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Proximity Based Care

Some time ago you probably read a post by Sam Ireland about how staying on scene can improve our time-to-intervention. If not, click the poop clock for a direct link.

There is another side to this coin.

I want you to imagine this familiar situation..

1. As you work through your treatment algorithm you reach a point where you will be pulling into the ER bay in 3 or 4 minutes. 2. Your patient is not critical but would definitely benefit from whatever comes next in your treatment pathway.

3. You mentally imagine the steps involved preparing and performing the procedure.

When adding this up in your head it can be easy to come to the conclusion that you will be there soon enough. You then realize that to do all of this that you would actually sit parked in the ER for several minutes.

Is it counterintuitive to think that staying in the ambulance parked in the ER could possibly benefit the patient?

In most cases when we come to the ER with an ALS patient requiring intervention we are shown right to a bed with registration waiting. The nurse takes report and the treatment seamlessly continues. You may even get a chance to speak with the physician or mid-level.

While this is the ideal scenario, we cannot rely on this 100% of the time. In some case we arrive at the ER with no beds available outside of triage, and all of the registrars tied up. Even if we are met with a nurse right away, there could still be a significant lag before the physician can put in orders for an intervention.

If we cut our treatment short just because we pulled into the hospital, we add a layer of stress and even a possible lapse in treatment.

The stress comes from a concerned nursing staff not having a bed right away and the contagious nature of stress. Since we took a few minutes parked in the ER bay, we can bring the stress level down by telling the charge “it's ok if we have to wait a minute or two, we have [insert treatments here] ongoing with plenty of time left.” Not to mention that the patient is benefiting from your more aggressive care in general.

This is especially true of pediatric patients my service transports. Our walk to the pediatrics department involves an elevator ride. This prolongs the difference in time of hospital arrival to time of hospital intervention significantly.

The paramedic profession was founded on the delivery of the ER to the patient’s house. When you frame it like this in your head we might end up causing a lapse in emergency department care just so it can be delivered in a different bed. We need to not short sell ourselves when it comes to the meaning and benefit of the interventions we do.

Please remember that this only applies to meaningful interventions. This would not be the approach I would take to the “S’s” (stroke, surgery, STEMI) that Sam talks about.

To help navigate this decision, a detailed map has been provided:

Notice how there is no complicated addition problem in the map. Shouting to your partner up front for an ETA to the hospital and adding up the time it will take to perform an intervention causes two problems.

1.This process allows rationalization for omission to take place, do not train your brain to do this!

2. It simply wastes time. In extreme cases this can cause a confirmation bias.You spent all your time thinking about this simple matter, so you “don’t have time”, so you never see the benefit of this strategy playing out.

I had the great pleasure of hearing some of the brightest minds in EMS speak this week at EMSWorld.

A medical director of a large progressive EMS system was asked what his transport times are as they pertain to an intervention. “It doesn’t matter” he replied. He then went on to say that 5 or 10 minutes for some patients is still too long and relying on the hospital was simply not good enough.

This was a common thread in several of the sessions I was fortunate enough to attend this week.

Just like Sam mentioned that a few minutes on scene pays dividends for patient care, not cutting treatment off for the sake of getting into the hospital sooner pays just as much.

-Ryan Bolger

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