Moving the point of contact further out…"community health responders"

mycrofft

Still crazy but elsewhere
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I described the concept to my layperson wife. She asked if the paramedics or whatever could refuse to transport. I said yes if they decide it meets criteria.

She asked why do this, people call paramedics because they have emergencies. I said not always but she replied sometimes they do.

After 40 years she still makes me think.:wub:

What can be done to keep this concept from becoming perverted into "doc in a box for house calls, or as a means to "relieve" doctors from seeing emergency patients who in some cases really need to be seen?

Will rigs need to carry lab equipment and fluoroscopes? Will everyone get transported anyway? Will hospitals demand and be granted the pushback of the true "edge of decision" out from their doorway to the tech in the field? How about ordering prescriptions?

This is rooted in doing "nurse sick call" for years and years (institutional community medicine) where the nurse was the gatekeeper to the MD and had a thick binder of standardized procedures to follow. (I might add that with every mistake or alleged mistake, that book got thinner and the words "Refer to MD" became more and more prevalent).

Aussies, tell us how it has been for you!

And to pervert the words of the Greeks:
"Those whom you would make look stupid and dangerous, first make proud".
 
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mycrofft

mycrofft

Still crazy but elsewhere
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Will hospitals' emergency departments use this to try to push triage way from their door and into the ambulance?
 

Medic Tim

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Up here many services triage our pts using the same rules the ER does. Ctas canadian trauma acuity scale. They assign a bed or department based on our triage. It is also common for medics to run triage at hospitals. Some work the floor taking pts, suturing, casting, and running codes. Critical care medics will sometimes work icu. Not as techs but as medics.

I work rural/remote clinics. We mostly treat and release or treat and refer. We do alot of primary care as we are the only health care available to many.
 
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mycrofft

mycrofft

Still crazy but elsewhere
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Up here many services triage our pts using the same rules the ER does. Ctas canadian trauma acuity scale. They assign a bed or department based on our triage. It is also common for medics to run triage at hospitals. Some work the floor taking pts, suturing, casting, and running codes. Critical care medics will sometimes work icu. Not as techs but as medics.

I work rural/remote clinics. We mostly treat and release or treat and refer. We do alot of primary care as we are the only health care available to many.

Are there any books or biographies about the sort of life?!

How is the need for labs and other diagnostics addressed? (Given, that we/USA over-test sometimes).
 

Handsome Robb

Youngin'
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Tim, how often do you run a true emergency? Once a week? A month or even less than that? I'm still contemplating trying to come up and join you. I've been looking at the reciprocity stuff, looks like a pain in the *** but it's doable.

I know our community medics have iStats to do POC labs and also draw blood tubes, take them to the contracted lab and then depending not the results can go back for a followup appointment and treat and release in the patient's home, can call them and refer them to their PCP or appropriate specialist and help arrange the appointment or if it's acute enough call our dispatch center and have a 911 unit sent to transport the patient to the ED. The thing with our Community Health Paramedic (CHP) program is 911 patients cannot be triaged to them and have the dispatched to the call. We do some crazy stuff with our dispatch triage but that's not one of them, yet. They have to be referred by a field crew or a physician at time of discharge then our CHPs will consult with the physician or referring crew, set up an appointment to meet with the patient and assess them for being part of the program. They originally started with CHF patients but are now branching out to other chronic diseases.

I think eventually it will transition to having the CHPs as part of the dispatch system but I don't think it's in the near future. I think if you're going to be treating and releasing like the UK or AUS there needs to be a better educational foundation. Labs would definitely be nice and I think as POC tests become more affordable and widely available we'll start to see them on units more consistently but with the price tag they carry now i doubt they'll be standard equipment for more than a select few agencies anytime soon.

I think it's going to really depend on the hospital for how they react to a program like this. if they're overcrowded and make plenty of money I could see them welcoming it to reduce workload and overcrowding. However, I could see small facilities who don't have the problem of constantly being slammed not being happy about it because it takes money out of their pocket.
 

EpiEMS

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Will hospitals' emergency departments use this to try to push triage way from their door and into the ambulance?

If they aren't, their operating model is sorely in need of modification. After all, how many EMS-transported patients should go to the waiting room (or not even be seen in the ER at all)? Most, I'd wager, would be better off dealt with by a primary care provider.
 

Medic Tim

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Tim, how often do you run a true emergency? Once a week? A month or even less than that? I'm still contemplating trying to come up and join you. I've been looking at the reciprocity stuff, looks like a pain in the *** but it's doable .


It really depends. I average 3 pts a day right now. This summer it will go up to around 8-10. I only transport truly serious pts. I average about 1 a week. That said we do suturing and antibiotics on site. My last clinic saw around 40 pt a day and transported 5-6 a week on average. Most serious cases are flown but I am usually lucky enough to always have to transport.
 

MonkeyArrow

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The only problem I have with community paramedicine or whatever they are calling it now a days is follow up care. The idea is to reduce ER traffic by handling non-emergent things in the field. What does that mean? The people who usually need an ambulance will be those who can't get the necessary follow-up care. Where will they go to get their sutures removed? Will medics be allowed to write Rx? What about for narcs? The people who have the capability to reliably go to their clinic (Ie. have health insurance) more than likely will not be calling an ambulance for non-emergency purposes in the first place. They will just take themselves to the clinic and let insurance cover it all.
 

Bullets

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Just read about a program getting of the ground in the Twin Cities, where the hospital informs the FD of a discharge and they visit, go over discharge instructions ect.

We are a BLS agency and we are trying to do some of this, obviously limited in the actual medicine we can provide but we have found that even just coming to talk has had some improvement. We have a significant senior population and the hospital is in town, so much of the towns industry is supporting medical facilities.

We have begun to ask the senior center to give us a call when regular attendees dont show without notice, do a welfare check, we also use our records to follow up with frequent fliers after we take them to the ER and see if they need anything.

Especially in the senior population, i was shocked at how much we were able to influence their call volume. Most dont drive, so we might transport to the ER and they get a prescription, they have no way to get to the pharmacy to fill it, they get worse and call 911 and we go back a few days later. Now, Ill go over to the patients house, review their discharge instructions, call in prescriptions for pickup or delivery, get them in touch with their GP or specialist for an appointment, arrange transport for such, also do a home survey looking for things like fall hazards, loose carpeting, narrow and cluttered hallways, ect

We dont really work with the hospital, they are less than receptive about helping this program, so we are just focusing on our residents, maybe it will expand, but we rely on our charts, the cops and the senior center to notify us as to potential issues.

Weve also started talking to our FD, who are all EMTs, to come with us when they can and check smoke detectors, CO detectors, and do a little fire inspection. It helps them be more familiar with the fire loads they may have to deal with, and hazards or challenges, ect.
 

Carlos Danger

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The only problem I have with community paramedicine or whatever they are calling it now a days is follow up care. The idea is to reduce ER traffic by handling non-emergent things in the field. What does that mean? The people who usually need an ambulance will be those who can't get the necessary follow-up care. Where will they go to get their sutures removed? Will medics be allowed to write Rx? What about for narcs? The people who have the capability to reliably go to their clinic (Ie. have health insurance) more than likely will not be calling an ambulance for non-emergency purposes in the first place. They will just take themselves to the clinic and let insurance cover it all.

Access is the crux of the whole EMS/ED abuse-overuse issue, really. Until people are able to get themselves to a clinic to get their minor problems taken care of, they are going to keep using EMS to get to the ED for non-emergencies.

Along those lines, follow-up is just as big a problem for patients seen in the ED. Sutures need to be removed whether they were placed in the ED or the patient's living room. Hypertension/chronic pain/diabetes needs to be managed regularly, or else they'll keep needing to be seen urgently.

There is no question that EMS can and should play a major role in this, but EMS can't be the only solution. There have to be clinics where people can access primary care. And the people need to want the primary care bad enough to tolerate the inconvenience of obtaining it; we can't forget the important role that personal responsibility plays here.

I personally dislike the term "community health paramedicine" because it implies there is something new and special and different about taking care of the community, when in reality, very basic primary care, sign-offs, and referrals to clinic or home care agencies is stuff that EMS should have doing all along, across the board anyway.
 
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mycrofft

mycrofft

Still crazy but elsewhere
11,322
48
48
Just read about a program getting of the ground in the Twin Cities, where the hospital informs the FD of a discharge and they visit, go over discharge instructions ect.

We are a BLS agency and we are trying to do some of this, obviously limited in the actual medicine we can provide but we have found that even just coming to talk has had some improvement. We have a significant senior population and the hospital is in town, so much of the towns industry is supporting medical facilities.

We have begun to ask the senior center to give us a call when regular attendees dont show without notice, do a welfare check, we also use our records to follow up with frequent fliers after we take them to the ER and see if they need anything.

Especially in the senior population, i was shocked at how much we were able to influence their call volume. Most dont drive, so we might transport to the ER and they get a prescription, they have no way to get to the pharmacy to fill it, they get worse and call 911 and we go back a few days later. Now, Ill go over to the patients house, review their discharge instructions, call in prescriptions for pickup or delivery, get them in touch with their GP or specialist for an appointment, arrange transport for such, also do a home survey looking for things like fall hazards, loose carpeting, narrow and cluttered hallways, ect

We dont really work with the hospital, they are less than receptive about helping this program, so we are just focusing on our residents, maybe it will expand, but we rely on our charts, the cops and the senior center to notify us as to potential issues.

Weve also started talking to our FD, who are all EMTs, to come with us when they can and check smoke detectors, CO detectors, and do a little fire inspection. It helps them be more familiar with the fire loads they may have to deal with, and hazards or challenges, ect.

Much of this is what the "Visiting Nurse" used to do.
 

vc85

Forum Crew Member
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What about authorizing other transport destinations besides the ER for some of these people.

i.e. someone cuts their finger slicing food: transport to adult urgent care clinic

kid falls down and scrapes knee -> pediatric urgent care clinic

This should help free up the ER for real emergencies and maybe convince people to get their own transportation to urgent care.
 
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mycrofft

mycrofft

Still crazy but elsewhere
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Side slivers

1. Is a FD going to dispatch a pumper along with the paramedics each time as they do now? JIC? (just in case)

2. I can see thus having a very different complexion medically, personally and socially for rural rescue units. Perhaps this ought to be an argument for third service? And boy will this start to kick the "rescue ricky" stuffings out of responder services!

3. I think a nationally standardized certificate needs to be promulgated, with a curriculum to support it. Especially if you are going to be doing followup visits; patient teaching becomes important, and while many "elder statesperson" EMS people do that to other EMS people or aspiring students, teaching a sick 80 y/o or a caregiver whom hasn't passed the eighth grade or comes from a culture foreign to the responder is a whole 'nut her deal.
 
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mycrofft

mycrofft

Still crazy but elsewhere
11,322
48
48
1. Is a FD going to dispatch a pumper along with the paramedics each time as they do now? JIC? (just in case)

2. I can see thus having a very different complexion medically, personally and socially for rural rescue units. Perhaps this ought to be an argument for third service? And boy will this start to kick the "rescue ricky" stuffings out of responder services!

3. I think a nationally standardized certificate needs to be promulgated, with a curriculum to support it. Especially if you are going to be doing followup visits; patient teaching becomes important, and while many "elder statesperson" EMS people do that to other EMS people or aspiring students, teaching a sick 80 y/o or a caregiver whom hasn't passed the eighth grade or comes from a culture foreign to the responder is a whole 'nut her deal.

OK so I'm sick….
 
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mycrofft

mycrofft

Still crazy but elsewhere
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If you are out there suddenly making much wider judgments ...

Here's something with which we had trouble while working off standardized procedures and away from a doctor (who nonetheless countersigned our work within 72 hours).

IF an administrator or one of our MDs complained about the patient visit's outcome not being what they wanted, but it was within the protocol, the phrase they would use was "I would think you could use your nursing judgement about that!".

"Nursing judgement" is the concept that the body of technical knowledge and training in ethics should enable a nurse, in the absence of explicit orders, to recognize and react to emergent situations. Not necessarily "true emergencies", but things that "pop up" (emerge unexpectedly).

It is vague and can be used to defend or punish a nurse, there being no firm balance point between using this vague "judgement" and being "out of control". "Strict Protocol" advocates get real loosey-goosey and retreat to that if things are going badly for them and the organization.

This is exactly why you need a union.
 
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