ALS/BLS Handover

[EpiEMS]

Does your agency have standards or assessment requirements before a patient can be "downgraded" to BLS transport? I've only been in agencies where there is an ALS co-response or ALS resource assigned to all calls, and have seen various practices by various providers.

 

[DesertMedic66]

We have a county based protocol for the times when we have an ALS engine on scene and only a BLS ambulance responding. It’s a huge list on what kind of patients can and can’t be sent with just the BLS ambulance. If the patient falls outside then the ALS engine will either have to wait for an ALS ambulance to respond or the fire medic will have to rider in and provide all patient care.

If the ALS ambulance is already on scene then the downgrade process can not be utilized.

 

[EpiEMS]

If the ALS ambulance is already on scene then the downgrade process can not be utilized.

Presuming you usually (as per standard practice) get an ALS ambulance response?

 

[NomadicMedic]

We routinely run a medic in a chase truck with a transport unit that’s staffed by EMTs or AEMTs. There are downgrade protocols,but most of the time it’s a pretty obvious “not as reported” type of thing.

Our medics have to write a chart for any downgrade that that give to a mutual aid agency. If it’s our BLS truck, they write a downgrade statement in the BLS chart. We QA 100% of downgrades looking for anything inappropriate.

 

[DesertMedic66]

Presuming you usually (as per standard practice) get an ALS ambulance response?

Every 911 call gets an ALS ambulance until none are available or are extremely far away. Then a BLS ambulance can be sent.

We started utilizing EMD a couple of years ago but still haven’t transitioned to fully using it. All 911 calls still get an ALS fire engine and ALS ambulance. All EMD is used for right now is to determine a code 2 (normal driving) or code 3 (lights/siren) response. There are some issues right now between city fire departments and the county fire department so I wouldn’t be surprised if our EMD goes away.

 

[DrParasite]

in NJ: BLS can cancel ALS for any dispatch. Even questionable ones. if ALS arrives, perform a full assessment, and determine no ALS care is needed, they can triage the call back to the BLS crew for final disposition. There isn't really a checklist, but if ALS isn't going to be doing anything, do they really need to be there?

in NC: crews are typically Medic/EMT, and it's typically medic discretion for what the EMT will treat, and what the medic will treat. Again, if no ALS criteria, following an ALS assessment, the medic will drive to the hospital.

 

[CCCSD]

Every 911 call gets an ALS ambulance until none are available or are extremely far away. Then a BLS ambulance can be sent.

We started utilizing EMD a couple of years ago but still haven’t transitioned to fully using it. All 911 calls still get an ALS fire engine and ALS ambulance. All EMD is used for right now is to determine a code 2 (normal driving) or code 3 (lights/siren) response. There are some issues right now between city fire departments and the county fire department so I wouldn’t be surprised if our EMD goes away.

Wouldn’t removing EMD, a CA Standard of Practice, create all sorts of issues?
(Disclosure: I’m not a great fan of the road it leads dispatch down.)

 

[DesertMedic66]

Wouldn’t removing EMD, a CA Standard of Practice, create all sorts of issues?
(Disclosure: I’m not a great fan of the road it leads dispatch down.)

Really the only EMD that is pretty standard in CA is call takers who can guide callers to do basic first aid/CPR the whole other aspect of tiered responses and dictating response modes is not any sort of standard in CA and many entire systems do not have it in place.

The issue that we are having is county fire is using it to dictate code 2 vs code 3 responses but the other city fire departments are not. So all 911 calls that come in from a city fire department causes an automatic code 3 response. So any units we have assigned to code 2 calls will be diverted to the code 3 calls. This is causing county fire units to wait a long time before an ambulance arrives.

 

[CCCSD]

Thanks for the explanation on that. I guess NorCal is a bit smoother on this.
I was always taught that SoCal was the epitome of Fire Rescue though…

 

[DesertMedic66]

Thanks for the explanation on that. I guess NorCal is a bit smoother on this.
I was always taught that SoCal was the epitome of Fire Rescue though…

Fire based EMS is very popular in SoCal however when it comes to transporting that is a very different story. In many areas there is a contracted private ambulance company that handles all transports.

 

[EpiEMS]

We started utilizing EMD a couple of years ago but still haven’t transitioned to fully using it.

My first agency was like this -- left when they started to transition but it really...left much to be desired. I feel like EMD is harder than it looks to implement well!

in NJ: BLS can cancel ALS for any dispatch. Even questionable ones. if ALS arrives, perform a full assessment, and determine no ALS care is needed, they can triage the call back to the BLS crew for final disposition. There isn't really a checklist, but if ALS isn't going to be doing anything, do they really need to be there?

in NC: crews are typically Medic/EMT, and it's typically medic discretion for what the EMT will treat, and what the medic will treat. Again, if no ALS criteria, following an ALS assessment, the medic will drive to the hospital.

BLS can cancel ALS even when there's an ALS indication? No standard criteria?

I was always taught that SoCal was the epitome of Fire Rescue though…

 

[DrParasite]

BLS can cancel ALS even when there's an ALS indication? No standard criteria?

Yep... it's the provider's discretion. So when a paid FD ambulance was dispatched to an allergic reaction, and they administered an epi pen, they advised dispatch to cancel the ALS. When dispatch relayed the reason for cancellation to the paramedic fly car, the ALS unit decided to continue in, and the patient was an ALS patient to the hospital. but BLS can (technically) cancel ALS any time they wanted.

Now, don't misinterpret this as me saying there are BLS crews inappropriately cancelling ALS all the time; that was just a rare example. But it's not like there is a standard, other than ALS services will not be needed for the patient, which is subject to providers discretion.

BLS can also cancel ALS if they can be at the ED before ALS arrives, if they have an ALS patient.

 

[Akulahawk]

Personally, I think that any time you have a BLS transport unit on scene and they can transport a patient to an ED before an ALS transport/fly car can arrive on scene, the BLS unit should transport as staying on scene in that instance is delaying time to a more definitive care, regardless of the reason for the call. Back when I was very active in the field, the LEMSA specified a 10 minute load and transport time of 10 minutes for BLS units for ANY type of call, and beyond that, if ALS arrival was greater than transport time to the ED, BLS could transport. That allowed for quite a bit of flexibility in the system. Under normal circumstances, and the call was basically a non-RLS trip to the ED, BLS could transport. It's the RLS trips to the ED that the time limits kicked in. Quite literally, under those circumstances, BLS could transport ANY patient to the ED, regardless of acuity, because the system recognized that time to ALS was the important thing instead of requiring ALS transport to an ED. I've transported codes to the ED because I could get a patient to an ED in 3-4 minutes and ALS would have been >8-10 minutes out. I have also called for, and turned patient care over to, 911 ALS because they were the quicker option to ALS care. On one occasion, I called for a 911 response, got a Medic Supervisor, didn't get ALS transport, and ended up transporting the patient with the Supervisor... who was from a different provider from ours. This was in a system that wasn't set up for ALS fly-cars.

 

[Tigger]

We run Paramedic/EMT staffed ambulances and do not use specific criteria for which provider attends. It is expected that the paramedic observe the EMT's assessment if the EMT is leading the call. Paramedics can add their own assessments in or do it entirely themselves and then downgrade the patient to the EMT if they feel the patient does not require paramedic monitoring or treatment during transport. For instance we respond on syncope, patient receives an assessment that includes a 12 lead EKG, and is transported by the EMT after no findings are noted. In ESO we document both an "ALS Assessment" and an EKG in the flowchart by the paramedic. Our system used to really harp that if "you're suspicious enough to put the monitor on it's ALS," and found that paramedics were just not getting EKGs on borderline patients so they could BLS it under policy.

We have BLS ambulances in our system, they can respond to alpha level EMD coded calls only. There is some vital signs and symtology guidelines for requesting ALS (chest pain, severe dyspnea, umanagebale pain, etc). EMTs that work on these trucks go through field training on an ALS unit which is where they are supposed to learn when to call for an ALS ambulance. If they're close they just transport to the closest ED instead.

 

[VentMonkey]

My county’s ground providers are allowed to downgrade from ALS to BLS in the field, and also at ED handoff if it ties them up too long and they’re needed to go back in service. My understanding is that the in-field handoffs are rare and often impractical so they don’t happen as often as the protocols dictate.

The ground providers did recently implement fly-car ALS response, but I am unsure as to how it’s working out thus far. I do know they utilize EMD and a tiered response. This is in Central California, and to my knowledge pretty standard for The Central California Valley, this is not “SoCal EMS”. It isn’t perfect, but it is largely overlooked.

 

[EpiEMS]

Personally, I think that any time you have a BLS transport unit on scene and they can transport a patient to an ED before an ALS transport/fly car can arrive on scene, the BLS unit should transport as staying on scene in that instance is delaying time to a more definitive care, regardless of the reason for the call.

Totally makes sense - I think this is a foundational principle that every system ought to have. My closest ALS might be the hospital, in a phrase!

Our system used to really harp that if "you're suspicious enough to put the monitor on it's ALS," and found that paramedics were just not getting EKGs on borderline patients so they could BLS it under policy.

Troubling to see folks skell like that...bad consequence of a policy!

at ED handoff if it ties them up too long

That's interesting -- how do they monitor that these handoffs are appropriate?

 

[Tigger]

I dunno. If a paramedic does an adequate assessment with nothing found, what’s wrong with having EMTs attend? The same thing happens in the ED with different provider levels and the patient is still going to the ED in the ambulance. I encourage the paramedics to provide the most thorough assessment as possible. What they do with such information is of interest too, but first I want the assessment.

 

[VentMonkey]

That's interesting -- how do they monitor that these handoffs are appropriate?

https://kernpublichealth.com/wp-content/uploads/2023/09/ALS_BLS_Hosp.pdf

 

[EpiEMS]

I dunno. If a paramedic does an adequate assessment with nothing found, what’s wrong with having EMTs attend? The same thing happens in the ED with different provider levels and the patient is still going to the ED in the ambulance. I encourage the paramedics to provide the most thorough assessment as possible. What they do with such information is of interest too, but first I want the assessment.

Oh I'm totally in agreement with you, I just don't like to see people playing in the grey zone by not doing an assessment (the missed ECGs).

 

[Tigger]

Oh I'm totally in agreement with you, I just don't like to see people playing in the grey zone by not doing an assessment (the missed ECGs).

Nope. We no longer really have specific policies directing assessments, I think a good onboarding and then later QI is a better tool to address deficiencies.