Triaging down to BLS

[ParamagicFF]

I'd like to start a discussion regarding systems where both ALS and BLS transport are available, particularly ones where ALS can triage calls down to BLS for transport.

For those of you who work in systems like this, do you have a clear and specific protocol for what requires ALS intervention and/or transport? Is it solely based on provider decision? Maybe it's somewhere inbetween with lots of grey area? Are there any patients that are mandated as ALS transports with no specific ALS intervention required?

How comfortable are you in these systems? Do you feel like the standards for ALS/BLS transports are applied fairly evenly across your system? Are there any patient conditions that you feel on the fence about?

Having only been in a system like this for 2 years, I'm interested to hear about others' experiences!

 

[NPO]

I previously worked in a system where both ALS and BLS was available but hand down was not allowed. They have since transitioned to a hand down system but I'm not familiar with the ins and outs.

My current service staffs only ALS ambulances, but we can allow the EMT to take the call if we think it's appropriate. There is no written guideline or policy on this. It is provider discretion, and as such some paramedics are loose with this, some are very conservative. I tend to be conservative.

A lot of my decision on if I hand off to a BLS partner is their competency level, and my level of familiarity with my partner. If it's my normal partner, I know he's a skilled and capable provider that I can trust. With newer EMTs who may lack experience in assessment, I may be more cautious.

 

[ParamagicFF]

My current service staffs only ALS ambulances, but we can allow the EMT to take the call if we think it's appropriate. There is no written guideline or policy on this. It is provider discretion, and as such some paramedics are loose with this, some are very conservative. I tend to be conservative.

At the risk of starting a tangent, this is how my previous department was. I thought it was a great system for developing EMTs, especially those who were looking to become paramedics. If something goes wrong you can always pull over and swap out if an ALS intervention becomes necessary. That shouldn't be happening often, but it's a good safety net.

 

[NPO]

At the risk of starting a tangent, this is how my previous department was. I thought it was a great system for developing EMTs, especially those who were looking to become paramedics. If something goes wrong you can always pull over and swap out if an ALS intervention becomes necessary. That shouldn't be happening often, but it's a good safety net.

I've had to do that only once. It was on a transfer. The patient became extremely anxious and nauseous. To the point of being a safety concern. I took over and treated the nausea. I almost gave him some Versed, but we were getting close. Had it been further I'd have considered it.

 

[EpiEMS]

For those of you who work in systems like this, do you have a clear and specific protocol for what requires ALS intervention and/or transport? Is it solely based on provider decision? Maybe it's somewhere inbetween with lots of grey area? Are there any patients that are mandated as ALS transports with no specific ALS intervention required?

As a BLS provider in a system where we are often B/B with a medic fly car, I often take handovers from ALS: the fly car medic with or before us, evaluates the patient (with or without our collaboration) and hands over the patient to us.

My protocols are pretty explicit:

When transferring care from one provider to another, the transfer must be to a provider of equal or higher level, unless the patient’s condition and reasonably anticipated complications can be effectively managed by a lower level provider’s scope of practice.

In our old protocols, we had a comprehensive list of conditions, signs, and symptoms where paramedic transport (rather than downgrade to BLS) was warranted. I like this approach, but the most important thing is covered in the block quote above...basically, ALS transport is indicated unless there's no foreseeable reason why the patient needs (or could reasonably need) anything more than BLS care.

I've refused to take patients that were downgraded to me and was glad I did. I'm not transporting somebody when I think I can't manage them.

 

[DrParasite]

NJ is an entirely tiered system.... having ALS triage a patient to BLS was very common, especially if ALS arrived first and the patient was BLS.

As a general rule, ALS may triage a patient who is stable, and who does not require any ALS interventions. This patient should not require any ALS interventions until they arrive at the hospital. Have ALS triaged questionable patients? yep. have they been pulled into the QA office when the patient deteriorates? yep. does it happen often? no.

 

[soflomedic14]

As far as my knowledge is concerned, we only have ALS departments in South Florida unless you work for a private ambulance company.
I definitely think the option of triaging down to BLS would be very beneficial especially in the area I work because it is SO busy all the time so it would help with transports for sure and getting ALS to the scene of a call where ALS is needed and keep BLS where BLS is needed (I hope that makes sense.)

 

[Jim37F]

My current service staffs only ALS ambulances, but we can allow the EMT to take the call if we think it's appropriate. There is no written guideline or policy on this. It is provider discretion, and as such some paramedics are loose with this, some are very conservative. I tend to be conservative.

Pretty much how my County's EMS runs. I've seen some medics ride in for everything, others will have their EMT attend as much as they can get away with. I've seen a medic hop in the drivers seat calling out thru the passthru for his EMT to go ahead and start a line and give zofran for an otherwise BLS trip lol

 

[Uclabruin103]

I used to work in LA County, and there was a specific protocol on what constitutes ALS vs BLS. I now work in a B/P staffed ambulance where no one lets their basic attend. There was a protocol to downgrade to ALS if no medic boxes were available, but it was rarely used in my current county .

I was totally comfortable transporting. Only once did a patient deteriorate, so we just pulled over and got an intercept .I feel it's not an appropriate use of resources to tie up medics, let alone ambulance, on obvious BLS transports.

There's always that thought of what might happen, but that's found everywhere . We have to use common sense for some of our policy choices. People die in hospital waiting rooms, so you never can prevent everything.

Of course there's abuse of the downgrade, especially at night when tired, but that's not the norm.

 

[ParamagicFF]

In our old protocols, we had a comprehensive list of conditions, signs, and symptoms where paramedic transport (rather than downgrade to BLS) was warranted. I like this approach, but the most important thing is covered in the block quote above...basically, ALS transport is indicated unless there's no foreseeable reason why the patient needs (or could reasonably need) anything more than BLS care.

I'd be interested in seeing what was outlined as requiring ALS. Would you mind sharing some of those details?

 

[DrParasite]

For clarification, are you talking about a B/P system, where the Paramedic "triages" to their EMT partner? or a case where you have a B/B ambulance, with a paramedic intercept used for ALS criteria calls, and will triage the patient to the EMT crew for transport to the hospital?

The reason I ask is a paramedic can ALS almost anything. It can be based on the "well, this might happen, so I can't triage it" or it's the "hey EMT, start a line on the patient and give zofran, oh wait, I need to run a 12 lead now, no longer a BLS patient." Downgrading can be similar, although it's tough (but not impossible) to justify downgrading a 70 year old with chest pain, despite everything else being normal (NSR, no ectopy, no other signs of cardiac issues, etc). From a clinical standpoint, does your medical director or clinical administration trust your providers judgement as to what should be ALS vs BLS?

Also, in the B/P system, often the paramedic has to write a chart on the patient anyway (based on anyone they assess), so if they triage to their partners, now both need to write a complete chart. Otherwise, how can the paramedic justify his or her rationale for triaging?

As an EMT, I felt very comfortable working in an intercept system. EMTs were expected to be good at determining whether ALS was needed or not. Paramedics knew their jobs: to treat sick patients who required ALS interventions. EMTs treated the rest. I think it was roughly 80:20 BLS to ALS ratio in terms of BLS treats vs ALS treat.

There are some paramedics who triaged questionable patients. QA reviewed the calls and took action if needed. I was on calls where the paramedic triaged a questionable patient. sometimes nothing happened, and we had an uneventful transport.... during one such calls, where my EMT partner and I were dumbfounded that the ALS triaged the patient, and she went into respiratory arrest on the way to the ER. But they are the higher level of medical care, so it's their call on who they treat (we ventilated the patient, continued on to the ER, and requested a different unit for an intercept).

for most EMS calls, the patient can be transported by BLS without any negative patient outcome. There are absolutely those calls that warrant ALS, but if you are working in an all ALS system, and most calls are BLS, than you have those highly trained and educated providers spending most of their day dealing with BLS patients, which leads to skill deterioration and dilution.

 

[ParamagicFF]

For clarification, are you talking about a B/P system, where the Paramedic "triages" to their EMT partner? or a case where you have a B/B ambulance, with a paramedic intercept used for ALS criteria calls, and will triage the patient to the EMT crew for transport to the hospital?

I'm referring to systems where an ALS first responder or ALS transport unit triages down to a solely BLS transport unit.

 

[EpiEMS]

I'd be interested in seeing what was outlined as requiring ALS. Would you mind sharing some of those details?

Sure, here's some examples from a similar set of protocols (albeit not exactly the same):

The following are some examples of high-risk conditions that will, for the most part, merit Paramedic care and/or monitoring.
1. Primary complaint of chest pain, chest discomfort, palpitations, or syncope in patients of any age.
2. Complaint of shortness of breath or difficulty breathing.
3. Patients with a new neurological deficit or presentation of stroke.
4. Patients with an initial diagnostic finding of blood glucose <60 or >400
5. Patients who meet the physiologic or anatomic triage criteria for transport to a level 1 or 2 trauma center.
6. Patients for whom the transporting service requests the presence of the Paramedic.
7. Patients for whom Paramedic treatment (not assessment only) has been initiated.
8. BLS crew comfort with transport

Now, I don't agree with all of these (i.e. just because the complaint is difficulty breathing doesn't mean they need ALS transport, particularly if they have a DNR or are screaming at the top of their lungs "I can't breathe!"), but they're mostly reasonable if interpreted within the context of reasonable provider judgement.

Here's another (more current) version of a nearby area's guidelines on this:

The paramedic may release a patient to a lower-level ambulance crew for further care and transport only if all the following criteria have been met:
1. The paramedic has performed a complete assessment as outlined in these guidelines and has a high degree of confidence that the patient would not benefit in any way from advanced life support measures on scene or at any time during the transport
2. The paramedic and lower-level ambulance crew agree on a plan for subsequent patient care and the ambulance crew agrees to accept responsibility for subsequent patient care
3. The paramedic may not release a patient to a lower-level ambulance crew if any of the following exists:
Assessment findings indicate a need for ALS
 ALS-level assessments initiated by EMS, including ECG monitoring 4 or 12 lead and/or active Capnography
 ALS treatment initiated, including vascular access and /or any medications except oral glucose
 Lower-level ambulance crew is unwilling or expresses any concern with taking responsibility for patient care. Providers have the right to decline the transition of patient care
 The paramedic and lower-level ambulance crew cannot agree on a subsequent BLS treatment plan
 All cases in which patients are released to the care of BLS personnel must be thoroughly documented.
 A patient care report documenting all assessment findings, treatment rendered and the clinical decision making factors that played a role in the patient’s release to a lower-level ambulance crew must be completed.

 

[hometownmedic5]

My second job is with a municipal service that runs P/B. I tech every call, not because I dont have faith in my basics(I generally don’t, but thats not the point here), but because I hate to drive.

I have however worked in a tiered system. I triaged what I considered to be BLS calls. I defined BLS calls as calls that needed no acute ALS interventions, and were likely to remain in that category. I blew a few calls, like every other medic in the same circumstances, and I definitely took some patients that would have been just fine with a basic. Nobody is going to get this a hundred percent right and no amount of lists of complaints are going to make it a foolproof system. Some people having MI’s have crushing chest pain etc. Some have benign appearing belly pain. You do this job long enough, you’re going to end up in the bosses office trying to dig your way out of a hole.

 

[DrParasite]

would something from the annals of emergency medicine help?

Can Paramedics Appropriately Downgrade ALS to BLS Transport Based on a Given Set of Protocols?

 

[ParamagicFF]

would something from the annals of emergency medicine help?

Can Paramedics Appropriately Downgrade ALS to BLS Transport Based on a Given Set of Protocols?

I don't have access to this study. What's the outcome?

 

[DrParasite]

just read the abstract's conclusion, it's in the freely available section.

the answer is yes.

 

[Tigger]

Also, in the B/P system, often the paramedic has to write a chart on the patient anyway (based on anyone they assess), so if they triage to their partners, now both need to write a complete chart. Otherwise, how can the paramedic justify his or her rationale for triaging?

I cannot say I have ever heard of this. In both states I've worked with split staffing (one medic, one something else), the only person writing a chart was the attending provider. If my EMT takes the call, they can document that I performed an assessment in addition to theirs or put someone on the monitor, and that's about it. Is this common in other areas? That sounds awful.

The BLS ambulances in my area are all but required to transport to either ground ALS or a helicopter. If they do transport to a hospital, it must be the closet facility regardless of patient complaint or status. This sounds bad (and it is) but these are services running at most 300 medical calls a year and they just don't have/won't accept the education to improve to the ability to manage their own patients on what are very long contact times.

 

[ParamagicFF]

I'd be interested to discuss different providers' barometers on different cases. In my agency ALS is definitely a limited resource. You won't be singled out for occasionally transporting a BLS call, but if your charts are reviewed and many BLS transports are found, they will have a discussion with you. Also, there aren't enough ALS resources to simply transport on every call with x complaint.

Do any of your systems triage down chest pain patients? For those that do, does it make you uncomfortable?
I'm also interested in how altered mental status secondary to intoxication is treated. I don't mean a little impaired, I mean conscious patients that are entirely incoherent and unable to produce any meaningful verbal response to questioning.
A point of contention among providers I've spoken with seems to be asymptomatic high BP readings with a history of HTN and non-compliance with medications. Are you all transporting them ALS "just in case"?

 

[NPO]

Disclaimer, I tend to err on the side of caution and ALS.

I'd be interested to discuss different providers' barometers on different cases. In my agency ALS is definitely a limited resource. You won't be singled out for occasionally transporting a BLS call, but if your charts are reviewed and many BLS transports are found, they will have a discussion with you. Also, there aren't enough ALS resources to simply transport on every call with x complaint.

I don't necessarily have a problem when that. Appropriate resource management is important, especially smaller systems with fewer resources.

The most important thing is how it's implemented and enforced when they call you in for a talking to.

Do any of your systems triage down chest pain patients? For those that do, does it make you uncomfortable?

It depends. Does the EMT know how to assess chest pain and determine the difference between ischemic and nonischemic chest pain? Heck, does the consulting paramedic? Will there be a paramedic doing a full assessment to include EKG, or is this an immediate hand off?

For nonischemic chest pain with certain presentations it may be appropriate, but if there are adequate resources available it should probably be taken via ALS.

If an agency has a need to reduce ALS transports due to availability, this is one that needs a specific protocol definitions for hand down if it's going to happen on a routine basis.

I'm also interested in how altered mental status secondary to intoxication is treated. I don't mean a little impaired, I mean conscious patients that are entirely incoherent and unable to produce any meaningful verbal response to questioning.

Is there evidence or trauma? Other etiologies cleared? Risk of aspiration or airway loss?

If they are conscious, that's better than not.

Again, I feel pretty much the same way, it should probably be ALS, but nonroutine use of BLS when necessary could be acceptable.

A point of contention among providers I've spoken with seems to be asymptomatic high BP readings with a history of HTN and non-compliance with medications. Are you all transporting them ALS "just in case"?

If they have a history of hypertension, and are CHRONICALLY noncompliant (as oppose to just missed a dose today), and are truly asymptomatic to the hypertension, then I am fine with that going BLS as long as their BP isnt encroaching over 180 systolic