Posted by: medicblog999 | March 28, 2009

Leaving patients at home

imgp0492Over recent weeks, both myself and happy medic have been discussing various aspects of the UK and US EMS models of care. Many US paramedics and EMTs have left comments stating their amazement at our ability to leave patients at home after they have called 999 for emergency help. Obviously though, this is only after a thorough assessment and if necessary, an agreed referral to another urgent or out of hours healthcare provider.

I personally think that this is a great thing to be able to do and gives us a much more involved and autonomous role in providing care and advice for our patiens in their own homes and communities whilst negating the need for many unnecessary visits to the A&E (ER) dept.

Alot of the readers of this blog have expressed a desire to be able to do this in their service, as we all have the same patient types and demographics whichever country we work in. We have all had that frustrating feeling when we have to take a patient to A&E when we know there is no need for the transport, and all they are doing is wasting our time and tying up valuable resources for those others who may truly be needing our help at that very same time.
Being able to “Cat C” a patient and leave them at home or refer onto another provider brings a whole other raft of personal challenges and needs a complete rethink and adjustment to the way we look at what many would call time wasting jobs. As soon as I had completed my Cat C course and was allowed to “Respond not Convey”, all of the jobs which would previously have caused me some amount of frustration suddenly became more interesting that the Chest Pains, CVAs, Traumas etc. For all the major illness and injury that we see, the care and treatment we give pretty much follows protocols and guidelines and always results in a trip to an appropriate hospital for definitive care.

With regards to the minor injury and illness patients, these now become the challenge. All of a sudden, you become a fully fledged clinician and now you have to do something that previously hasn’t been in your choice of treatments. To be able to leave patients at home, you need to be able to decide on a provisional diagnosis and more importantly, be really sure about it!

There are a few golden rules that I practice by:

You need to be incredibly thorough:

Your patient assessment is now just as much focused on ruling out significant problems as trying to diagnose what is actually occurring. You will find yourself doing more assessments than you may do on a much more poorly patient who you are transporting to an A&E. Most of my patients who I am leaving at home will have BP, pulse, Pulse oxymetry, temperature, Blood glucose and 12 lead ECG. If any of these are significantly out of normal limits, then they are having a trip to hospital. 

You need to be able to consider all differential diagnosis:

You need to be really up to scratch on presentations of minor illness and injury, but also be aware of the many, many conditions that can come up which have the potential to trip you up. Its no longer accetable to say I think that you have a minor chest infection, without being aware of the possibility of other conditions such as early exacerbation of COPD, early pneumonia, etc etc.

You need to trust your instincts:

There have been 3 times when I have gone through the whole process of assessment and documentation, have provided follow up advice and who to contact for help if any other concerns but had a nagging feeling that maybe I was missing something. A quick change of direction is all that is needed and a trip to hospital to put everyones mind at rest (mine included!). I did follow these up and none were anything more than what I had originally thought, but a little bit of paranoia is a good thing and has kept my practice safe so far.

You need to accept the sometimes bad things happen to good people:

During my Cat C course we were told in no uncertain terms that no matter how safely we practice, if we leave people at home, even with appropriate referrals in place, at some point someone will deteriorate once we have left. This needs to be accepted and you have to be able to live with your decisions if this ever does happen. I personally, would be devastated if someone ended up being really poorly or even died after I had assessed them and decided that they did not need to go directly to A&E. However, what I would know, would be that at the time that I had assessed that patient, there will have been no signs of any significant illness or injury. There will have been nothing to spark that moment of doubt and I would have been happy with my decision at that time. The most obviously scary one is the child with the minor fever and headache which results in a meningococcal septacaemia. This happens, thankfully not me or any of my patients, but I know it has happened to children that have been sent home from A&E, only to be taken back into hospital by an ambulance a few hours later with a life threatening infection. The questions is always asked:

“Did someone miss anything?”

In the vast majority of cases, the answer is a definite no. No one missed anything, it was just that the child did not present as a meningitis at the time of assessment. As I said, sometimes bad things happen to good people.

Your documentation is your lifeline:

Without an excellent patient report form, you have no proof that the patient was in the “minor illness, minor injury” category. Without an excellent patient report form, the follow up caregivers, whether they be the GP, urgent care team nurses or district nurses, will have no record of what has happened an been observed before them. Without an excellent patient report form you have no defence if your decisions are called into question at a later date.

 
Reading all of this makes it seem a frightening thing to be able to do. In all honesty, some paramedics feel that it is a risk they are unwilling to take, and are happy doing what they always have done……taking the patient to hospital, and that’s fine. You cannot criticise any paramedic for not feeling comfortable with the extra responsibility that this training allows them to shoulder. It isn’t for everyone, and if it does come to your service or something similar, you will have an interesting time finding out how this sits on your shoulders too.

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Responses

  1. It’s even worse round our way.

    As a (volunteer) CFR, I attended a patient yesterday. It was obvious that she needed transport to hospital to diagnose what was causing her fever, headache, sore throat, stiff neck and breathig difficulties.

    The crew were two ECAs, so were not permitted to take her to A&E without the say-so of a paramedic or technician.

    What a bl**dy waste of time!

    (It wouldn’t have been so bad but one of the ECAs was actually a trained technician, originally from another Trust. It seems that his qualification didn’t count!)

  2. Great post. I’m one of those US paramedics that would love the concept of the “Treat and Release” which would be our term for it, but would be scared of its implementation. Can you detail the requisite education you need to do that over and above your Paramedic?

    http://proems.blogspot.com

  3. […] of rapid response is being Cat C trained (see here for a full explanation on that), although recently, newly qualified staff can find themselves on a […]


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