On Every Patient, Get A [Insert Here] Measurement?

EpiEMS

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To what degree are you required to take X number of "vital signs" (these being [insert your requirement here]) for each patient? My agency's standards requires a minimum of 2 sets of vitals for each PCR, which must include HR, BP, and RR, unless it's an RMA, for which we are only required to get a single set.

What are the minimum vital signs we should be obtaining on every (or almost every) patient? Are there any others than HR, BP, and RR? How about a BGL?

NB: This is a throwback to an older thread (in part).
 

VentMonkey

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To what degree are you required to take X number of "vital signs" (these being [insert your requirement here]) for each patient? My agency's standards requires a minimum of 2 sets of vitals for each PCR, which must include HR, BP, and RR, unless it's an RMA, for which we are only required to get a single set.

What are the minimum vital signs we should be obtaining on every (or almost every) patient? Are there any others than HR, BP, and RR? How about a BGL?

NB: This is a throwback to an older thread (in part).
I think it's all patient dependent. I personally will not get a BGL on every patient like I was "taught". With that, I will do it for more than just diabetics or those that it fits. The same can be said for a 12-lead, etc.

Again, all circumstantial taking into account things such as case/ scenario presentation, co-morbidities and the like.

Index of suspicion is my go to, and this would be where I truly think what I have been taught through all phases of training, as well as overall experience (con-ed included) will dictate what I will, and won't do.
 

hometownmedic5

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Massachusetts says two sets for every transport. It would seem that there are no exceptions, officially anyway.
 

VentMonkey

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I should add, in the beginning of my paramedic career it was a bit difficult deciding when to cut cookies for protocol compliance sake vs. using critical thinking skills.

Over time it gets easier, so the 20 year old with chest discomfort after an argument, and no precursors just doesn't get the same sense of urgency as say the 60 year old diabetic who smokes, has CAD, HTN, and a family's long rap sheet of heart trouble in spite of an "unimpressive" 12-lead.
 
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EpiEMS

EpiEMS

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I do listen to everyone's lungs though.
This is something that I definitely don't see everybody doing! I've got to remember to do this - I've been told that listening to everybody's lung sounds is the best way to figure out "Hey, this just doesn't sound right!"

I should add, in the beginning of my paramedic career it was a bit difficult deciding when to cut cookies for protocol compliance sake vs. using critical thinking skills.

Absolutely, this is probably my biggest challenge - that being said, I'm given to covering my *** in my assessments & documentation to avoid the headaches, insofar as it's appropriate for the patient.
 

VentMonkey

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I do listen to everyone's lungs though.
This is something that I definitely don't see everybody doing! I've got to remember to do this - I've been told that listening to everybody's lung sounds is the best way to figure out "Hey, this just doesn't sound right!"
I won't say that I do everyone (guilty as charged), but will say I do most everyone.

And yes, you're correct. It really is the only way to decipher normal from adventitious. I did lots and lots of auscultations in the beginning of my career. I still do lots and lots, but again would be lying if I said I did every single patient.

It's actually an excellent habit to develop. I still try and listen to heart sounds when pertinent as well.
 

StCEMT

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We are supposed to get 2 sets for everyone of the basic hr, BP, RR, gcs. Very annoying when we do some .2 mile transfers. Sorry billing, you're getting the same **** twice.

Outside of that, I will go a little further if the nursing center doesn't have a great history or the patient is equally useless in knowing what's going on. Just depends on what's going on.
 

RocketMedic

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We have a mandatory assessment model that includes temperature as a mandate. With that being said, reality applies....I didn't get a sugar or a temp on my last trauma because Reasons
 
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EpiEMS

EpiEMS

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hometownmedic5

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I feel like these blind mandates result in little more than fabricated PCR data. If you make a field mandatory, it's going to get filled in or I can't send the report in and go home; but that doesn't necessarily mean I'm able or willing to actually measure all these things.

I get a sugar on every patient I start a line on. That's a no brainer. No line, then it's an assessment item that gets put on the list of stuff to do before I get to the hospital, which may or may not get done depending on proximity to the hospital.

My thermometer doesn't show reliable readings, thus it doesn't come out of the cabinet. If you make temperature a mandatory field, you'll get a temp which I will fabricate because my guess is going to be just as good as my broken thermometers, maybe better.
 
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EpiEMS

EpiEMS

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@hometownmedic5, I totally agree that it can be a poor mandate, especially if there's not the right/functional equipment available. That being said, I'm comfortable with some mandates (BP, HR, RR, GCS -- or AVPU, which might be more useful in a prehospital setting).

So are folks generally opposed to requiring BGL and/or SpO2 and/or temperature measurement for all patients (assuming all equipment is available and functional)?
 

Jim37F

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The vitals section on our ePCR has fields for blood pressure, pulse rate, respiratory rate, SPO2, CO2, blood sugar, pain, and temperature fields (in addition to time and crew member fields for each row). Only time (there's a PTA check box to chart vitals fire gets before we get there), crew member, respiratory rate, and pain are required to fill in. Oh and you need two rows (2 sets) to upload. So we don't need a BSG or temp on every patient, but we can chart those when we get them (pretty much all our local hospitals want us to grab a temp on their thermometer when we walk in anyway, unless it's a critical patient getting a bed right away).

GCS is a required field on every patient, but it's not in the vital signs section, it's in the "Patient Assessment" section where the check boxes for airway (patent, partially obstucted, obstructed for example), breathing rate and quality, lung sounds, skin color, temp, and moisture, capillary refill, edema, pupils, and mental status in addition to GCS are all in that section and are required to be filled out to upload.

There is a second GCS that was originally only used if there were any changes, and it is not coded as a critical field, i.e. I can still upload without it. However it is still company policy to chart a second GCS at time of transfer of care (more often then not results in two identical 4-5-6's....however if a patient's GCS does change enroute, we need to document that in the comments box in the vitals field at time of the change so it's possible to end up with three charted GCS's).

While two sets of vitals are required, there's no required time limits between them. I.e. I won't get any kickbacks from management if I only chart 1 set when I get the patient and a second set an hour later at transfer of care. However, the last set does have to be within 5 minutes of our clear time as a transfer 9f care set. (RN's signature and the second GCS also has to be within that 5 min....yeah you didn't hear it from me, but those times may or may not get adjusted from time to time....)
Personally I'll chart what fire tells me (if I wasn't there for that set), and I'll try to get my own enroute, plus the set we get at the hospital when we walk in (all our hospitals require us to do so), and unless we're holding the wall for hours, I'll use those (if we are, I'll try to get a last set once we're in a room and I'm waiting on the nurse) but if I only have 2 sets no problemo
 
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EpiEMS

EpiEMS

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@Jim37F, do you happen to use...(dun dun dunnnnnn) EMSCharts?

I don't mind charting our fire's (BLS-only) vitals for PTA, except for the couple of times where they've given me vitals that are absolutely wrong/lazy - like 90/palp for somebody where I can get a nice 120/80 pressure (or 90/palp when I get 90/60 nice and clearly).
 
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EpiEMS

EpiEMS

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We use HealthEMS Mobile actually

Gotcha. Maybe the similarity is some sort of convergence in the industry, or maybe related to NEMSIS.

Thanks!
 

captaindepth

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I get a sugar on every patient I start a line on. That's a no brainer. No line, then it's an assessment item that gets put on the list of stuff to do before I get to the hospital, which may or may not get done depending on proximity to the hospital.

Sorry but I have to ask, why is getting a BGL on every patient you start an IV on a "no brainer"? That seems unnecessary for "every patient" and it seems like (IMO) there is some aspects of the initial/ongoing assessment that are missing if everyone gets a BGL no matter what. Are you checking sugars on emergent trauma patients? What about a cardiac alert patient thats alert and orientated with a good history of the event, onset time, and answering all questions appropriately? I can think of dozens of types of patients that get IVs and dont warrant a BGL. Id like to think critical thinking, physical assessment, and obtaining a hx (medical and current event) would determine when its appropriate to get a BGL. I think lung sounds on every patient is a "no brainer" not a BGL.
 

hometownmedic5

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Because I can assess the glucose from the blood in the flash chamber, and I can do it at my convenience. Ive already poked them once, I have an appropriate sample and that sample will be there waiting for me whenever I get to it. No brainer.

The difference between capillary and venous blood in terms of assessing the glucose level may be statistically relevant enough to give the hyper accurate type A's something to fret over, but it isn't clinically relevant(meaning even at the extremes, it isn't going to change my treatment). You're either hypo enough for sugar, hyper enough for the list of potential therapies there unto pertaining, or you're fine and the 0.03% difference isn't going to sway that result.

Perhaps its extreme to say "every patient I start a line on". I try to refrain from absolutes, but am not always successful. However I will say this. The last thing I throw away is the IV and if I have a free minute, I get a sugar from it. Perhaps I've done all I can or need to do. Perhaps I need a moment to collect my thoughts. For whatever reason, I can usually find 30 seconds to accomplish this task.

It's all about prioritizing needed actions and then getting as far down that list as I can. Sometimes, I run out of transport before tasks. Sometimes I ran out of stuff to do 10 minutes before getting to the hospital. Anything is possible. Also, the nurses in my ER would love it if we brought every patient in with a bgl, and it never hurts to keep the nurses happy...
 

captaindepth

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I get wanting to keep the nurses happy, I am always surprised by how nurses ask if I checked a BGL even when I bring in a patient where checking a BGL would be completely irrelevant. I usually reply with something like " the pt is AAOx4 answering all questions appropriately with skin P/W/D, no signs of AMS, also the pt has no hx diabetes (and their chief complaint is a stubbed toe : )" But really why check a BGL when it is not part of your differentials, patient hx of DM I or II, AMS, a r/o for a potential CVA, or some other justified reason to check one? It seems totally unnecessary. Anyways I know each EMS system has its ways and what's normal in one place might not be in another. I was just curious as to what your reasoning was.
 

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