Administration and Leadership, Patient Care

Understand EMS’ Role in the Chain of Care

Issue 4 and Volume 40.

EMTs and paramedics work in a world that can go from absolute boredom to sheer panic in mere moments. To be successful in EMS, these same clinicians must learn to make decisions in what some call a “non-history-taking environment,” meaning they generally know very little about the patients they treat.

Most calls allow very little time to gather information, synthesize what was learned, and then apply the appropriate treatment before sending patients down the road to become a distant memory, or even forgotten. All too often, EMS clinicians are only concerned about what’s happening while they’re providing direct care. Many either forget about or ignore the continuum of care that began long before they arrived and will continue long after the patient is delivered to the hospital.

It’s not the intent of this article to ignore or reduce the value of prevention programs, emergency medical dispatching, or the rediscovered community paramedicine program (Joe Ryan, MD, introduced the idea in Pinellas County, Fla., in the late ’80s). But when 9-1-1 is called, responding EMS personnel will have little to no impact until they arrive “at patient.” However, the astute clinician knows the actions that occurred before their arrival can have a huge impact on the care they provide.

For example, has the chest pain patient taken any aspirin or nitroglycerin? Or how many breathing treatments has a dyspneic patient had, if any, and what were the results? We also know the actions taken, or decisions made, by the patient, family members or bystanders can help or hinder the actions of EMS, such as providing CPR to the patient in cardiac arrest prior to EMS arrival—a critical link to survival.

The Other Side

Let’s look at the other side of the response and the impact on the hospital, ED physician, or the anesthesiologist from actions taken by EMS. Years ago, EMS was treating hypertension with Procardia—poking a medication-filled gel capsule with a needle and squirting the contents under the tongue. This always seemed a little odd and most likely not what the manufacturer intended. This practice was later determined to interfere with therapies the hospital may have wanted to administer and could cause harm to the patient, so this treatment was abandoned.

A similar situation where EMS may negatively impact the next caregiver is with the insertion of certain types of invasive airway devices. For instance, if the emergency physician wants to intubate the patient and the paramedic has inserted a supraglottic airway device that has to first be removed, the medic may have affected the treatment choice of the physician.

In this scenario, physicians have several options. They can either elect not to intubate, or they can remove the airway device and assume the risk—and potential liability—of the patient aspirating. Patients who aspirate not only have an increased mortality rate, but those who survive have significantly longer hospital stays. In addition, this problematic occurrence can have a significant financial impact on the healthcare system, as one day on a ventilator in the ICU equates to approximately $10,000 in costs.1

The physician could also choose to “kick the can down the road” and let the next physician in the hospital airway management chain deal with the problem, either in the ICU or perhaps in the operating theater. However, had the EMS provider given careful consideration to the continuum of care when selecting airway equipment and techniques, this issue might have been avoided.

In addition to the type of airway device being placed, there are many other procedures that can have a significant impact, good and bad, on the hospital’s “bottom line,” financially speaking. One procedure that gets overlooked in EMS is suctioning through the endotracheal (ET) tube. ET suctioning is often glossed over in training, and providers don’t perform the procedure optimally. After all, dealing with phlegm can be a turnoff to even the most seasoned prehospital provider. But applying this procedure in a timely manner can significantly impact patient outcome when performed appropriately. However, it requires the provider to suction out the ET tube with a long suction catheter, rinse and flush the catheter with sterile water or saline, and repeat the tube suctioning until the airway is cleared. This suctioning, if not performed correctly, can put the patient at higher risk for pulmonary infection and, in a way, the prehospital clinician also is placed at some increased risk through performing the procedure in a suboptimal manner, including potential exposure to infectious disease if personal protective equipment isn’t worn properly.

While it may be difficult to trace a patient’s new infection back to EMS management, this possibility speaks to the need for ET suctioning to be performed in as sterile a technique as possible. Indeed, with the increasing resistance of infections to antibiotics—and the potentially devastating consequences of pneumonia, in some patients—the need for prehospital personnel to use all appropriate precautions with such procedures is emphasized.

One suggested solution to patient suctioning would be to use an enclosed suction device such as a Ballard device, where the catheter is enclosed in a sterile plastic bag. Not only could the use of this device promote the use of suctioning—and doing it correctly—it may also decrease the risk of ventilator-associated pneumonia (VAP). Indeed, the development of VAP can be responsible for longer hospital stays, clinical events that may not be reimbursable under various guidelines. So, when an advanced airway device is placed in the prehospital environment and the patient develops VAP, the question becomes: Was EMS a contributing factor?

Another treatment that’s been shown to reduce hospital stays, and therefore reduce costs, is the proper use of continuous positive airway pressure. Prevention of a problem is always better than treating a problem. Although it may be easier, or even preferable, for some providers to sedate a patient and “drop a tube,” patients intubated in the field may stay in the hospital up to twice as long as non-intubated patients, and up to 50% of these patients may develop VAP with a dramatic increase in morbidity and mortality.2

The Treatment Chain

The real question is this: Can EMS effectively treat a patient without interfering with the next provider in the treatment chain? The answer is a guarded “yes” with this caveat: The problem that you know about—that you’re prepared to take action on—should be a problem you can manage.

Under the Accountable Care Act, hospitals are being held more accountable than ever before for patient outcomes, and are being measured by patient satisfaction scores.3 The charges for procedures by hospitals are under increased scrutiny. Moreover, if a patient’s condition worsens while in the hospital from hospital-acquired problems, such as the development of a nosocomial infection—a problem, incidentally, that may have been caused in part due to prehospital treatment—the hospital may not be allowed to bill for the additional care or increased length of stay in the hospital. In addition, the in-hospital care rendered is compared against the care given at similar facilities in the locale and across the country.

Why it Matters

Aside from the consideration that any one of us or a family member may be hospitalized, why should EMS care about the impact of the ACA on the hospitals?

First, we should all be concerned about the skyrocketing cost of healthcare. Second, EMS personnel must be aware that their actions may place an increased financial burden on both the hospital and the patient. It must be remembered that EMS is part of a larger system of healthcare: EMS is not the healthcare system by itself.

EMS is now a recognized physician subspecialty. The prehospital phase of evaluation and management has assumed its rightful place in the overall care of patients, from field to hospital to rehabilitation to home. EMS patients aren’t treated in a vacuum, away and separate from other patients received in the hospital. EMS is no longer a “separate system,” but rather the rightfully designated “prehospital medical care component of the medical system.” And finally, with the enormous growth and popularity of community paramedicine—and with severe EMS medical emergencies making up a smaller percentage of overall responses—EMS will be expanding its role in the overall care of the patient in the out-of-hospital arena in ways that we can only dream about today.

Conclusion

Prehospital providers are under constant examination for their rendered care now more than ever. EMS medical directors, clinical educators, receiving hospital providers and prehospital providers must prospectively plot strategies to reduce incidents of post-treatment infections, decrease complications, and work to decrease morbidity and mortality. The future is now, and EMS systems must accept their role as system caregivers, while avoiding being the potential source of patient treatment complications. To achieve this target, EMS systems must be proactive, becoming problem solvers as part of an innovative and concerned healthcare agency.

References

1. Dasta J, McLaughlin T, Mody S, et al. Daily cost of an intensive care unit day: The contribution of mechanical ventilation. Crit Care Med. 2005;33(6):1266–1271.

2. Koenig SM, Truwit JD. Ventilator-associated pneumonia: Diagnosis, treatment, and prevention. Clin Microbiol Rev. 2006;19(4):637–657.

3. DewBerry CM, Rose S. (July 2010.) Hospital Medicare reimbursement: Moving to reimbursement based on quality of care. Washington Healthcare News. Retrieved Jan. 15, 2015, from www.wahcnews.com/newsletters/whn-gsb0710.pdf.

Resources

• Mansoor AF, von Hagel Keefer LA. (July 2002.) The dangers of immediate-release nifedipine for hypertensive crises. Pharmacy and Therapeutics. Retrieved Jan. 15, 2015, from www.ptcommunity.com/system/files/PTJ2707362.pdf.

• North Central EMS Institute. (n.d.) The community paramedic program—A new way of thinking. Community Paramedic. Retrieved Jan. 15, 2015, from www.communityparamedic.org.

• Wu F. (Oct. 5, 2010.) EMS officially recognized as an EM subspecialty. Academic Life in Emergency Medicine. Retrieved Jan. 15, 2015, from http://academiclifeinem.com/ems-officially-recognized-as-an-em-subspecialt.