulance.  We already know that most patient do not require IV meds during transport, and many never require any during their ED stay.  I reject the "they'll get one in the ED anyways" argument.  Let them get the IV in the ED if the RN or doc want it, but that should not be used to justify your IV (especially when many hospitals mandate removal of prehospital IVs within 24 hours).  

With the prevalence of IOs, the argument over the need for experience with difficult IV sticks is almost moot.  Also, if most EMS systems were truly tiered, there'd be little discussion because the patients that paramedics would transport would actually be ALS patients.  But, yeah, when you're sent to every call and you (or your medical director and/or other stake-holders) need to justify your existence despite the fact that 80% of your patients only need a ride, of course you'll start resorting to "what if" scenarios to justify treatment.


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## unleashedfury (Nov 24, 2013)

medicsb said:


> It IS reasonable to start IVs if you suspect there will be a need for it (e.g. ACS, respiratory failure, etc.) due to patient deterioration.  However, you should not be apply "what if's" to everyone who gets on your ambulance.  We already know that most patient do not require IV meds during transport, and many never require any during their ED stay.  I reject the "they'll get one in the ED anyways" argument.  Let them get the IV in the ED if the RN or doc want it, but that should not be used to justify your IV (especially when many hospitals mandate removal of prehospital IVs within 24 hours).
> 
> With the prevalence of IOs, the argument over the need for experience with difficult IV sticks is almost moot.  Also, if most EMS systems were truly tiered, there'd be little discussion because the patients that paramedics would transport would actually be ALS patients.  But, yeah, when you're sent to every call and you (or your medical director and/or other stake-holders) need to justify your existence despite the fact that 80% of your patients only need a ride, of course you'll start resorting to "what if" scenarios to justify treatment.



Well I can agree to that not everyone needs an IV, and the what if's can be narrowed down by a good assessment, Some BLS patients may benefit from ALS interventions, like your nausea vomiting patient is technically BLS but can benefit if administered Zofran, IIRC we are not required to carry the tablets, so IV is your route. 

In my area IO's are primarly a last resort in adults. mostly used in cardiac arrests especially your morbidly obese patients where IV access is limited.


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## AeroClinician (Nov 25, 2013)

unleashedfury said:


> like your nausea vomiting patient is technically BLS but can benefit if administered Zofran



Technically? Really. 

More like nausea/vomiting is without a doubt ALS, and needs full ALS exam including 12-lead if not 15-lead assesment, with an IV! Fluids/Zofran as well.

I see that your a student, so I don't fault you for this as much as I would an experinced provider. The last thing Paramedicine needs is more non-agressive money medics, please don't be one of these, take pride in the quality of your care.


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## mycrofft (Nov 25, 2013)

Skipping all other comments (sorry, folks):

Purposefully starting unnecessary treatment is a tort, and can constitute assault and battery. Purposefully administering unnecessary drugs is poisoning as well. Charging for such may constitute fraud, see a lawyer.


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## EMSforever (Nov 25, 2013)

Where i work the general consensus is if theyre going to the ER, the ER expects us to have a line in place. It just looks better when bringing a pt in. Its less work for the hospital staff, it gives them a quicker route to giving meds or getting labs, and generally just makes us look better that we have the pt all set up before getting there.


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## Tigger (Nov 25, 2013)

EMSforever said:


> Where i work the general consensus is if theyre going to the ER, the ER expects us to have a line in place. It just looks better when bringing a pt in. Its less work for the hospital staff, it gives them a quicker route to giving meds or getting labs, and generally just makes us look better that we have the pt all set up before getting there.



Since when is "it looks better" a reason to perform an invasive procedure? This is (among other reasons) why much of the healthcare community looks down on us. 

Let us not forget Rule 13.


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## Dougw133 (Nov 25, 2013)

Pre Hospital IV's are grossly over used. So are backboards however. I have worked in a lot different systems. Some were so thankful you even came into the ER with a line while others would raise holy hell if the 21 year old with ear pain didn't have one. With the current state of health insurance most EMS providers are trying to find anyway to increase revenue. I know of many Private/City based services requiring ALS assessments and in some cases the medic to ride every call for every patient. This way they can always bill for the ALS assessment.  

Fraud? I don't think so. Fraud is more like getting a refusal and then trying to bill their insurance for an ALS 1 call. 

I know thankfully in my area pre hospital IV's have recently been withered down to "Only if needed or unstable". That is why we had IV's pre hospital in the first place. We needed to actually use it to administer something through it. Not just to say we can and please the miserable ED nurse. I dont get intimidated by ER staff anymore and when they whine about me not having a line in place I tell them to consult my protocols and that's my only boss, my protocols. Things change...Look at CPR in the last 5 years...ACLS has changed dramatically and I expect more will follow. Hopefully we'll ditch the backboards soon and (No offense this true to my locale) BLS will stop fully immobilizing grandma that fell and broke her arm.


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## Dougw133 (Nov 25, 2013)

CriticalCareIFT said:


> Again I am not advocating starting IV access on every single person. However if you only initiate IV access on people *you are giving IV medications* to that number will be very small to maintain IV skill proficiency.
> 
> So more experience and more iv sticks = more successful insertions.



Totally disagree. You should be proficient regardless. I honestly don't think IV's are a very difficult thing to do. You either know how or you don't. Some people are better than others. In the case of being green and new, yes time and experience will certainly help. However, any one of us should be able to put down the needle and come back without issue. Like riding a bike. I just don't think maintaining IV skill proficiency is any argument to start unnecessary IV's. Tired of seeing medics bring in a PT that didnt need an IV in the first place with 3 gauze and tape sights because of the "I must get an IV mentality". Ego's and EMS are dangerous.


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## ExpatMedic0 (Nov 25, 2013)

Dougw133 said:


> Fraud? I don't think so. Fraud is more like getting a refusal and then trying to bill their insurance for an ALS 1 call.



It depends on the situation. If you start an IV with no medical necessity or benefit to the patient, and this bumps your billing code up, yes, this is fraud. 

I think most billing staff would agree on that. However, it would appear that many of us are debating on what is considered an unnecessary prehospital IV. Which is a pretty interesting argument.


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## Dougw133 (Nov 25, 2013)

ExpatMedic0 said:


> It depends on the situation. If you start an IV with no medical necessity or benefit to the patient, and this bumps your billing code up, yes, this is fraud.
> 
> I think most billing staff would agree on that. However, it would appear that many of us are debating on what is considered an unnecessary prehospital IV. Which is a pretty interesting argument.



I tend to agree with you on that remark. I do know of situations where Fire Companies/EMS have used Air Medical in "unnecessary" situations resulting in insurance refusing to pay. In these cases the patients are suing those departments responsible for the activating Air Medical. While a 15K bill is a different story it follows the same line. If intention of starting an IV is based on the ability to bill for it, then yes it's absolutely fraud.

Even if a patient turn south quick we as providers should be able to initiate access quickly enough that we don't need to ride around with insurance IV's in place on all patients. Again, times have changed. Most of us now have IO in our trucks and protocol. Of course, the typical cases of low BP, cardiac and trauma or exceptions. I feel like when I came through medic school IV's and Drugs were the cure all. I quickly discovered elevating someones legs often brought a patients pressure up as opposed to dropping 2 liters in. Focus used to be intubation and drugs on codes. Now its CPR CPR CPR and maybe a blast of Epi if you feel like it. Things changed quick, we're getting smarter and being asked to more everyday in our protocols.


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## ExpatMedic0 (Nov 25, 2013)

If you are going to use the IV for something, or if there is potential for the IV to be used while the patient is in your care then I say fine.

However, if you start the IV for the hospital as a courtesy, I say no for most situations(there are some when it may be acceptable). Pre-hospital IV starts have been linked to high infection rates and most hospitals try not to use them or D/C them within a few hours. 

If you start the IV for no medical reason at all, for practice, or "because you can", then I also say no.


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## Carlos Danger (Nov 25, 2013)

AeroClinician said:


> Technically? Really.
> 
> More like nausea/vomiting is without a doubt ALS, and needs full ALS exam including 12-lead if not 15-lead assesment, with an IV! Fluids/Zofran as well.



Why?


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## AeroClinician (Nov 25, 2013)

Halothane said:


> Why?



Have you ever had a STEMI present with only nausea/vomiting before?

I have. That's why.


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## AeroClinician (Nov 25, 2013)

ExpatMedic0 said:


> Pre-hospital IV starts have been linked to high infection rates and most hospitals try not to use them or D/C them within a few hours.



I blame this on the bad apple paramedics that don't care enough to use proper method resulting in higher infection than hospital lines.


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## triemal04 (Nov 25, 2013)

AeroClinician said:


> The last thing Paramedicine needs is more non-agressive money medics, please don't be one of these, take pride in the quality of your care.


If you mean that the last thing we need is people who are "aggressive" and over-treat patients, treat patients that don't need it, and try to justify their existence by by hyperbole, then yes, I agree completely.

If by "non-aggressive" you mean people who won't learn and get educated about medicine so that they won't be able to determine what is, and what isn't actually needed and thus fall back on hyperbole for deciding their treatements, then yes, I also agree completely.

I you mean something else I disagree.


AeroClinician said:


> Have you ever had a STEMI present with only nausea/vomiting before?
> 
> I have. That's why.


Have you ever had a patient go into cardiac arrest for no immediately discernable cause?  

I have.

Probably should start putting defib pads on everyone...because you never know...

If people actually bother to take the time to learn and go beyond what get's taught in paramedic school and the handful of weekend certification classes and paper endorsements, a lot of this type of arguement will go away.

Doing something because of "well this one time" or "something could change" is very different than doing something because there is a distinct possibility that the cause of the problem may be something abnormal, or because it's likely, based on the problem and presentation that the patient's status will decline.

Our job is not to do stuff because it's fun or because we want to, it's to do what is in the best interests of the patient.  A lot of times that means doing very little.


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## dixie_flatline (Nov 25, 2013)

AeroClinician said:


> Have you ever had a STEMI present with only nausea/vomiting before?
> 
> I have. That's why.



Well, sure, but Occam's Razor needs to be applied here.  Odds are that your nausea patient is food poisoning, or an infection, or pregnancy much more often than it is a STEMI.  Getting a 12-lead doesn't mean that it can't be turfed back to the BLS transport unit when it turns out that it really is a BLS nausea call.


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## Carlos Danger (Nov 25, 2013)

AeroClinician said:


> Have you ever had a STEMI present with only nausea/vomiting before?
> 
> I have. That's why.



Cardiac problems can present with nausea?

Oh my. I guess everyone who is nauseous does need an EKG then.....

While we are at it I suppose we better CT every headache, spinal tap every stiff neck, and culture every cough.

And just to be safe, let's give everyone oxygen and use c-spine precautions for all trauma.


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## Bullets (Nov 25, 2013)

CriticalCareIFT said:


> Would you object IV access on these patients?
> 
> 1- Postictal patient, who is now A&OX3 not seizing on your arrival. Family states has hx of epilepsy and had a seizure 20 minutes ago prior to your arrival. If you start IV on him now what IV medicine are you giving? Do you advocate not starting IV access?


Patient with seizure history are BLS patients, no ALS is dispatched, so they would not get an IV


> 2- Chest pain 8 (1-10), has cardiac history, 12 lead no elevations or depressions looks normal, sinus rhythm. You protocols do not have IV meds to be given for this call.   If you start IV on him now what IV medicine are you giving? Do you advocate not starting IV access.



If there is no IV medication, then this patient should also not get an IV


Is IV access the new backboard? Anecdotal evidence is not evidence. My last transport was a patient that was complaining of nausea and vomiting. Do you think she was having a heart attack or more likely a normal side effect fo the clindamycin she was just prescribed yesterday


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## unleashedfury (Nov 25, 2013)

AeroClinician said:


> Technically? Really.
> 
> More like nausea/vomiting is without a doubt ALS, and needs full ALS exam including 12-lead if not 15-lead assesment, with an IV! Fluids/Zofran as well.
> 
> I see that your a student, so I don't fault you for this as much as I would an experinced provider. The last thing Paramedicine needs is more non-agressive money medics, please don't be one of these, take pride in the quality of your care.



Whilst I can agree to an extent, This is where a solid assesment comes into play. Hx of present illness and PMH included. 



AeroClinician said:


> Have you ever had a STEMI present with only nausea/vomiting before?
> 
> I have. That's why.



Yes I have had similar much more prevelant in women than men. But like I stated earlier. Solid assesment skills are the key, alot of Paramedics I meet do things "cause thats whats protocol" Which is totally acceptable, but if we want to distinguish ourselves as healtchare providers and clincians we need to work on a differential diagnosis, and a working hypothesis of the patient to decide what care they need, what they don't need,what you suspect the problem is.


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## MedicPam (Nov 25, 2013)

EMSforever said:


> Where i work the general consensus is if theyre going to the ER, the ER expects us to have a line in place. It just looks better when bringing a pt in. Its less work for the hospital staff, it gives them a quicker route to giving meds or getting labs, and generally just makes us look better that we have the pt all set up before getting there.



Since I don't work for the ER, I like to run my calls based on my assessment and plan for the actual patient. And when the ER nurse asks where the UNNECESSARY IV is, I usually tell them I assume it's in their cabinet awaiting an unnecessary "physician order".


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## Rialaigh (Nov 25, 2013)

CriticalCareIFT said:


> *And what is your response when the patient truly requires IV access and you are unable to obtain it due to skill degradation*? So you will stab him multiple times and then transport to the ED telling you battle story "It such a hard stick you know, very hard!".






CriticalCareIFT said:


> *Certainly it's called empirical evidence. Do you have any evidence to disprove my claim*?




Can you show me any evidence that says the mortality rate or hospital stay length for patients is lower with prehospital IV access than without....because I can show you plenty of evidence outlining the infection risk of prehospital IV's. 


If the situation is not emergent, than IV access if generally secured for patient comfort (pain, nausea, fluids, steroid, etc). If IV access if emergent then IV access would be preferred but any access if acceptable including IO (cardiac arrest, RSI, etc...). IO in cardiac arrest is just like King airway in cardiac arrest, not as fun, not as invasive, not as "cool"...but just as if not more effective. 



I'm all about starting IV's on people that have a good chance of getting use out of them. what a "good chance" is depends on the provider. 


Rarely can providers not obtain access in truly emergent situations. If I try twice to stick the Abd pain and can't, then they get no fluids or zofran on their 15 minute ride to the hospital....


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## ffemt8978 (Nov 25, 2013)

AeroClinician said:


> I see that your a student, so I don't fault you for this as much as I would an experinced provider. The last thing Paramedicine needs is more non-agressive money medics, please don't be one of these, take pride in the quality of your care.


Don't put too much faith in the training levels listed in our members' profiles.  They aren't always updated, accurate, and sometimes people choose a student level because they believe they are always learning in this field.


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## EMSforever (Nov 26, 2013)

Halothane said:


> Why?



If im not mistaken, sometimes nausea and vomiting could be the only symptom of myocardial infarction. Especially in older populations where there may be little to no pain at all


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## teedubbyaw (Nov 26, 2013)

Halothane said:


> Cardiac problems can present with nausea?
> 
> Oh my. I guess everyone who is nauseous does need an EKG then.....
> 
> ...



That's a pretty poor outlook to have as a healthcare provider. 

And yes, N/V can be an anginal equivalent.


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## unleashedfury (Nov 26, 2013)

ffemt8978 said:


> Don't put too much faith in the training levels listed in our members' profiles.  They aren't always updated, accurate, and sometimes people choose a student level because they believe they are always learning in this field.



Well its true Were all always learning in this field, I am an actual student in a paramedic program. 

But in this field as any field, You are always the student. Once you feel as if you are a master, and cannot achieve any new knowledge its time to leave the field.


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## the_negro_puppy (Nov 26, 2013)

IV goes in when I need to give an IV med or reasonably think I will need to give one / pt is at risk of deteriorating.

12 lead ECGs for nausea and vomiting?

If I did a 12 lead ecg on an otherwise healthy 20 y.o F with N&V I would get a big "please explain".

The time you spend sitting on scene trying multiple IVs just so the hospital doesn't have to do it is increasing time between the patient and hospital.


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## VFlutter (Nov 26, 2013)

teedubbyaw said:


> That's a pretty poor outlook to have as a healthcare provider.
> 
> And yes, N/V can be an anginal equivalent.



I do not think he was arguing that N/V can be an anginal equivalent but rather that every N/V complaint should get a 12 lead. A 60 y/o Diabetic female smoker complaing of N/V? Of course. 

Just as a new LBBB can be a STEMI equivalent not every patient is getting an emergent cath.


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## ExpatMedic0 (Nov 26, 2013)

the_negro_puppy said:


> IV goes in when I need to give an IV med or reasonably think I will need to give one / pt is at risk of deteriorating.


This.


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## Mariemt (Nov 26, 2013)

And procedure a provider does knowingly unnecessary I would consider fraud


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## AeroClinician (Nov 26, 2013)

Chase said:


> I do not think he was arguing that N/V can be an anginal equivalent but rather that every N/V complaint should get a 12 lead. A 60 y/o Diabetic female smoker complaing of N/V? Of course.
> 
> Just as a new LBBB can be a STEMI equivalent not every patient is getting an emergent cath.



It's is precisely because nausea/vomiting can be an anginal equivelent is the reason why most, but not all N/V Pt.s need a 12-lead.

If I give you morphine for pain management and you feel nauseated afterward, a 12-lead is of no benefit.


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## clydemoses781 (Nov 26, 2013)

i think so.


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## Carlos Danger (Nov 26, 2013)

We keep drifting back and forth here, but I think we should focus a little because the OP's original question was an important one.


Yes, starting an IV when not indicated IS fraud, if you bill for it. It is the very definition of fraud, in fact. That isn't my opinion, that is how CMS and the insurance companies and the courts see it. People - usually physicians but not always - are sued and fined and have their CMS "privileges" revoked for medically unnecessary procedures all the time.


Starting an IV (or performing any other procedure) without a true indication, even if it doesn't rise to the legal definition of fraud (perhaps because you don't bill for it), is still wrong any way you look at it. You will not find a professional association that endorses exposing patients to the discomfort and risk of unnecessary procedures for "practice", nor would you likely be able to argue that you were following the standard of care or acting in the patient's best interest if some serious complication were to arise from a procedure that you performed just because you hadn't done one in a while. Not to mention the fact that it requires you to falsify the medical record, that is unless you actually document "IV started just because I need the practice".


As far as what constitutes whether or not an IV or other procedure is indicated, well that is obviously up for debate. I think it is silly to do something in the field just because "they are gonna do it in the ED". I disagree that nausea is an indicator for an EKG for instance, but obviously there are those that disagree with me. I don't think most patients should be back boarded or have a NRB placed, but there are those who disagree with me. So that's the real question here, I think.


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## Sandog (Nov 26, 2013)

I think this whole discussion may be moot. With the Affordable Health Care Act in affect, EMS may see big changes, one being accountability. For EMS companies, I see a big change looming and every penny spent will need paperwork. By 2018 I foresee a whole new practice in the US EMS system. In other words, you drop an IV, better have a reason. Just my prediction/opinion.


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## unleashedfury (Nov 26, 2013)

Halothane said:


> We keep drifting back and forth here, but I think we should focus a little because the OP's original question was an important one.
> 
> 
> Yes, starting an IV when not indicated IS fraud, if you bill for it. It is the very definition of fraud, in fact. That isn't my opinion, that is how CMS and the insurance companies and the courts see it. People - usually physicians but not always - are sued and fined and have their CMS "privileges" revoked for medically unnecessary procedures all the time.
> ...



It goes back to my point that I stated probably a few pages back now, Patient assessment is the most important factor in any healthcare profession. A 20 yr old female who is currently experiencing N/V most likely does not need an 12 lead ECG, if the N/V is motion sickness related Zofran is a moot point as its not indicated for motion sickness. Depending on the length of the nausea vomiting and a good HPI can warrant an IV especially if they are dehydrated if they are two sheets to the wind. It might be best to let them puke that crap out and babysit the airway.



Sandog said:


> I think this whole discussion may be moot. With the Affordable Health Care Act in affect, EMS may see big changes, one being accountability. For EMS companies, I see a big change looming and every penny spent will need paperwork. By 2018 I foresee a whole new practice in the US EMS system. In other words, you drop an IV, better have a reason. Just my prediction/opinion.



In todays system, if you drop an IV you better have a reason. If I went and sunk a line into a patient with a rash. what was the purpose of my IV? Especially if they go to the ED and they give them a topical ointment and send them packing?


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## ExpatMedic0 (Nov 27, 2013)

Sandog said:


> By 2018 I foresee a whole new practice in the US EMS system.


I also believe big changes are coming for EMS


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## Carlos Danger (Nov 27, 2013)

ExpatMedic0 said:


> I also believe big changes are coming for EMS



Such as? I've heard very little about how the ACA might affect EMS.


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## ExpatMedic0 (Nov 27, 2013)

Halothane said:


> Such as? I've heard very little about how the ACA might affect EMS.



One thing that comes to mind is the sudden explosion in "Mobile Inter-graded Health Care" by EMS in the past 12 months, along with how this may effect ACO's.

Its still early to say, but that is one thing I am following.


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## Sandog (Nov 27, 2013)

This from the ACA. This could be a good thing in some ways and bad in others. From the driving routes we take to hospital x, to the non-emergent patients we routinely transport. Affordable health care will change EMS as we know it. Again just my prognostication. 



> *Emergency/Trauma Regionalization* – Law directs the Secretary of HHS, acting through the Assistant Secretary for Preparedness and Response (ASPR), to award at least four multi-year contracts or competitive grants to support pilot projects that design, implement and evaluate innovative models of regionalized, comprehensive and accountable emergency care and trauma systems.
> 
> *Trauma Centers* – Law requires the Secretary of HHS to establish three programs to award grants to qualified public and Indian trauma centers that would assist in defraying substantial uncompensated care costs; further the core missions of trauma centers (including addressing costs associated with patient stabilization/transfer, trauma education/outreach, coordination with local/regional trauma systems, essential personnel and other fixed costs, and expenses associated with employee/non-employee physician services); and provide emergency financial relief to ensure the continued/future availability of trauma services.
> 
> *Emergency Medicine Research* – Law requires Secretary of HHS to support federal programs administered by NIH, AHRQ, HRSA, CDC and other agencies involved in improving the emergency care system to expand and accelerate research in emergency medical care systems and emergency medicine, including: (1) the basic science of emergency medicine; (2) the model of service delivery and the components of such models that contribute to enhanced patient health outcomes; (3) the translation of basic scientific research into improved practice; and (4) the development of timely and efficient delivery of health services. In addition, the Secretary of HHS is required to support research to determine the estimated economic impact of, and savings that result from, the implementation of coordinated emergency care services.


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## ExpatMedic0 (Nov 27, 2013)

Sandog said:


> This from the ACA. This could be a good thing in some ways and bad in others. From the driving routes we take to hospital x, to the non-emergent patients we routinely transport. Affordable health care will change EMS as we know it. Again just my prognostication.



all that stuff and more is probably enough for it to justify its own thread. I think there are a lot changes coming down the pipeline. Looking forward to it.


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## Sandog (Nov 27, 2013)

Yes, sorry for hijacking your thread...


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## unleashedfury (Nov 27, 2013)

ExpatMedic0 said:


> all that stuff and more is probably enough for it to justify its own thread. I think there are a lot changes coming down the pipeline. Looking forward to it.



Quite Possibly if your ambitious start the thread I would be looking forward to hear how this going to work and elaborate a little bit better


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## ExpatMedic0 (Nov 27, 2013)

unleashedfury said:


> Quite Possibly if your ambitious start the thread I would be looking forward to hear how this going to work and elaborate a little bit better



 Sandog should do the honors lol. I have info to add on it also


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## lwems (Mar 3, 2014)

We took over transport at a local hospital, and we found out what this unnecessary IV stuff is about. 

The previous EMS had implicitly trained the hospital staff in how to get everything billed as ALS, even stable, AOx4 wheelchair discharges. The attendings would sign anything you shoved in front of them, regardless of legal risk.

One of our paramedics was onscene, did an assessment, and announced that the patient was wheelchair, offering to call it back in to dispatch to summon a wheelchair van. The attending cheerfully offered to put in an IV, and seemed bewildered when told no, that's fraud.

We didn't have that contract for long.


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## mycrofft (Mar 3, 2014)

Unnecessary IV's are fraud if you charge for them or lie about them.
They can be assault, battery, and medical malpractice too.


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## vc85 (Mar 3, 2014)

Unfortunately it is not only hospitals that pull things like this.

For example:

Adolescent male pt. CAOx4, PMSx4, helmet worn, denies LOC, Vitals Within Normal Limits, 3/10 knee and lower leg pain after hitting leg into a pole while snowboarding.


ALS shows up because the caller saw him laying face down on the ground.

ALS proceeds to start a line, *run a 1000 bag*, and place 4-lead ekg on him.

Two different ER nurses asked why an IV was started with fluids running, to which ALS tried to pass it off as "mechanism of injury".  Even better, this isn't the first time that service had tried something similar. I have watched them *multiple times* sit in the ambulance IN THE ER parking lot for 10 minutes putting an IV in a patient before wheeling them in (i.e. delaying transfer to definitive care).


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## mycrofft (Mar 3, 2014)

Used to see that in 1981. Rural rescue squads would call hospital after hospital to find one willing to give them a radio order for an IV. Embarrassing to listen to it on the med net.


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## Akulahawk (Mar 3, 2014)

vc85 said:


> Unfortunately it is not only hospitals that pull things like this.
> 
> For example:
> 
> ...


Given my own training and expertise, I would have attempted to evaluate the extent of injury, offered first aid "RICE" therapy for pain control and only bumped it up to IV medication for pain if the pain still wasn't tolerable, and even only titrating the pain med to a tolerable level of pain, not a completely snowed, pain's all blotted-out level. I wouldn't have sat in the parking lot for an extra 10 minutes to establish a line/lock to allow those meds to be administered unless those meds were actually needed...

Of course, I might have wanted to sit on scene for a little while to release the kid to the parents, depending upon the actual injury severity. But what do I know...


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## vc85 (Mar 3, 2014)

Oh the teenager with the leg didn't even get pain meds, just an IV; they also started this one in the rig, luckily.  Medics were called because the initial (incorrect)dispatch information was head and neck injuries.  

Apparently this crew treated based on MOI of the dispatch information and not what the REAL MOI and patient condition on scene was.


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## Roadmedics (Mar 3, 2014)

*No, just bad medicine*

No starting an IV is not fraud.  Fraud in this case would require that you say you did something and actually did not.  Starting unnecessary IV's is just bad medicine.  The risk of phlebitis and other problems should always outweigh unnecessary IV's.  My students are not allowed to start IV's just because they need them, the patient must need them first.


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## blindsideflank (Mar 4, 2014)

I can't believe I'm posting in this thread because this topic comes up often at the station and it's obnoxious. The justifications people use for (what if he went into vtach) and arguments against (your Iv could cause sepsis or an embolism).

Generally speaking all patients I carry get a lock. We are tiered so most calls are chest pains, and if I want to trial nitro I get a line, SOB a line is good practice for meds and if you need meds to take control of airway, and altered LOC (which usually comes down to asking someone to get a line while get do a longer exam and history, I fond ALOC usually require a longer exam that leaves people sitting around and I believe this is valuable time to have a line placed)

If these are not high acuity then they go with bls and it's their discretion of what they would like. As a side note, it seems it has been my job to discourage the use of narcan by our bls crews on all ALOC despite no other relevant symptoms.


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## drjekyl75 (Mar 4, 2014)

In the area I work it depends on which of the local hospitals I take a patient to. One of them requests a line on nearly every patient. The others not as often. I'm hanging fluids less often and start saline locks about 90% of the time. I've had the hospital request a line, then ask me to lock it and send a patient to triage.


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## mycrofft (Mar 5, 2014)

Roadmedics said:


> No starting an IV is not fraud.  Fraud in this case would require that you say you did something and actually did not.  Starting unnecessary IV's is just bad medicine.  The risk of phlebitis and other problems should always outweigh unnecessary IV's.  My students are not allowed to start IV's just because they need them, the patient must need them first.



KNOWINGLY starting an IV when it is not necessary _and lying about it_ is fraud. KNOWINGLY incurring an unnecessary fee or financial charge _and lying about it_ is fraud. 

If you didn't know any better and didn't lie, it is just excess treatment, since assault and battery require knowledge the contact is detrimental (or if the pt protests).

Roger that on those last two sentences!!!


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