What Gets ALS?

[medicsb]

In terms of what sort of treatment?

Far and away the most common over treatment is the "IV and monitor".

 

[EpiEMS]

Far and away the most common over treatment is the "IV and monitor".

Do you think this is primarily for billing purposes?

 

[DrParasite]

Do you think this is primarily for billing purposes?

or because it objectively states that ALS was needed? IE, if they didn't need IV and monitor, did they really need a paramedic (at least from an insurance reimbursement point of view)

 

[EpiEMS]

or because it objectively states that ALS was needed? IE, if they didn't need IV and monitor, did they really need a paramedic (at least from an insurance reimbursement point of view)

Oh, good point!

 

[medicsb]

Do you think this is primarily for billing purposes?

I think it's multifactorial. On some level I think it makes a paramedic feel like they're needed/useful - "since I'm here, might as well...". Part of it is that some think of it as a courtesy to the hospital. Of course you won't see EMS administrators discourage this since it does increase billing.,

 

[EpiEMS]

I think it's multifactorial. On some level I think it makes a paramedic feel like they're needed/useful - "since I'm here, might as well...". Part of it is that some think of it as a courtesy to the hospital. Of course you won't see EMS administrators discourage this since it does increase billing.,

Sounds reasonable to me. I hate to see people doing unnecessary procedures that have the potential for harm (prophylactic IVs come to mind) or purely for billing purposes. At the hospital level, do you chastise folks for doing unnecessary interventions?

At the end of the day, it's a systems issue stemming from a cultural issue ("I have the disco patch so I should do X, Y, and Z") and a business issue (revenue), I'd guess

 

[GMCmedic]

I dont care about billing, i just do what I think is right for the patient.

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[StCEMT]

I don't start IV's unless I am giving IV fluid or meds. The only prophylactic I do is for things like strokes or I suspect something bad could happen. Otherwise, if the nurses want one they can do it themselves.

 

[VentMonkey]

I don't start IV's unless I am giving IV fluid or meds. The only prophylactic I do is for things like strokes or I suspect something bad could happen. Otherwise, if the nurses want one they can do it themselves.

I'm going to have to respectfully disagree. While I understand the "over triage" perspective, I place locks in patients that "I" feel (IMO) would benefit from not just my meds, but perhaps an ED bed, lab work, or even a quicker "treat and street", or admission that much sooner.

Am I always right? Probably not, but I still like relying on my personal judgement, and clinical cues. In short, my thinking is the exact opposite:

If the nurses want to yank my IV, and send them to triage, that's on them.

My last ground shift we had a fall victim in tremendous shoulder pain who got an IV, and Fent. The patient was sent to triage by nurse ratchet, when we went back with another patient this patient was being discharged home with a humerus fx, but at least they were comfortable. My job was done, I could have cared less what this particular burnt out MICN thought, the patient was much happier than when we found her.

I realize this example yielded meds, but many don't. Sometimes the meds they may need aren't in my scope, nor do they fit a "check off" protocol box.

 

[StCEMT]

I still like relying on my personal judgement, and clinical cues.

While my initial post is my general rule, it isn't set in stone. This here is the ultimate deciding factor. I've withheld lines on people I'd prefer to start one on and started others on folks I didn't particularly want one for the quoted reason. Its rare that I go a shift without starting one.

 

[medicsb]

Sounds reasonable to me. I hate to see people doing unnecessary procedures that have the potential for harm (prophylactic IVs come to mind) or purely for billing purposes. At the hospital level, do you chastise folks for doing unnecessary interventions?

Chastise EMS? Or physicians chastising other physicians? Or whatever flavor? Depending on the procedure/intervention, yes people do get chastised in different ways. But, it depends on the circumstances and patient outcome or if any complaints.

EMS here is lucky in that they don't get much flack. Most docs and RNs just kind of accept the bad stuff they do as "the way it is" or because "they have a tough job". I typically only interact with EMS if the patient is potentially sick and I am evaluating the patient along with nursing. I try to give feedback when I can. I have reported crews for bringing in esophageal tubes.

 

[VentMonkey]

I don't think I've ever started an IV with "billing purposes" even crossing my mind.

 

[DesertMedic66]

I don't start IV's unless I am giving IV fluid or meds. The only prophylactic I do is for things like strokes or I suspect something bad could happen. Otherwise, if the nurses want one they can do it themselves.

This is what our county is having us do now. Even if we know the patient will get blood draws at the ED or will need an IV at the ED we do not start it unless we are going to use it for meds or fluids.

 

[StCEMT]

This is what our county is having us do now. Even if we know the patient will get blood draws at the ED or will need an IV at the ED we do not start it unless we are going to use it for meds or fluids.

What is their reason for it? I don't think people are really right or wrong either way in cases like this. Or does it have anything to do with having a low return on billing and trying to cut down on supply costs that isn't reimbursed?

 

[DesertMedic66]

What is their reason for it? I don't think people are really right or wrong either way in cases like this. Or does it have anything to do with having a low return on billing and trying to cut down on supply costs that isn't reimbursed?

Way to many medics who are in the mind set of "every patient gets an IV" and also long bed delays and a policy change on how those delays are delt with.

Per county protocol if we have a BLS patient (no IV) and are on bed delay for an extended period we can literally sit the patient on a chair and tell the nursing staff "hey guys, I'm leaving this guy here. Bye"

 

[NPO]

Redacted.

 

[GMCmedic]

Ive noticed a bit if a trend. Those that work in busier systems where the hospitals generally seemed overwhelmed are less likely to start an IV, presumably because the patient then cant go to triage or the waiting room.

Here the hospitals are typically aware of what complaints we will ALS and usually block off a few rooms for EMS. We still take patients to triage occasionally but most patients will get a room right away.

Of course the picture this paints is that patients get seen faster if they call an ambulance, but that is a topic for another day.

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[EpiEMS]

Chastise EMS? Or physicians chastising other physicians? Or whatever flavor? Depending on the procedure/intervention, yes people do get chastised in different ways. But, it depends on the circumstances and patient outcome or if any complaints.

EMS here is lucky in that they don't get much flack. Most docs and RNs just kind of accept the bad stuff they do as "the way it is" or because "they have a tough job". I typically only interact with EMS if the patient is potentially sick and I am evaluating the patient along with nursing. I try to give feedback when I can. I have reported crews for bringing in esophageal tubes.

I meant chastise EMS - sorry for the unclear language there! I see what you mean. It's unfortunate to hear that there are excuses made for bad EMS performance.

Those that work in busier systems where the hospitals generally seemed overwhelmed are less likely to start an IV, presumably because the patient then cant go to triage or the waiting room.

Practically speaking, does a saline lock - for example - really necessitate a patient getting a bed ASAP? I'm not entirely sure.

 

[agregularguy]

I meant chastise EMS - sorry for the unclear language there! I see what you mean. It's unfortunate to hear that there are excuses made for bad EMS performance.



Practically speaking, does a saline lock - for example - really necessitate a patient getting a bed ASAP? I'm not entirely sure.

I know we've sent a few out to triage with locks on. As long as you're not actively giving meds through it, why not?

 

[GMCmedic]

I wouldnt think so. When our hospitals do get overwhelmed its not unheard of for them to draw labs while in the waiting room.

For whatever reason its a big deal when patients walk out with an IV still in though

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