tsktsk
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I think some organizations still expect you to follow the recipe....
Protocol-Based Medicine
- Thread starter RocketMedic
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I agree 100%
Only thing I'd change about that statement is most agencies instead of some. Per our QA/QI if you can articulate why you did or did not do something you aren't going to get burned for it. However, if that case goes to court you will be called to the table for deviating from protocol and potentially could lose the support of your agency in that type of situation.
Not trying to start an argument but the way I read the link you posted it seems like it grants the provider permission to "straddle" two protocols or switch from one to another and determine where to start in the protocol you switch from rather than starting at the top, but that's my sleep deprived, post 12 hour shift brain talking so take it with a grain of salt.
mycrofft
Still crazy but elsewhere
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Some may feel following a protocol will save you from suit; the closer truth is, that deviating or disregarding them will open you for conducting care that will not be reimbursed. You can be sued at any time.
Our MD"s rebeled at the computerized charting systems they were offered (1990's) because the documentation tended to presume adherence to protocols or reimbursement schema, I'm not sure which; to document care freely one had to basically sit down and type in a narrative, no timesaver and bound to raise their administrators' eyebrows.
Someone does something egregious-->someone else takes notice and wants to prevent it so "they"* get together and make a rule-->the rule generates a protocol so adherence can be measured and presumably enforced, and practitioners with questions or without experience/training in that area won't make a bloody botch of it.
Using protocols isn't bad if the protocols are good. Wanting to work more independetly is a sign that either the protocols are losing relevence (admin trouble), or practitioners are losing confidence (cultural/leadership trouble), or it is a sign someone needs to "take it to the next level" and go back to school.
*Hopefully, "they" are/is people with a superior degree of experince and knowledge backed by research. As time goes on, the membership in "they" may slip towards lawyers, insurance company representatives, and non-practicing MD's.
Our MD"s rebeled at the computerized charting systems they were offered (1990's) because the documentation tended to presume adherence to protocols or reimbursement schema, I'm not sure which; to document care freely one had to basically sit down and type in a narrative, no timesaver and bound to raise their administrators' eyebrows.
Someone does something egregious-->someone else takes notice and wants to prevent it so "they"* get together and make a rule-->the rule generates a protocol so adherence can be measured and presumably enforced, and practitioners with questions or without experience/training in that area won't make a bloody botch of it.
Using protocols isn't bad if the protocols are good. Wanting to work more independetly is a sign that either the protocols are losing relevence (admin trouble), or practitioners are losing confidence (cultural/leadership trouble), or it is a sign someone needs to "take it to the next level" and go back to school.
*Hopefully, "they" are/is people with a superior degree of experince and knowledge backed by research. As time goes on, the membership in "they" may slip towards lawyers, insurance company representatives, and non-practicing MD's.
Same here. The protocols are a place to start from, where that treatment will be appropriate for 90% or more of patients that "fit" that particular protocol. There are times where we need to deviate, and we have a clause in our 500+ page manual that addresses this, but we do need to consult OLMC. Also, like NVRob stated, we have the ability to blend or straddle protocols depending on the presentation without having to call the doc-in-the-box. It's when we want to do more than the protocol states that we have to call.
Contrast this to the NYC 911 system circa 2003-2007 when I last worked there (may be different now). You had to fit a pt to a protocol. If you had a pt with multiple issues, you would have to call OLMD and get permission to switch protocols, which we don't have to do here. As far as OLMC options, there were only one or two specific interventions to choose from, with no lattitude to suggest anything else. When you have a bunch of hospitals and a couple of privates in the system along with FDNY EMS, this is understandable.
We also have a protocol that addresses all the patients that don't fit a particular protocol. It names several suspected diagnoses such as pericarditis, pneumonia, PE, pneumothorax that doesn't meet decompression criteria, HTN, etc. We're directed to perform relevant diagnostics, attempt to name a differential diagnosis, and give supportive care such as pain management, appropriate oxygenation, etc. without naming a specific protocol. It says "treat symptoms if indicated," which gives us a certain amount of lattitude.
I feel protocols have their place in that they give a standard treatment which is usually appropriate for a certain presentation, such as CPAP/0.8mg NTG w/ repeats for the hypertensive cardiogenic pulmonary edema pt. Protocols are helpful for the new provider that has not had many pt contacts. The protocols are a good base to start from. As the provider sees patients with co-existing conditions, or unusual presentations that require intervention, the need to regard protocols as guidelines rather than a religous document becomes more important.
I remember my first few tours as a new medic. I did really well in class, and had worked in the field as an EMT for several years up to that point, but I was still nervous and scared (in the punitive sense) to treat unless a textbook presentaion was evident. "Am I really supposed to give this neb, or push this much morphine, is this the right protocol?" The fear of a medication error and subsequent discipline/termination was a true concern.
You know how it is - after a while, you've followed up on many pts with the Attending several hours later, where you had no idea what was going on with them. You're matching pt histories and meds with certain presentations, and can be reasonably sure what the proper differential Dx is. You know what the pt needs, although their presentation doesn't fit all the bullet points of the protocol. This is when the protocols ought to be more like guidelines rather than a cookbook. This requires a solid medical education, so this is often a catch-22 of course.
I remember my first few tours as a new medic. I did really well in class, and had worked in the field as an EMT for several years up to that point, but I was still nervous and scared (in the punitive sense) to treat unless a textbook presentaion was evident. "Am I really supposed to give this neb, or push this much morphine, is this the right protocol?" The fear of a medication error and subsequent discipline/termination was a true concern.
You know how it is - after a while, you've followed up on many pts with the Attending several hours later, where you had no idea what was going on with them. You're matching pt histories and meds with certain presentations, and can be reasonably sure what the proper differential Dx is. You know what the pt needs, although their presentation doesn't fit all the bullet points of the protocol. This is when the protocols ought to be more like guidelines rather than a cookbook. This requires a solid medical education, so this is often a catch-22 of course.
mycrofft
Still crazy but elsewhere
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"It names several suspected diagnoses such as pericarditis, pneumonia, PE, pneumothorax that doesn't meet decompression criteria, HTN, etc. "
A litmus test for protocols/standardized procedures. Open the table of contents. Are the contents arranged by name of disorder, or some other system (usually body zone such as back, leg; also, based on presenting c/o such as dyspnea)?
If they are arranged by name of disorder, you potentially have a problem because that system presumes you have a diagnosis, rather than an assessment. (Assessment: pain in thigh, shortening of same leg, fell off roof in the dark. Diagnosis: fx femur). And it is unusual to find anyone being responsible for diagnosing per se besides MD's FNP"s, PA's, etc etc. Not technicians.
A litmus test for protocols/standardized procedures. Open the table of contents. Are the contents arranged by name of disorder, or some other system (usually body zone such as back, leg; also, based on presenting c/o such as dyspnea)?
If they are arranged by name of disorder, you potentially have a problem because that system presumes you have a diagnosis, rather than an assessment. (Assessment: pain in thigh, shortening of same leg, fell off roof in the dark. Diagnosis: fx femur). And it is unusual to find anyone being responsible for diagnosing per se besides MD's FNP"s, PA's, etc etc. Not technicians.
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One of the provinces I am licensed in we are self regulated. I own my scope of practice 24/7/365. We have a medical director and protocols where I work but as long as we can back up what we are doing we can treat the pt and not force them into a protocol. Our protocols are probably similar to an progressive service in the US.
There is a shift now from protocols to treatment guidelines. we create a treatment plan based off of our assessment tailored to a specific pts needs. Here is a link to the BC treatment guidelines as an example. http://bctg.bcas.ca .
We still have medics that force people into the protocols and treat protocols as black and white.... these medics are usually not confident/comfortable assessing and treating a pt. For them to continue in this system they are going to need to retire or up their game.
There is no degree requirement for medics in Canada. Our BLS medics(primary care paramedic) are in school for usually 1-2 years depending on the province. Their scope would be similar to an AEMT in the US. After a few years experience they may be selected or elect to take an ALS medic course (advanced care paramedic) which is another 1-2 years. Scope is similar to medic or CCT medic in the states.
One thing I have noticed is that up here people become paramedics to be paramedics. You do get a few that go into nursing or med school but it is not really common. For the most part EMS is separate from Fire. The province I currently work in has no volunteers or drivers or first responders. Only medics work on the ambulance. There is a big push on now for Paramedic led research and other provinces to self regulate.
I think/hope that answers your question. I apologise now for spelling and grammar....am on my cell phone