Fall Recertification Session CQI

CQI Issues from the desk of Steve t About Transfers t Documentation Issues t Trauma Triage Guidelines and Destination Determination t Learning from misteaks

Transfers t Increasing number of transfers of very ill patients from EDs t Crews have expressed concern re stability of patients t Who is responsible? What should we do?

Medical Responsibility t You assume care of all patients you carry on behalf of Dr. Welsford, our Medical Director unless the patient is escorted by a physician or nurse

t The sending physician is responsible for ensuring that the patient will receive adequate care during a transfer t YOU could also be responsible if you accept a patient that is obviously ill without questioning or asking for an escort t You are also responsible to ensure that that physician understands your scope of practice

t Ask for a report re patient’s condition t Examine the patient as appropriate for the complaints t At least one set of vitals at the scene is mandatory t Document assessment findings from when assuming care t If possibly unstable - consider contacting a BHP to consult about the patient

t Do NOT accept orders for ongoing care from sending physician or RN t Can use protocols if the patient fits parameters t Can contact a BHP and advise of wishes of sending physician

Contact a BHP Prior to Transfer To: t Discuss care for a patient while enroute/ receive orders for anticipated treatment t Receive orders to treat a patient as per the wishes of a sending physician t Express concerns about transferring an unstable patient

t Cannot administer a medication, perform a procedure or accept responsibility for equipment that you are not certified to use. t Some patients are responsible for their own medications / pumps / equipment t Some sending facilities could elect to send a patient recognizing that you are not taking responsibility (ie PICC line, capped off) t It must be clear that you are not accepting responsibility

Documentation Issues t Cancelled calls –CTAS scores –final primary problem –the majority of patients who refuse care will seek medical attention at a later date t Paperwork left with patient and /or at hospital

Documentation Issues t Heart Sounds –Not a required field –‘Normal’ is not a valid description unless you can comfortably describe each sound and identify what is abnormal –Heart sounds are relevant for VSA patients Present or absent is sufficient –Are not required for other patients and should not be documented unless you know what you are describing

Trauma Triage Guidelines t Know the guidelines, and document when used t Many concerns from receiving hospitals t Destination for trauma patients t Ultimately – get the patient to the right hospital t 30 minutes is a soft guideline

Ask for Air /Modified Scene Response if Appropriate t If you elect to take a trauma patient to a facility other than the Trauma Centre, –Ask CACC for an air response –Document request –Document reason for destination (> 30 minutes, uncontrolled airway)

Destination Determination t Destination for psychiatric patients t Overdoses t Dialysis patients

Learning from other’s misteaks t Patient with stab wound to chest t Appears superficial t No SOB, no subQ emphysemia t Patient refuses most interventions t Trauma Centre? t ACP or PCP?

Learning from other’s misteaks t A 30 year-old female patient c/o abdominal pain. t Treated and released, advised to come back if her condition worsens. t Approximately 3 hours later, calls back because her pain has worsened. t Transported again to the same Emergency Department

t Found to have an ectopic pregnancy, requires emergency surgery and almost dies. t Does not complain about her care in the Emergency Department on her first visit, despite the fact that a near-fatal condition was not diagnosed. t Does complain that the second paramedics were rude and disrespectful.

Walking patients t Several recent complaints t Patients with medical complaints, encouraged to walk to the stretcher t Complaints from family members t Investigations by MOH, Service Operators, Base Hospitals and Coroners.

Partner errors t What to do? t Your partner is acting as the primary attendant and about to make a patient care error t You believe the proposed tx not in patients best interest

QUESTIONS?