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Twenty-First Century Patient Assessment

The past twenty years have been witness to many changes in field medicine. In response to a profession-wide commitment to evidence-based practices, EMS stakeholders have put forth extensive efforts to ensure that their education and training programs are grounded on solid principles.1–3

As the new century unfolds, methodologies based on dogma and tradition continue to be replaced with those substantiated by research, and validated by what are often dramatic improvements in patient outcomes.4

As a result, many significant aspects of EMS, ranging from cardiac resuscitation to trauma care, appear quite different now than at the end of the twentieth century. There are several examples of some of these new understandings, which can be categorized into three important changes in practice.

Photo by the National Highway Traffic Safety Administration
Instructors at Palomar College propose a new patient assessment framework that’s designed to be more intuitive, have a better flow in terms of what actually happens on scene and integrates evidence-based developments of prehospital patient care.

1. Circulation is of primary importance. Cardiac resuscitation protocols that provide for continuous, uninterrupted, high-quality chest compressions over considerations such as ventilation and advanced airway management have resulted in a marked increase in cardiac arrest survival, and, in particular, a significant increase in the proportion of patients discharged from the hospital neurologically intact post-cardiac arrest.5-7

Around the same time that these new approaches to cardiac arrest management were being examined, research from the austere environment was demonstrating the importance of immediate, aggressive hemorrhage control.3

Responding to data obtained from studies of military casualties, The National Association of EMTs (NAEMT) Tactical Combat Casualty Care (TCCC) course and TCCC guidelines designate bleeding control to be the primary consideration, ahead of airway management and breathing.

Building on this research, data collected from urban EMS systems demonstrated that tourniquet use, once considered verboten in all but the direst of circumstances, is an appropriate and safe routine intervention in the civilian setting. This finding has led to widespread implementation, with recommendations for further liberalized use.7-9

2. Teamwork is integral to successful outcomes. Beginning in the year 2000, aviation models of crew resource management were adapted for use in medicine, with a focus on communication and interactive teamwork.11,12 These same principles were considered during the development of team-based cardiac arrest resuscitation methodologies.

Research has demonstrated that clearly defined roles and an emphasis on leadership and delegation play a central role in realizing improved resuscitation outcomes.13,14

In 2017, the NREMT added a scenario-based component to their advanced level psychomotor examination. This new approach, known as the integrated out of hospital (IOOH) scenario, acknowledges the importance of leadership and delegation in the course of patient assessment, and paramedic candidates are now assessed on their ability to lead a team, vs. simply perform individual, discrete skills.

3. Field medicine is a profession. In sharp contrast to the dogma of the past (i.e., “EMS doesn’t diagnose”), the expectation is that today’s paramedics will treat patients based on a diagnosis formulated during the course of the patient assessment. This is an acknowledgement of the ongoing professionalization of paramedic-level care. Several states now require a college degree in order to attain a paramedic credential, and the trend toward requirements for higher levels of education is continuing.

A Need for Change

Whereas these principles have gained widespread acceptance, the basic format of the patient assessment model outlined in the National Education Standards (NES) and Instructional Guidelines for paramedic education has remained essentially unchanged since 1998.

The 1998 model specified that the assessment proceed in stepwise fashion, addressing priorities of care as they were understood more than 20 years ago. For example, the model mentions delegation, but doesn’t emphasize its importance, and acknowledges the paramedic as a healthcare team leader, without providing guidance as to what is and is not an appropriate scope of leadership. This current model, while exhaustive and comprehensive in terms of its content, isn’t pragmatically different from prior versions.

That the patient assessment curricula taught today remains essentially unchanged from the previous century begs the question as to whether or not there may be a better approach: Should we continue to teach and practice patient assessment based on a model that isn’t in alignment with much of what is now being done in the field?

Given the evidence validating factors such as leadership, delegation and interactive teamwork as being integral to successful outcomes in emergency medicine, the absence of emphasis on these considerations from the current NES model is significant, and is in conflict with the evidence-based principles upon which many important aspects of EMS are now based.

In addition, the current NES and NREMT models don’t consider one of the most critical aspects of maintaining circulation—bleeding control—until the primary assessment is well underway.

As such omissions and delays are at odds with the extensive research findings upon which the successes described above are founded, the answer to the question as to whether or not we should look toward the development of a new model for paramedic education and practice would appear to be an unequivocal “yes.”

Deficincies in Current Assessment Models

In January 2017, in conjunction with a study of patient assessment guidelines currently followed in San Diego County, I began an examination of patient assessment education in the San Diego region.

The goal was to bring our regional assessment guidelines into alignment with evidence-based practices that have driven successful outcomes. Moving beyond the initial considerations of bleeding control and team dynamics, four additional deficiencies were identified following observation of patient assessment simulations at Palomar College in San Diego County, in which an assessment model based on the current NES is followed:

  1. A lack of emphasis and specificity with respect to scene management;
  2. Non-patient contact components of the assessment aren’t separated from those that involve direct patient interaction;
  3. Patient exposure isn’t properly compartmentalized in a manner conducive to optimum performance; and
  4. History-taking doesn’t follow a standard medical model that allows for optimum working diagnosis formulation.

General Considerations of a New Patient Assessment Model

A new model for patient assessment was designed at our EMS training academy at Palomar College in response to the deficiencies within both the NES and NREMT models. The goal was not to discard existing assessment practices entirely, but to integrate evidence-based developments into both paramedic curricula and practice.

In the process of doing so, it became clear that simply adding new elements into the existing curriculum would further inflate an already information-intensive process.

Therefore, taking into consideration that the NES curriculum is already replete with discrete points of patient assessment, the objective became to create a framework that satisfied the need to address the concerns identified without creating an alternative encyclopedic algorithm.

Our faculty believes that the new model realizes this objective, is more intuitive, and has better flow in terms of what actually happens in a modern EMS environment.

The aim is to provide the paramedic with a concise interpretation of what both the NES and NREMT are trying to accomplish in terms of prescribing leadership and delegation, while integrating lessons learned from disciplines such as TCCC and resuscitation science.

All assessment models are based on priorities of assessment and care. Any fears about adopting a new model should be assuaged by first explaining that, in a macro sense, these priorities haven’t changed. Let’s take a look at the progression of the patient assessment in the new model:

Scene control:
As in the current model, the scene is addressed first. The new model acknowledges that a safe scene is the most important consideration upon arriving at a medical emergency, and expands management of the scene to include specific steps designed to create an optimum patient care environment.

Identification and correction of immediate threats to life:
The need to identify and correct immediate threats to the airway, breathing and circulation are still priority steps in patient care. In the new model, the primary assessment is streamlined to be exclusively devoted to assessing and acting on these considerations through removing components that don’t involve direct, hands-on involvement.

History, physical exam and vital signs:
The secondary assessment consists of a thorough history taking, physical examination and vital signs assessment. In the new model, technical tasks are assigned during this phase of the assessment via delegation to the healthcare team, thereby optimizing use of resources and allowing important assessments and interventions to be performed quickly and efficiently.

Treatment and reassessment:
Patient reassessment is the last phase of the assessment. Renamed “treatment and reassessment,” this phase of patient care begins with a working diagnosis based on the information and findings obtained during the primary and secondary assessments and concludes with reassessment for improvement or deterioration.

Overview of the New Patient Assesssment Model

In light of these similarities, I will address what’s different about the new model, and why it represents a new approach to patient assessment in three key areas.

1. Leadership, delegation and interactive teamwork:

The NES model prescribes that assessment and treatment be carried out in a linear format, with only vague mention of the need for leadership and delegation. This allows for wide latitude of interpretation in terms of leadership; the paramedic is free to delegate in a haphazard fashion, or the paramedic can perform all assessment and care in a sequential manner, providing no leadership whatsoever. No specific direction is provided as to what should or shouldn’t be delegated.

Although the NREMT further advances the role of the paramedic as a team leader through having implemented the IOOH scenario, the example portrayed in a current NREMT video promoting the IOOH scenario portrays a team member conducting an inefficient assessment, with questionable technique and providing incomplete information to the paramedic. The paramedic neither corrects the team member nor asks for clarification.

By contrast, the new model was constructed within a framework of interactive teamwork consistent with the model followed by modern emergency healthcare teams. As such, delegation with competent performance by all members of the team isn’t simply an option, it’s a prerequisite for an efficient and thorough assessment.

Furthermore, specific tasks are required to be delegated during the course of the secondary assessment. In recognition of the professionalization of ALS providers, there’s an acknowledgement of the paramedic as a healthcare team leader throughout the entire assessment; the paramedic is responsible for ensuring that all assessment is performed properly and all information obtained is accurate and complete.

2. Appropriate compartmentalization of the different assessment components:

At present, the NREMT patient assessment model prescribes consideration of stabilization of the patient’s cervical spine as the final element of the scene size-up.

Although this is certainly an appropriate early consideration in terms of patient care, incorporation of spinal stabilization into an evaluation of the scene is non-intuitive and unnecessarily dilutes scene safety and management with non-scene specific considerations.

Also at present, patient exposure is found toward the end of the primary assessment in both the NES and NREMT models. Neither of these placements lend themselves to an emphasis on, or understanding of, just how important removing clothing is in terms of being able to apply equipment, follow best practices in taking vital signs, or perform an optimum physical exam—all of which occur during the secondary assessment.

The experience at Palomar College, in which groups of students were instructed to consider exposure as the first priority of the secondary assessment, rather than as one of the last priorities of the primary assessment, led to more consistent patient exposure and to greater ease and efficiency in performing secondary examinations.

In sum, the new model compartmentalizes the assessment components within three distinct phases of patient care: 1) scene control; 2) assessment; and 3) treatment/reassessment.

Non-patient contact components are separated from those that involve patient care, while still allowing vital aspects of assessment and treatment to be given priority consideration.

In addition, components that don’t involve direct, hands-on patient contact (i.e., “from across the room” observations) are separated from those that do (i.e., assessment of the level of consciousness).

Finally, components that lay the foundation for the steps that follow are designated as first steps of a given assessment category. In our experience, appropriate compartmentalization has at once simplified the assessment process and made for better understanding and prioritization, all while ensuring that patient assessment is practiced in a manner consistent with the significant advances we’ve seen in many other aspects of EMS.

3. Diagnostic emphasis:

In the course of obtaining a patient history, mnemonics such as SAMPLE are replaced with a simplified three-part open-ended history: 1) present illness; 2) general medical history (to include allergies and medications); and 3) a family, social and lifestyle history. The purpose of a more in-depth exploration of the patient’s history is to allow the paramedic to more fully explore the possible etiologies that inform the working diagnosis during the time the other team members are obtaining vital signs, applying ECG electrodes, providing BLS treatment such as oxygen therapy, and otherwise performing tasks delegated to them at the outset of the secondary assessment.

Specific Points of the New Model

In addition to the preceding general considerations, the following specific elements of assessment are introduced:

Scene size-up is expanded into the broader and more comprehensive phase known as scene control, with specific considerations provided. Establishing a safe scene is the first priority of scene control, followed by specific steps taken to create an environment most conducive to patient care and extrication:

  • The EMS unit should be positioned to allow for the most safe and efficient removal of the patient, and the outdoor environment should be controlled accordingly;
  • Floodlights should be used in order to illuminate the scene, if needed;
  • All obstacles should be removed from the path of entry and egress prior to making contact with the patient;
  • The area in the indoor environment should be well-illuminated;
  • Animals (overtly dangerous or not), need to be confined;
  • Entertainment media should be turned off;
  • Distractions, to include uninvolved bystanders, should be removed; and
  • The area around the patient should be cleared of furniture and other impediments to patient assessment and treatment.

A preliminary assessment category is introduced. Designed to be a prior-to-contact, “from across the room” evaluation of the patient, this new category precedes the primary assessment and addresses three points:

  1. Recognition and control of severe hemorrhage: It’s not insignificant that many of the major changes that have taken place in emergency medicine follow from recognition of the need to maintain tissue perfusion. In response to substantial evidence proving that exsanguination is a greater threat to life than temporary airway or ventilation compromise,hemorrhage control is introduced as an immediate, first intervention as soon as the patient is visualized, rather than delaying this critical consideration until the airway, breathing and pulse have been evaluated. Upon visualizing the patient, the paramedic assesses for any severe bleeding and immediately delegates hemorrhage control, if indicated.
  2. Evaluation of mechanism of injury/C-spine control: The next step of the preliminary assessment is to evaluate for mechanism of injury, and to delegate immediate cervical spine immobilization, if indicated.
  3. Formulation of a general impression: The third and final step is to obtain a general impression of the patient’s condition based on behavior, work of breathing and appearance of the skin.

In creating a distinct, prior-to-contact category that immediately addresses critical patient care priorities, we at once allow scene control to remain separate from patient care considerations and allow the primary assessment to begin with patient contact.

Additionally, we become more immediately responsive to the needs of the critical patient. In allowing these evaluations to take place prior to patient contact, we both ensure that they’re given consideration with each patient encounter at the appropriate time and provide a more intuitive framework in which to perform them.

The primary assessment is streamlined and begins with patient contact. With considerations such as hemorrhage control, determination of mechanism/nature of illness, and the general impression already addressed, the primary assessment begins with hands-on patient contact and assessment of responsiveness/orientation.

For the conscious/responsive patient, airway, breathing and pulse are assessed simultaneously as questions are asked that establish orientation and chief complaint.

For the unconscious/unresponsive patient, pulse and breathing are assessed simultaneously and circulatory, airway and breathing interventions are initiated based on need. Finally, the patient’s status is determined: critical, emergent or non-emergent.

The secondary assessment is organized into four components. The secondary assessment begins with exposing the patient, followed by a thorough delegation to the team of tasks to be performed. While these tasks are being performed, the three-part patient interview takes place. The physical exam concludes the secondary examination.

  • Expose: The patient must be exposed in order to allow for complete and thorough inspection, palpation, auscultation and percussion of the body during the physical examination, as well as to permit the unimpeded application of ECG electrodes, proper application of blood pressure cuffs, and the establishment of IV lines and administration of medications. Moving this component from the final steps of the primary assessment to the first step of the secondary assessment emphasizes its importance as a first priority of this phase of the assessment, and thereby lays the foundation for the interventions that occur during the secondary assessment. This often neglected aspect of field care now has a position within the assessment model that’s more relevant to the process of applying equipment, and performing examinations will make exposure a more intuitive step—one more likely be followed.
  • Delegate: The paramedic’s delegation of assessment modalities and interventions brings a sense of inclusivity, reinforces the leadership dynamic and accomplishes a number of important tasks simultaneously in a short period of time. Everything from obtaining an ECG, providing oxygen therapy, measuring blood glucose and oxygen saturation, obtaining vital signs, and locating a patient’s medical records and medications can be performed by the team while the paramedic interviews the patient. In specifying delegation as a distinct component of the secondary examination—rather than simply allowing for non-specific tasks to be delegated—we encourage efficiency and team dynamic.
  • Interview: The interview represents an expanded approach to history taking. Mnemonics such as SAMPLE are de-emphasized in favor of a more subjective, open-ended history of the present illness (HPI), a general medical history to include allergies and medications, and a lifestyle, social, and family history, if applicable. This three-part process lends itself to being able to take more subtle aspects of the current condition and events involved into consideration. Delegation of tasks ensures the paramedic is no longer tied up with performing hands-on technical tasks and allows more time for a thorough exploration of that all-important aspect of the assessment that’s regarded as “80% of a diagnosis.” In addition, the history taking becomes more dynamic, as the HPI informs the questions to be asked with respect to the lifestyle, social and family history (i.e., family history of cardiac problems, smoking history).
  • Examine: Finally, the physical examination is conducted and incorporated into an overall review of systems, consistent with a medical model.
  • Treatment and reassessment begin with a diagnosis: The final step of the assessment is to integrate all of the findings and information into a field diagnosis, treat any conditions that haven’t yet been addressed, and reassess the patient for improvement/deterioration in level of consciousness, vital signs and changes in the chief complaint and/or other problems.

    Teaching & Implementing the New Assessment Model

    As the progression of the assessment remains essentially unchanged from the current model, learning the new model can be accomplished with minimal difficulty. Scenario-based simulations are suggested to achieve competency. (See Figure 1 or download a PDF of Figure 1 for a visual guide/overview through the new assessment model.)

    The experience at Palomar College revealed a disconnect between students’ performance in the classroom, laboratory and simulation settings and their subsequent performance in the field. In particular, once students entered the field, scene control became very poor, delegation became underutilized, and patient exposure was performed in an incomplete/haphazard fashion.

    Any one of these omissions or deficiencies is sufficient to compromise patient assessment. When collectively integrated into every call on a frequent basis, they all but guarantee less than optimum patient care as a routine outcome.

    Although further study is needed to determine the source of the breakdown between the simulation environment and practice in the field, lack of familiarity with priorities of assessment and care on the part of precepting agencies can’t be ruled out.

    The simulation evaluation form is provided in order for instructors in the classroom and lab, as well as in the field, to have a reference that directly addresses these issues. (See Figure 2 or Download a PDF of Figure 2.)

    In creating a model that’s straightforward in its expectations with respect to these vital considerations, it’s hoped that we might begin to see better performance on both sides of the educational equation.

    Conclusion

    Emergency medicine’s most significant progress over the past 20 years isn’t reflected in any one practice or technique, but rather in an overall commitment to rigorously validated approaches that save more lives.

    It’s hoped that something as dynamic as a patient assessment model will be considered not as simply one more novel methodology, but rather as a new framework in which to provide treatment with greater efficiency and accuracy. In designing a process that’s congruent with the significant strides we’ve made over the previous two decades, the hope is to provide a better structure; one more conducive to realizing positive outcomes in the discrete domains in which we’ve seen dramatic improvements.

    With this new model, we at Palomar College are aiming to not only achieve this end, but also to lay the groundwork for revisiting the discipline of patient assessment from an epistemological standpoint in the coming years more frequently than has been done in the past.

    Acknowledgments: I want to thank Palomar College Paramedic classes 52, 53 and 54 for their contribution to the development of the new model. Their participation in simulation exercises utilizing the new model and their willingness to provide honest and unrestrained feedback about it’s strengths and weaknesses, speak as much to their character as it does to their commitment. I also want to thank Pete Ordille and Sarah DeSimone of Palomar College for allowing a new professor the freedom to challenge existing practices without restraint or fear of censure.  Finally, a “thank you” to Tom O’Connor and Andrew Dowd of Ventura College for their courage and for their unwavering support.

    Figure 1: Outline of a new patient assessment model for paramedics (Download PDF)
    Figure 2: Simulation evaluation form for new paramedic assessment model (Download PDF)

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