9-1-1 call comes in from a diabetic patient with altered mental status. EMTs respond to the scene, assess the situation and administer oral glucose to a sweaty, confused man. After a few minutes, his mental status returns to normal. He thanks the EMTs for coming out and convinces them he doesn_t require transport to the hospital. The emergency responders ask the patient to sign a release form, tell him to eat something and return to the station. Mission accomplished; nothing more to be done. Or is there?
An EMS crew is called for a 45-year-old woman complaining of severe leg cramping and inability to walk. By the time they arrive, the cramps have passed and the patient can walk. As part of their assessment, the EMS providers discover her BP is 165/100. They inform the patient of her high blood pressure reading and she acts surprised, saying she’s never had this problem before. They leave the patient at home and tell her to call her physician if the problem recurs. End of call. Could the EMTs have done more?”
Both of these scenarios probably sound familiar and, in fact, more could have been done. In the first scenario, the patient could have also received written, detailed after-care instructions specific to diabetic patients. In the second case, the patient could have received a written, personalized alert about her high blood-pressure reading, including follow-up steps to take. Written after-care instructions can be a vital addition to the patient-care toolkit of EMS personnel. Providing written instructions is routine in hospitals and emergency departments (EDs). Perhaps it’s time for EMS to embrace the practice as well.”
Why After-Care?
Benefits of an after-care instruction program include a possible reduction in future 9-1-1 calls. For example, some studies indicate patients are often unaware of how to best take care of themselves following a hypoglycemic episode, particularly when it comes to adjusting insulin dosages, food intake and exercise. This leaves patients vulnerable to recurrences requiring additional EMS care. Further research has shown that only about half of patients follow up with a physician following a hypoglycemic event.”
For some patients, EMTs and paramedics are the only link to the health-care system and the only source of after-care information. Another strong benefit of an after-care instruction program is the reduction in EMS out-of-service time due to non-transport of stable patients.
When applying an after-care instruction protocol, however, it_s important to use specific inclusion/exclusion criteria to ensure appropriate medical care and prevent adverse events. Certain circumstances necessitate automatic patient transport versus the treat-educate-release method. Patients who are elderly, children, patients with symptoms that persist after treatment, patients who use oral hypoglycemic medication, and patients with any additional complicating factors should not be considered for this protocol.
After-Care for Common Calls
Hypoglycemia: “The hypoglycemic episode is only one of many possible medical emergencies during which patients could benefit from receiving after-care instructions. Diabetes-related hypoglycemia is a frequent call for EMTs and paramedics. In King County, Wash., this type of medical emergency occurred 2,103 times in 2006, and 67% of patients were left at the scene.”
EMS personnel have an opportunity to increase the quality of care for a significant portion of hypoglycemic patients, especially those who are stable enough to not require further emergency care. Detailed after-care instructions could potentially prevent future 9-1-1 calls or visits to hospital EDs and they could reduce EMS out-of-service time.”
In King County, EMTs are trained to use glucometry devices and authorized to treat with oral glucose. They may leave hypoglycemic patients at home under the following circumstances:
- The patient fully recovers following oral glucose;
- The patient’s post treatment glucose is > 60 mg/dl;”
- Someone will be with the patient for another six hours.”
Paramedics are frequently called to treat hypoglycemic patients who are unable to swallow and require intravenous glucose. The paramedics are also authorized to leave those treated patients at home.”
Several studies have examined the benefits of after-care instructions for hypoglycemic patients left at the scene after EMS evaluation. Typically, the instructions are as follows: remain with an adult and limit physical activity for six to 12 hours; eat something; refrain from drinking alcohol; contact the patient_s primary care physician concerning the event; and wake sleeping patients every two to three hours.
Instructions may also provide a list of post-incident symptoms to monitor, cues for when to seek additional medical care, and information on how to make adjustments in insulin if the patient is unable to reach their physician.”
In one study, researchers followed up with patients within 48 hours to assess their post-treatment outcomes and education. Of these patient encounters, 92% resulted in no further medical problems, and 5% of patients corrected minor complications on their own and didn_t require additional emergency care. In general, patients were satisfied with their care, felt they saved money through non-transport and favored the idea of treat-and-release as a permanent practice.”
High Blood Sugar & High Blood Pressure: “The Centers for Disease Control and Prevention (CDC) estimates 7% of Americans have diabetes and an additional 2% remain undiagnosed. Approximately one in three U.S. adults has high blood pressure, and nearly one-third of them don’t even know they have it.”
These two chronic health problems can pose serious complications, especially if the patient remains unaware and untreated. High blood pressure is a leading cause of heart disease and stroke. Diabetes can result in myocardial infarction, kidney disease, neuropathy and blindness.”
Through a program in King County, called “Supporting Public Health with Emergency Responders” (SPHERE), EMTs have an opportunity to help manage these two principal public health problems. EMTs routinely alert patients to findings of high blood pressure and high blood sugar. Blood pressure is measured routinely on virtually every patient and blood glucose is determined on selected patients. When blood pressure or blood sugar values are above the standard values (see Figure 1 p. 47), the patient is given customized written follow-up instructions.
Each alert is personalized for the patient, specifying:”
- their blood pressure or blood sugar measurements;
- how their numbers relate to normal ranges;
- possible complications of their condition;
- a recommendation for follow-up as soon as possible; and
- information on where they can find out more about hypertension or diabetes.”
In King County, EMTs provide approximately 500 high blood pressure alerts and 100 high blood sugar alerts every month.”
Immunizations & Elderly Falls: “Other opportunities for emergency responders to leave after-care instructions involve falls in the elderly population and immunizations. A study conducted in New York tested the effectiveness of such interventions in elderly adults. During calls, EMS personnel screened individuals at risk for falls, influenza and pneumococcal infections. Providers questioned patients about their history of falls in the past year, the presence of hazards in their environment (such as throw rugs) and whether they had received any recent immunizations. If EMTs identified a risk, they provided educational materials concerning the pertinent topic from the CDC. The patients_ physicians were also contacted to promote their involvement in a health maintenance intervention. Patients without primary care physicians were offered a referral during a follow-up telephone interview. Although promising in theory, results from patient follow-up showed a significant improvement only in pneumococcal immunization rates.”
Advantages
The main benefit of providing after-care instructions on scene is the potential for improving patient health care and quality of life. EMTs and paramedics encounter many individuals who might not have a primary care physician. Further, EMS personnel see a large percentage of the population, which constitutes a large number of people with possibly undiagnosed chronic medical problems.”
In addition to acute treatment, responders have a chance to participate in prevention and screening. They can look for problems that may not yet be apparent to patients. Dispensing after-care instructions may increase the potential that a patient will receive the necessary information to successfully care for their ailment.”
Implementation of these actions should be carried out through written and personalized patient instruction forms to help increase efficiency at the scene and provide consistent information a patient or caretaker can review later. Ultimately, these measures could decrease health-care costs by reducing the need for EMS in the long run.
Limitations
One significant drawback to providing after-care instructions concerns the rate of patient recall about having received such materials. In the confusion and disorder of the emergency response, individuals are likely to forget the information provided. But such a reality only reinforces the need to leave personalized, written instructions.”
Another potential limitation is that the alerts for high blood pressure and high blood sugar may raise anxiety with patients. To guard against this, we use terms like “possible” and “possibly” rather than say the patient “has” a “disease.”
Finally, implementation of an after-care instruction program requires extra time on scene. However, the few minutes needed to deliver instructions and counseling to a patient is short in proportion to the overall time spent on a call or future calls.”
Looking Forward
Current studies on providing after-care instructions are limited mainly to the medical issues discussed above. However, the possibilities for educational intervention can stretch to encompass several other medical emergencies. For instance, after-care instructions could be given for various lesser afflictions, such as asthma attacks, minor sprains, burns and wounds. Patients could easily learn to care for these incidents on their own with minimal guidance from EMS personnel.”
Patients who call 9-1-1 for chest pain could be given educational material on preventing and recognizing heart attacks. Prevention efforts could also be directed toward other issues, including tetanus shots, infant safety, etc.
Although the primary goals of emergency responders are acute treatment and patient stabilization, providing after-care instructions is an important service EMTs and paramedics can provide. Education is a secondary objective and should only be applied when the situation permits. To employ such protocols for many of the above situations, emergency responders will need to have additional training. Perhaps more importantly, though, they will need to view educating patients as an extension of their duties. Who else has such opportunity to perform these services and reach so many underserved individuals? Who better to take on that responsibility?“
Katherine Williams is a fourth-year medical student at the University of Washington School of Medicine. She’s currently interested in the fields of emergency medicine and pediatric cardiology; she will be applying for a residency position later this fall.”
Lindsay White, MPH, is a research assistant in the Medical QI section of King County EMS in Seattle, Wash. She has been working in the field of EMS since her graduation in 2006.
Michele Plorde, MPH, is the section manager for Strategic Planning and Data Management, EMS Division, Public Health-Seattle & King County. She has worked 12 years at the EMS Division in program development and evaluation.
Mickey Eisenberg, MD, PhD, is a professor of medicine at the University of Washington and medical program director for King County EMS. He_s an active researcher in prehospital resuscitation.
Acknowledgment: The authors wish to thank the emergency dispatchers, EMTs and paramedics of King County for their support of innovative EMS programs and ongoing commitment to the highest quality patient care.
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