London Ambulance Service (LAS), which servesEngland's largest city, has created "patient-specific protocols" to prospectively tailor EMS care to high-risk patients for whom regular protocols don't fit. Each PSP provides specific instructions for a named individual. LAS Medical Director Fionna Moore, MD, described the LAS program at the Metropolitan Medical Directors Consortium's "State of the Science" conference (aka, "A Gathering of Eagles") in February.
The purpose of a PSP, she said, is to provide a structured, uniform protocol to guide the management of a specific patient; provide a patient's pertinent medical history to the ambulance crew, ensure the patient is transported to a specific treatment centerand remind responders about that patient's special needs.
LAS has created a PSP for 252 patients since 2007, and 186 of those personalized protocols were "active" as of February. Each PSP is created and signed by the LAS medical director and the patient's primary physician and is written on LAS letterhead. "It's important for crews to recognize that these are approved protocols," Moore said.
She provided examples of several patients with PSPs, including:
- A 5-year-old child with difficult-to-control epilepsy and a severe sensitivity to benzodiazepines, requiring administration of rectal paraldehyde;
- A patient with severe COPD who is susceptible to type II respiratory failure and severe respiratory acidosis due to oxygen toxicity; and
- A patient with end-stage glioblastoma who should not receive bag-mask ventilation/intubation, chest compressions or cardiac drugs but should still receive suction of upper airway, face-mask oxygen and airway positioning.
Patients with a PSP are flagged on the "high risk" database and integrated into the CAD system. The patient's address (or multiple addresses) is flagged, and an audible alarm sounds on the mobile data terminal whenever a call comes from a PSP address.
Every patient (and/or caregiver) is sent copies of the protocol and a cover letter requesting that they keep a copy of the protocol with them at all times. In addition, copies of the PSP go to the patient's physician, to the ambulance stations closest to the patient's flagged addresses and to the LAS Clinical Support Desk, which keeps copies of all PSPs.
Moore said she now writes approximately four new PSPs each week, with each one requiring two to four hours of work. They also require liaison with hospital clinicians, she said, as well as constant review and updates. Because some PSP patients are challenging, she added, "You may live to regret some protocols."
The PSP program has also resulted in at least one global protocol change. "Because of a large number of requests for PSPs for steroid-dependent patients, LAS successfully lobbied for changes to national guidelines [to allow] administration of hydrocortisone by ambulance staff," Moore said.
She's now working with the LAS "Frequent Caller Team" to develop specific protocols for this group of patients.
For more information, contact Fionna Moore firstname.lastname@example.org.
For more on high-risk patients, read"Street Calls Program Reduces 9-1-1 Misuse and Delays in D.C."