The Golden Hour, Patient Acuity, and the CDC

EpiEMS

EpiEMS

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Just read a nice Rogue Medic post (it seems like lots of my thoughts are just lifted and reworded from there, I guess?) about the fallacy of the Golden Hour. Now, I've had a chance to read through many papers on the Golden Hour (and the lack of supporting evidence for it) mostly for funsies, and I was prompted to consider a publication from the CDC and ACEP regarding patient acuity. Yes, I realize they're different concepts -- but the relation is one of time to care, and especially to definitive care. So, what's your patient mix like? Do you really think most of your patients need definitive care immediately? Should your most "BS" of patients really be seen in the ED?

Any policy remedies?

TL;DR version: What's your patient mix like, in terms of acuity?
 
EpiEMS said:
TL;DR version: What's your patient mix like, in terms of acuity?
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The old saw is that around 10% of the patients are actually sick, and maybe 10% of those are true emergencies. Lots of variations on that theme, but most people seem to agree on the gist.

The thing is that the remainder aren't necessarily system abusers or the like; many are the "worried well," people who don't need immediate care but don't know that. They have a symptom and aren't sure whether they're fine or they're dying. Some we'd call nuts for worrying, some were actually sent there by a medical professional, but the point is they could be in that 10%, and for everybody to be sure they usually need a hospital-level workup.

Many of the others are seeking symptomatic relief. Patients who need the skills of EMS in the sense of managing ABCs are rare. Doesn't mean you can't help them, of course. We're part of the aforementioned triage process.
 
EMS and ERs are used as primary care and out of convienence by 80% of people who use those services. The system becomes clogged for those who actually need it.
 
A local hospital tried actually putting an urgent care suite (doc in a box) next to the ED as a triage choice. They still triaged most of their patients to the ED out of fear of missing something, as well as the "seasoned" ED consumers using c/o such as chest pain and dyspnea to get seen faster.
 
It is mind-boggling to me that someone would call an ambulance or go to an ER for a non-life threatening emergency. Maybe it's because I grew up in a rural area where the nearest ER was the next town over, a 20 minute drive away, and EMS/ambulance service were volunteer service that could easily take 30-60 minutes to get to you... We only called on those services if they were ABSOLUTELY necessary.

It is SO different here in the city.
 
You want to know why most patients still need to be seen in the ER? Medics suck at determining who needs a hospital and who doesn't. It's not their fault, they were never educated on it. But it doesn't change the risk. When your entire decision making algorithm is a subjective "sick, not sick" criteria that resolves around crashing patients you're going to miss a lot if stuff.
 
It's not that medics don't know how to differentiate who needs to go, it's just that most of us do not have a mechanism to send patients to other places. If we could leave patients home without the agency screaming "liability" or call a cab to transport the "not feeling well" patient to the urgent care, I'm sure we would. I know I hate bringing most of my patients to an already busy, over crowded ED.
 
n7lxi said:
It's not that medics don't know how to differentiate who needs to go, it's just that most of us do not have a mechanism to send patients to other places.
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That is not supported by the evidence.

http://www.ncbi.nlm.nih.gov/pubmed/19731166

http://www.ncbi.nlm.nih.gov/pubmed/12385603

http://www.ncbi.nlm.nih.gov/pubmed/14582100

Infact, every study on the topic shows paramedics cannot effectively determine who needs to go to the hospital. Though sometimes they can sometimes determine who needs transported to the outdated definition of what an Emergency Department is used for.

The reason is very understandable. Supporting what USALSFYRE said, paramedics and EMS in general do not have the education for it.

A patient who does not need emergency resuscitation may still need to be admitted to the hospital. For reasons ranging from observation to more aggresive treatments for common conditions.

An easy way to measure is for you to keep a log of all patients you think don't need ALS or transported and compare that to the ED census, including non-ambulance transports, who are admitted or treated in the ED with interventions not readily used at home or require advanced diagnostics. (like simple suturing)

But I think you will be shocked by what you find.

Keep in mind, EMS education is not general medical education. There is a lot more in medicine than hemodynamically stable and unstable patients.

Because of the dysfunction of the US healthcare system, the ED is the primary entry point to it now. To deny a person transport without alternative destination or treat and release is to deny them access to the healthcare system.

After much discussion with US EM physicians, even they claim their primiary role and value is in determining who can be safely discharged without being admitted.

That would mean paramedics are trying to replicate that ability with OTJ training and no follow-up.

n7lxi said:
If we could leave patients home without the agency screaming "liability" or call a cab to transport the "not feeling well" patient to the urgent care, I'm sure we would. I know I hate bringing most of my patients to an already busy, over crowded ED.
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This would be a very good use of the EMS system, to act as basically a healthcare traffic cop.

Unfortunately the education is simply not supportive of this role. Also don't forget, this will be taking money away from Emergency Physicians, and they will offer any and every excuse why this is a bad idea or cannot be done in order to protect thier money.
 
usalsfyre said:
You want to know why most patients still need to be seen in the ER? Medics suck at determining who needs a hospital and who doesn't. It's not their fault, they were never educated on it. But it doesn't change the risk. When your entire decision making algorithm is a subjective "sick, not sick" criteria that resolves around crashing patients you're going to miss a lot if stuff.
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this is so ridiculous it sounds made up
 
n7lxi said:
If we could leave patients home without the agency screaming "liability" or call a cab to transport the "not feeling well" patient to the urgent care, I'm sure we would. I know I hate bringing most of my patients to an already busy, over crowded ED.
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I think I know the type of pt you are referring to "not feeling well". However as a general complaint I have taken, and no doubt you too, many pts to the ER who were truly sick and needed admitting whose only c/c was "not feeling well".

I agree I see many people I want to leave home or make other health care arrangements for. Fortunately here change is coming. Not as fast as I would like, but still coming We have a program in Haliifax called "Extended Care Paramedic, ECP". This is a medic who responds solo to the area nursing homes and jail calls. They can make arrangements for the pt. Such as having IV antibiotics started and followed up on site, on site sutures, followup with the sites Dr. All of these places have a Dr. but they do rounds and go somewhere else, ie: office, clinics etc. All of which are off site. So if someone gets sick after they have been in the Dr., when called, often says to take them to the ER for assessment. Now we have a way of slowing this down as many pts can wait for the Dr. to come back or other appropriate care can be arranged. I believe at this time the ECPs only initiate transport on about 40% of their calls. This is one program that is going to be expanded across the province.

Another program we have is that a lot of Drs. have been taken out of small rural ERs at night. A Paramedic joins the staff. There is always a Dr. on call for all our Paramedics. This frees up the Dr. to have more daytime office hrs, instead of home sleeping after a night shift where they've done very little.

Change can be made and Paramedics can have a role to play.

However, I'm going out on a limb, and say that in the US Paramedic education has to improve overall. I know that there are many good education programs and medics there, but they are more the exception than the norm.
Please don't take that the wrong way as ours could use some improving too.
 
I agree that paramedic education is lacking, but should we able to make the decision as to who goes to a hospital ALS or BLS? If it’s not a call that requires ALS intervention, should I be given the latitude to send that person in with just a BLS provider? And, if the hospital emergency department is now the health care point of entry, shouldn’t the paramedic be allowed to make a reasonable determination, based on simple “if A, do B” triage criteria, as to who goes through the "Emergency" door and who goes to chairs in the waiting room? Everyone complains that EDs are overcrowded and poorly utilized… let’s find ways to more clearly define the entry criteria.

And yes, I know we haven't been given that triage criteria, and we’re not smart enough to do it on our own, but anecdotally, I would hazard that most of the patients that I transport, and consider non emergent, would be just fine sitting in a plastic chair, waiting their turn to see a PA and get a Z-pak. Let’s be honest, the nurse on the radio or at the triage desk makes that decision all the time, based on what we tell them. What’s the difference between sending them to them to the ED or a Fast track/Urgent Care?
 
n7lxi said:
What’s the difference between sending them to them to the ED or a Fast track/Urgent Care?
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Asked and answered, follow the money.
 
Try this.

Don't triage patients as they step off the street or out of the ambulance in the ED.

Triage them with a triageur (make that three or four), with the ED as a resource specialty, like Ortho or Pulmo, and a general care clinic (make up a good name for it like "Emergent Case Setting" or something that sounds fast and sexy but is a doc in the box).

TRIAGEUR
____________
/____________\
_____ED__________EMERGENT CARE​

The "ER" was always a spot to localize your problems ("I don't want those smelly icky bleeding sick people in my clean ward") and filter/bottleneck the admissions least likely to pay.

Imagine a Target store like that. One entrance twenty inches wide that opens outwards, one line of carts (no more than twenty to a store) and a tiny ill-ventilated waiting room with cruddy seats for ten. Maybe a TV set with rotary tuner and broken rabbit ears antenna.
 
Veneficus said:
Asked and answered, follow the money.
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Well, let's put it all in one facility then… Let's just call it the "healthcare superstore mega complex". All your needs taken care of from fractures to phlebotomy, STEMIs to corns and bunions
 
n7lxi said:
Well, let's put it all in one facility then… Let's just call it the "healthcare superstore mega complex". All your needs taken care of from fractures to phlebotomy, STEMIs to corns and bunions
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Many EDs have started putting attached urgent cares in the same facility.

A nurse trigaes the pt to the ED or Urgent care, it considerably increases the volume served.

In US medicine, volume is money, which is why they rush you out of the doctor's office after you only see her for 8 minutes.
 
Veneficus said:
Many EDs have started putting attached urgent cares in the same facility.

A nurse trigaes the pt to the ED or Urgent care, it considerably increases the volume served.

In US medicine, volume is money, which is why they rush you out of the doctor's office after you only see her for 8 minutes.
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Note my comment above (above the above one). My closest hospital and former employer did make a built-in emergent care next to the ED as a triage chic, but they ended up not using it and still referring the cases through the ED. Afraid of missing something, or all the pts c/o chest pain to get in quickly.
 
I'm sure there could be good protocols adopted to ensure concordance between physician and EMS assessment for transport to ED or an alternative facility. Plus, we have to determine what acceptable degrees of overtriage (Type I error, I suppose?) and under triage (Type II error?). When I say protocols, I'm thinking something along the line of prehospital C-spine "clearance", lots of study and lots of data points. Granted, I find that my protocols regarding C-spine usually result in over-triage, but for the patients that don't get C-spined, there is a benefit (or, I guess, no harm done).

Maybe the community medic programs could be used as a baseline.
 
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Triage should start the second a pt enters the system. If your 911 agency uses an EMD protocol they have an ability to determine a generic priority level (E-OMEGA if NAEMD). Echo being time-life prioity and OMEGA are no response calls. The problem is what I glean in a 2 minute interrogaton may not be a remotely accurate picture of the pt's condition. The fear of legal retribution for not sending appropriate care is just not worth the risk. That's why very few agencies in 911 utilize OMEGA. Now some places (2) are starting to utilizing triage nurses at the 911 level: http://www.naedjournal.org/content/future-ems-here
Hopefully in the long run it will be adopted elsewhere, and help the system as a whole. The earlier we can divert a pt to an appropriate level of care that satisfies their needs, the better we'll all be.
Triage and the Golden Period are wonderful guiding principals, that have become ruined by hap-hazard interpretation and implementation. But what else would you expect from military concepts arguably 250 and 151 years old that are from an error far removed from what our current healthcare systems look like.
 
Our local education site no longer teaches the Golden Hour, they call it the Golden Period and explain that the time a patient has to reach definitive care changes based on their presenting condition. So something like a AAA has maybe 1 minute, a stroke has 2 hours, ect.

Once again i find it interesting how other areas do it. Every hospital that we transport to has a Prompt/Fast Track/Care type facility directly attached to the ER. Most places have a dedicated Triage area when 2-3 RNs and 4-5 techs take a report, take a set of vitals and get a HPI. They then determine if the patient goes into the ER or the PromptCare. This prevents the ER from getting crowded and from EMS holding the wall for hours
 
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