Typically, BLS/EMT care doesn’t have online medical control. However, in King County, Wash., a majority of EMS calls receive care only by EMTs—plus, approximately 20% of those patients aren’t transported and remain at the scene. Therefore, in order to establish a “safety net” for the EMTs handling these calls, King County began a program for EMT medical control.
King County serves a population of 1.3 million (excluding the city of Seattle) with a two-tiered EMS system called Medic One. The first tier consists of firefighter/EMTs and the second tier consists of paramedics.
The 9-1-1 dispatch centers in King County adhere to criteria-based dispatch guidelines, which indicate different levels of response for different types of calls. For example, EMTs are sent to all 9-1-1 medical calls, but paramedics respond to only about 30% of calls—those considered more critical. After evaluation and treatment, patients may be left at the scene.
For paramedics, the decision to leave the patient at the scene must be approved by the online medical control (MC) physician, but patients evaluated by only EMTs and deemed appropriate to leave at the scene traditionally don’t require online MC approval.
In April 2013, King County instituted the EMT Medical Control (EMTMC) program, which gave EMTs direct access to an online MC physician at an ED, and evaluated its utility. The program was implemented to serve as a safety net for EMTs so that the appropriateness of leaving a patient at the scene would be discussed with an MC physician. This report evaluates the first six months of the program, which had no cost to the fire departments.
The program area included four fire departments (Redmond, Kirkland, Woodinville and Duvall) within the Redmond Medic One ALS service area of King County. EMTs in these fire departments were required to consult with the EMTMC physician when the patient met the following inclusion criteria:
- Received EMT-level care only; and
- The EMTs’ initial plan was to leave the patient at the scene.
EMTs did not need to consult with the physician if:
- Paramedics evaluated the patient;
- The patient needed basic first aid to extremities only;
- The patient refused care before call to MC;
- The EMTs planned on transporting the patient; or
- It was a “citizen assist” call.
A citizen assist call is when a person needs assistance that doesn’t require any medical care, treatment or evaluation—for instance, if someone only needs the batteries of their wheelchair replaced or needs help getting back into bed or a chair.
If a patient was eligible for an EMTMC call, the EMTs on scene were required to contact EMTMC and provide the following information:
- EMT names, department and BLS unit number; and
- A short report of the patient’s presentation, including age, sex, chief complaint, history, vital signs, patient exam results, OPQRST/ SAMPLE (see Table 1) and their current plan to leave the patient at the scene.
After exchanging this and any additional information relevant to the patient’s condition, the EMTMC either concurred with the plan to leave the patient at the scene, requested an ALS evaluation on scene, or had the patient seen at an ED of the patient’s choice. EMTs were required to document this conversation and its outcomes on the patient care record (PCR).
The EMTMC program coordinator (a paramedic in the region) reviewed all PCRs to evaluate patient eligibility, protocol adherence and EMTMC consultation outcomes. All data was entered into a spreadsheet and analyzed after the program was completed.
During the six-month evaluation period, EMS responded to 7,112 total incidents in the service area. Of those, 721 (10%) patients met the eligibility criteria for the EMTMC program. EMTs called MC for 575 (80%) of the eligible patients.
In addition to compliance, EMT and MC agreement on whether the patient should be left at the scene was also evaluated. MC agreed with the EMTs’ decision in most cases (500, or 87%). MC decided to transport the patient to an ED in just 71 (9%) of the cases. The MC requested a paramedic evaluation for just four patients (two of whom were subsequently transported by EMTs to an ED). A few of these patients refused transport and signed an Against Medical Advice form. (See Figure 2 for details on patient transports.)
Two local EDs provided outcome data on the 38 patients (61%) who were transported there after the MC physician altered the EMTs’ decision to leave the patient at the scene. Outcome data on the remaining 24 patients who were transported other local EDs could not be obtained.
Just six (15.8%) of the patients were admitted to the hospital for 1–4 days. These patients were admitted and later discharged home with the following diagnoses: gastrointestinal bleed, acute cerebrovascular accident with a history of coronary artery bypass graft, pyelonephritis, chest pain and atrial flutter, feeding problems in a newborn, and dizziness with an abnormal CT scan. ED diagnoses varied in the remaining 32 patients, whose time in the ED lasted three hours on average.
The results of the six-month program highlighted three major points:
- Compliance in calling the MC physician;
- EMT and MC agreement; and
- The program’s role as a safety net.
Compliance: Involved EMTs provided positive feedback on the program; they felt it offered the opportunity to validate their decision to leave the patient at the scene. However, EMTs called MC for eligible patients just 80% of the time. One factor we believe likely affected compliance was the familiarity with the new protocol. The program was a change in patient care protocols for the EMTs in the region. We expect that with more time, familiarity will increase compliance. Unfortunately, we didn’t conduct a formal survey of EMTs to understand their barriers to compliance.
EMT and MC agreement: In 87% of the cases when EMTs called MC, MC agreed with the EMTs’ initial plan to leave at the scene. The remaining 13% of cases received recommendations for further evaluation either by ALS paramedics or at an ED.
Safety net: The six patients admitted to local hospitals had potentially critical discharge diagnoses. Without an MC consult, these patients would’ve been left at the scene. This demonstrates and confirms the benefit of the EMTMC program as a safety net for the patients whom EMTs wanted to leave at the scene and for the EMTs and EMS system as a whole.
It can be argued that an ED evaluation wasn’t necessary for those patients who weren’t admitted to the hospital. It’s also possible that the six critically diagnosed patients would’ve called 9-1-1 again or driven to the hospital on their own had they been left at the scene. However, these potential scenarios can’t be studied.
The EMTMC program allows EMTs to provide the best care possible to their patients. It adds another level of care and consultation that didn’t exist prior to its initiation. Although it can potentially add burden on the MC physician to provide consultation for additional patients, the pros outweigh the cons. The overall health of the community increases when hospitals and EMS are able to coordinate their efforts. Based on the results of this pilot, King County will continue to expand this program into other regions of the county.
For more information on this program, contact Bill Lyons at [email protected].