EMS-Hospital Continuity of Care

[Rialaigh]

More then once the I have seen the issue brought up of a lack of continuity of care from the EMS or first response system through admission to the hospital. I think there is a much greater loss of continuity of care for those admitted to the hospital then those who are just treated and released in the ER.

Specifically I would like some insight from the wiser members on here about how you guys think this lack of continuity is related to a lack of respect or independence for EMS.

What I mean by this is, for example, hospitals that pull all field lines if the patient is going to be admitted and replace them with their own. I see very little reason to pull a perfectly good line, that was likely done in as sterile as a fashion as it would have been in the ER, especially when many patients admitted into the hospital tend to be on the older side and more difficult sticks. I believe this simple fact leads to an increase in the number of central lines placed in the hospital and obviously an increase in infection rates.

I also think in the above scenario some of it is perceived as not being able to "trust" the line put in by EMS. I was reading the Seattle/King County thread and I believe someone mentioned that the hospital pulls any femoral lines they place in the field upon arrival to the hospital. I know of hospitals here that the ER physician extubates patients when a tube was placed in the field and then re intubates them shortly after arrival to the ER just to confirm placement instead of just getting a customary chest x-ray that will be done anyway after the doc intubates.


How do you think that this continuity of care and the seemingly lack of trust in EMS affects the ability of EMS providers to function independently. How does this affect patient care and outcomes (as well as hospital stay lengths). And which procedures or interventions do you think are reasonable for the hospital to "redo" when EMS brings a patient in and what do you think would be better leaving put if EMS has done it.


I would especially love to hear some input from a medical director (if anyone would feel like raising this issue with them). I find it hard to believe that the medical director is completely on board with the hospital redoing everything that EMS does (especially since many medical directors work as ER physicians as well).

 

[VFlutter]

I do not think it is a trust issue it is a fear issue. Even though you may be perfect with your sterile technique the prehospital environment is thought of as "dirty" compared to the hospital. With hospitals getting tracked on line and ventilator associated infections they are not going to take any chances.

Peripheral lines are questionable but I would definetly pull any central line placed in the field. CLABSI are a huge deal in the healthcare field right now and there is a push for reduction in numbers. ET Tubes are kind of a grey area but I guess you could make an argument for it.

Bottom line it doesn't matter how amazing your EMS staff may be, even if was an MD placing it in the field, the hospital will still view it as a potential for infection in which the blame and complications will fall soley on them.

 

[Christopher]

Bottom line it doesn't matter how amazing your EMS staff may be, even if was an MD placing it in the field, the hospital will still view it as a potential for infection in which the blame and complications will fall soley on them.

Provided I time/date my line and initial it on a lil sticker, they'll let it stay for the first 48 hours. Otherwise, I believe it gets pulled before going to the floor. This is of course if everybody plays by the rules.

 

[shfd739]

Hospitals here use and leave our lines for 24-48 hours if the person is admitted.

If our tube is good as verified with capnography, chest X-ray it stays. I have seen ER docs do a laryngoscopy to make sure it's thru the cords; but havnt seen a properly placed tube pulled.

 

[Rialaigh]

I do not think it is a trust issue it is a fear issue. Even though you may be perfect with your sterile technique the prehospital environment is thought of as "dirty" compared to the hospital. With hospitals getting tracked on line and ventilator associated infections they are not going to take any chances.

Peripheral lines are questionable but I would definetly pull any central line placed in the field. CLABSI are a huge deal in the healthcare field right now and there is a push for reduction in numbers. ET Tubes are kind of a grey area but I guess you could make an argument for it.

Bottom line it doesn't matter how amazing your EMS staff may be, even if was an MD placing it in the field, the hospital will still view it as a potential for infection in which the blame and complications will fall soley on them.

Is there any evidence that peripheral lines or central lines placed in the field have a higher infection rate then those placed in the hospital. Honestly I don't wonder if hospital lines end up with about the same number of infections but that the infections of those placed in the hospital are worse then the infections from those placed in the field (because of the types of bugs that float around the hospital).

I would have a hard time believing the infection risk is reduced by leaving a peripheral or central line for 24 hours and then replacing it with a hospital line as opposed to leaving it as if it were placed in the hospital.....why do it twice when you could do it once...seems like an increased risk of infection to do it again.

 

[Veneficus]

I think you misunderstand the point of some of this.

Before I address your specific issues, please let me fill you in on some background?

There is a difference between "clean" technique (sometimes called medically clean) and sterile technique as well as accepted deviation from sterile technique.

In order for something to be sterile, it must be kept in a specific environment and for a specific length of time. Many EMS agencies simply do not supply sterile equipment. (like actual sterile gloves) Many EMS providers do not even know how to don them. (we won't get into the philosophy of those in EMS who don't agree with them)

Many EMS agencies do not properly observe the experation dates of sterile equipment. Nor do they carry sufficent quantities of betadine or other actual sterilizer.

As such, field procedures are "clean" procedures, not sterile ones. Sometimes this is acceptable in the interest of emergency care. In the hospital, clean procedures are often redone sterile in the ICU, surgery, or the ward immediately upon admission. Foley's, IV/IO lines, tubes, nothing is sacred.

In addition to immediate infection control, it permits timely replacement, and helps identify the exact organisms in the event of infection.

Sometimes the prehospital and ED procedures are not optimal for the patient. For example IVs in joints of a pregnant lady. Chances are she is going to bend said joint and occlude or infiltrate the IV. Sometimes the line is not optimally placed for the various aspects of patient care and relocating it can be more beneficial.

Now then...

More then once the I have seen the issue brought up of a lack of continuity of care from the EMS or first response system through admission to the hospital. I think there is a much greater loss of continuity of care for those admitted to the hospital then those who are just treated and released in the ER.

Anytime you have a handoff, there is loss of continuity. This is one of the reasons after working in a system where EM is not a specialty, I was convinced the EM specialty and its staffing of EDs is not only less than optimal, it is outright inhibiting patient care as well as adding costs that aren't really required. (those who have never operated in an environment and those with a financial interest will disagree, but the best evidence they can cite is admission rates from EDs at a time when ED duty was basically punitive for underperformers in other services but that is really a seperate topic. I will concede in the current US system, the EM controls access to care)

Specifically I would like some insight from the wiser members on here about how you guys think this lack of continuity is related to a lack of respect or independence for EMS.

The lack of respect is actually multifactorial. I would say the biggest problem is EMS refuses to change traditional treatments that donn't work. Look at what we go through on this board every few weeks on supplemental oxygen and spineboards. Ask many of the members of archaeic practices at their organizations.

The second biggest issue is EMS often doesn't know why it is doing what it does. Which leads to all kinds of treatment errors. In all other disciplines of medicine, performing a treatment not indicated is a medical error. While some level of overtreatment is going to be required in the emergency environment, in both the US ED and EMS, no effort is made to control it. The threat of litigation causes "defensive medicine" which is bad for the patients and bad for the system in multiple ways. Plus it is almost religious, people believe if they do it, they will miraculously be saved and ascend to heaven...Err I mean magically be protected from an overzealous personal injury lawyer.

The third is often talked about here too. Education. EMS providers don't have enough for modern medicine. There have been more advances in medicine in the last 16 years now than in the entire history of the world. There is simply more to know. But EMS is largely still operating on medicine from the 1980 and 1990s, with some treatments with no evidence dating back to the 1600s. So many things that seem like basic knowledge to educated providers is totally lost on US EMS providers. It is like watching kids try to do something professionals do. It is cute, but only for so long, and certainly not when you are tired or stressed.

Fourth. Some of the treatments EMS initiates actually make it harder for providers down the line to get better outcomes.

Finally, EMS gives no respect and not coincidentally receives none. Even here you can see examples of how EMS providers speak poorly of physician specialties they have no idea about. According to them everyone from PCPs to Ob?Gyn know nothing of how to treat emergent patients. Despite them doing so all the time and often teaching EMs parts of their field.

1.What I mean by this is, for example, hospitals that pull all field lines if the patient is going to be admitted and replace them with their own. I see very little reason to pull a perfectly good line, 2.that was likely done in as sterile as a fashion as it would have been in the ER, 3.especially when many patients admitted into the hospital tend to be on the older side and more difficult sticks.4. I believe this simple fact leads to an increase in the number of central lines placed in the hospital and obviously an increase in infection rates.

1 and 2.I talked about this. It was not done in a sterile fashion very often neither are the ones done in the ED. Simply having a line does not make it a good one.

3.Hospital providers are very skilled at their jobs, seeing many more patients in a given shift than most EMS providers do and for longer.

4. You would be mistaken about the central lines. Central lines have indications, and there are many more alternatives for peripheral access, such as ultrasound guided peripheral IVs.

I also think in the above scenario some of it is perceived as not being able to "trust" the line put in by EMS. I was reading the Seattle/King County thread and I believe someone mentioned that the 1. hospital pulls any femoral lines they place in the field upon arrival to the hospital. 2.I know of hospitals here that the ER physician extubates patients when a tube was placed in the field and then re intubates them shortly after arrival to the ER just to confirm placement instead of just getting a customary chest x-ray that will be done anyway after the doc intubates.

1. and they should. With the proliferation of IOs, there is really no prehospital indication for a central line. Since EMS doesn't carry blood usually, and all of their meds are designed for peripheral administration, the only reason I can see this done is to prove they can.

2. Going back to that sterile topic. ETI bypasses significant defense mechanisms against infection. The non clean conditions they are often placed in introduces pathogens past those defenses. The more often the tube is changed, the better. Especially replacing a field tube. (how often have we set those tubes on a patient instead of having another provider hand it to us from the package?) It also has the added benefit of making sure the physician maintains his skill competency.

Chest xray is one way to confirm a tube, we do not xray every patient tubed in surgery or the ICU.

How do you think that this continuity of care and the seemingly lack of trust in EMS affects the ability of EMS providers to function independently..

First, many of these issues is not lack of trust. It is misperception of lack of trust by undereducated and/or providers who do not understand hospital medicine and what happens there.

How does this affect patient care and outcomes (as well as hospital stay lengths). And which procedures or interventions do you think are reasonable for the hospital to "redo" when EMS brings a patient in and what do you think would be better leaving put if EMS has done it..

I think that these preventative measures improve outcomes. Following strict guidlines, some hospitals have acheived 0 (zero) infections for central line placement in a year. That demonstrates in reality the theory that they can be eliminated is sound. Intrahospital systems are constantly and actively under revision to make practices better. How often are EMS protocols even reviewed? How often are operations changed prior to a mishap? In my experience, almost never.

I think it is in the best interest of the patient for the hospital to redo all field procedures. I am not so sure it has to be redone in the ED and then again when the patient arrives in the ICU or ward. It could just be done at the destination, not in the ED as well.

I also think it is in the best interest of the patient for the ICU or ward to redo all ED procedures. Especially IOs, tubes, and central lines.

I would especially love to hear some input from a medical director (if anyone would feel like raising this issue with them). I find it hard to believe that the medical director is completely on board with the hospital redoing everything that EMS does (especially since many medical directors work as ER physicians as well).

The authority for these changes supercedes EMS medical control. Every ward, every specialty has a medical director. Dictating best practices in their respective arena. Hospital administration is responsible for costs, both making and losing money, without money no hospital or system can exist. They also have authority over what happens. In the hierarchy of medicine, EMS medical director is often "the big boss" to medics, but a minor player in the hospital outside of the ED. They are also easily overruled by services that admit.

The easiest step for EMS to fix this is to spend some time in the hospital following patients through their journey through it. Would be better if they actually spent some time working there in a tech capacity.

Another solution is to increase education to at least the level of the rest of the modern world.

Maybe just not perform "emergency" treatments thinking short term, that makes the patient worse over the long term?

Maybe give some credit to the knowledge of medical specialists outside of EM?

Maybe realize that "field medicine" doesn't exist and stop doing things without concern for what everyone else has to do? You'd be suprised how much positive effect EMS providers can have on patients setting them up for the next step instead of treating them based soley on now.

 

[RocketMedic]

Before I address your specific issues, please let me fill you in on some background?

There is a difference between "clean" technique (sometimes called medically clean) and sterile technique as well as accepted deviation from sterile technique.

In order for something to be sterile, it must be kept in a specific environment and for a specific length of time. Many EMS agencies simply do not supply sterile equipment. (like actual sterile gloves) Many EMS providers do not even know how to don them. (we won't get into the philosophy of those in EMS who don't agree with them)

Many EMS agencies do not properly observe the experation dates of sterile equipment. Nor do they carry sufficent quantities of betadine or other actual sterilizer.

As such, field procedures are "clean" procedures, not sterile ones. Sometimes this is acceptable in the interest of emergency care. In the hospital, clean procedures are often redone sterile in the ICU, surgery, or the ward immediately upon admission. Foley's, IV/IO lines, tubes, nothing is sacred.

In addition to immediate infection control, it permits timely replacement, and helps identify the exact organisms in the event of infection.

Sometimes the prehospital and ED procedures are not optimal for the patient. For example IVs in joints of a pregnant lady. Chances are she is going to bend said joint and occlude or infiltrate the IV. Sometimes the line is not optimally placed for the various aspects of patient care and relocating it can be more beneficial.

Now then...



Anytime you have a handoff, there is loss of continuity. This is one of the reasons after working in a system where EM is not a specialty, I was convinced the EM specialty and its staffing of EDs is not only less than optimal, it is outright inhibiting patient care as well as adding costs that aren't really required. (those who have never operated in an environment and those with a financial interest will disagree, but the best evidence they can cite is admission rates from EDs at a time when ED duty was basically punitive for underperformers in other services but that is really a seperate topic. I will concede in the current US system, the EM controls access to care)



The lack of respect is actually multifactorial. I would say the biggest problem is EMS refuses to change traditional treatments that donn't work. Look at what we go through on this board every few weeks on supplemental oxygen and spineboards. Ask many of the members of archaeic practices at their organizations.

The second biggest issue is EMS often doesn't know why it is doing what it does. Which leads to all kinds of treatment errors. In all other disciplines of medicine, performing a treatment not indicated is a medical error. While some level of overtreatment is going to be required in the emergency environment, in both the US ED and EMS, no effort is made to control it. The threat of litigation causes "defensive medicine" which is bad for the patients and bad for the system in multiple ways. Plus it is almost religious, people believe if they do it, they will miraculously be saved and ascend to heaven...Err I mean magically be protected from an overzealous personal injury lawyer.

The third is often talked about here too. Education. EMS providers don't have enough for modern medicine. There have been more advances in medicine in the last 16 years now than in the entire history of the world. There is simply more to know. But EMS is largely still operating on medicine from the 1980 and 1990s, with some treatments with no evidence dating back to the 1600s. So many things that seem like basic knowledge to educated providers is totally lost on US EMS providers. It is like watching kids try to do something professionals do. It is cute, but only for so long, and certainly not when you are tired or stressed.

Fourth. Some of the treatments EMS initiates actually make it harder for providers down the line to get better outcomes.

Finally, EMS gives no respect and not coincidentally receives none. Even here you can see examples of how EMS providers speak poorly of physician specialties they have no idea about. According to them everyone from PCPs to Ob?Gyn know nothing of how to treat emergent patients. Despite them doing so all the time and often teaching EMs parts of their field.



1 and 2.I talked about this. It was not done in a sterile fashion very often neither are the ones done in the ED. Simply having a line does not make it a good one.

3.Hospital providers are very skilled at their jobs, seeing many more patients in a given shift than most EMS providers do and for longer.

4. You would be mistaken about the central lines. Central lines have indications, and there are many more alternatives for peripheral access, such as ultrasound guided peripheral IVs.



1. and they should. With the proliferation of IOs, there is really no prehospital indication for a central line. Since EMS doesn't carry blood usually, and all of their meds are designed for peripheral administration, the only reason I can see this done is to prove they can.

2. Going back to that sterile topic. ETI bypasses significant defense mechanisms against infection. The non clean conditions they are often placed in introduces pathogens past those defenses. The more often the tube is changed, the better. Especially replacing a field tube. (how often have we set those tubes on a patient instead of having another provider hand it to us from the package?) It also has the added benefit of making sure the physician maintains his skill competency.

Chest xray is one way to confirm a tube, we do not xray every patient tubed in surgery or the ICU.



First, many of these issues is not lack of trust. It is misperception of lack of trust by undereducated and/or providers who do not understand hospital medicine and what happens there.



I think that these preventative measures improve outcomes. Following strict guidlines, some hospitals have acheived 0 (zero) infections for central line placement in a year. That demonstrates in reality the theory that they can be eliminated is sound. Intrahospital systems are constantly and actively under revision to make practices better. How often are EMS protocols even reviewed? How often are operations changed prior to a mishap? In my experience, almost never.

I think it is in the best interest of the patient for the hospital to redo all field procedures. I am not so sure it has to be redone in the ED and then again when the patient arrives in the ICU or ward. It could just be done at the destination, not in the ED as well.

I also think it is in the best interest of the patient for the ICU or ward to redo all ED procedures. Especially IOs, tubes, and central lines.



The authority for these changes supercedes EMS medical control. Every ward, every specialty has a medical director. Dictating best practices in their respective arena. Hospital administration is responsible for costs, both making and losing money, without money no hospital or system can exist. They also have authority over what happens. In the hierarchy of medicine, EMS medical director is often "the big boss" to medics, but a minor player in the hospital outside of the ED. They are also easily overruled by services that admit.

The easiest step for EMS to fix this is to spend some time in the hospital following patients through their journey through it. Would be better if they actually spent some time working there in a tech capacity.

Another solution is to increase education to at least the level of the rest of the modern world.

Maybe just not perform "emergency" treatments thinking short term, that makes the patient worse over the long term?

Maybe give some credit to the knowledge of medical specialists outside of EM?

Maybe realize that "field medicine" doesn't exist and stop doing things without concern for what everyone else has to do? You'd be suprised how much positive effect EMS providers can have on patients setting them up for the next step instead of treating them based soley on now.

Vene, one of the most-used hospitals in my area is a teaching hospital. They've got capacity for everything and get quite a few of our critical patients. The only thing that I would say is that a few of their individual doctors are a little bit snide, unwilling to educate, and quite arrogant. One of their residents chewed me out over not intubating a GCS 8 maintaining-airway ETOH head bleed (simple reasoning I didn't- too active to take the tube, resisted nasal attempt, maintained his own airway quite well, nonvomiting, and last but not least, no etomidate or paralytics and only 10mg of Versed available). Honestly, I didn't feel like I could quickly or accurately place the tube, so I left it alone(and it worked fantastically). She then proceeded to break off both of his teeth and miss twice before placing the tube, to the point where one of our supervisors called me to confirm that I hadn't attempted to intubate.


I think that this is not an EMS area to correct, but that EM physicians should better QI their transfer-of-care procedures in terms of how changing interventions are handled. As you said, I don't see a huge reason to change an IO line in the ER when you know that patient is going to ICU and will simply be changed again. I don't get offended when my interventions are discontinued (except tourniquets, those are on there for a reason!). I do think that it is more appropriate to properly replace a tube (potentially wth a bougie or something to maintain placement) than it is to simply deflate, pull and reintubate.

Here's a question sort-of related: when receiving a transfer patient from another facility, are those patients interventions redone?

 

[Veneficus]

1.Vene, one of the most-used hospitals in my area is a teaching hospital. They've got capacity for everything and get quite a few of our critical patients. The only thing that I would say is that a few of their individual doctors are a little bit snide, unwilling to educate, and quite arrogant. One of their residents chewed me out over not intubating a GCS 8 maintaining-airway ETOH head bleed (simple reasoning I didn't- too active to take the tube, resisted nasal attempt, maintained his own airway quite well, nonvomiting, and last but not least, no etomidate or paralytics and only 10mg of Versed available). Honestly, I didn't feel like I could quickly or accurately place the tube, so I left it alone(and it worked fantastically). She then proceeded to break off both of his teeth and miss twice before placing the tube, to the point where one of our supervisors called me to confirm that I hadn't attempted to intubate.


2.Here's a question sort-of related: when receiving a transfer patient from another facility, are those patients interventions redone?

1.There are jerks everywhere.

2. very often their interventions have to be undone. But generally yes, they are redone.

 

[mycrofft]

My time actually working in an ER was limited, but much contact through case management as as an EMT. Also, limited but focused time working on a med-surg ward .

I can support all of Veneficus' points but let me put my twist upon it.

Between two cities and three years plus USAF, I served up pts to eight hospitals. Some I later did clinicals in. Each hospital had its own flavor and approach to their intake interface via PEMS (prehospital EMS).

From what I could see, ED's (then more like the true ER's) and field EMS depended upon the personalities of the ER docs and their boss docs, ER nurses, and the personalities of the field providers to shape and color their relationships.

Like any realtionship, every hurt leaves a scar lasting longer than the blush from a "Thank you" or a job well-done. Every verbal report disregarded, every chewing-out from anyone working there or on the rigs, every over-treated or under-treated patient (especially when they die) creates a scar and colors later relations. Every snide person, loud-mouthed person, etc just undercuts positive relations.

And consider the feedback loop. Bascially the ED complains about cases (especially when they feel a fatality wasn't their fault but the responder's), and from there the formal loop is either legal or administrative. It's a horseshoe, not a loop, and the broken part of the loop is the field people, especially responder staff, who get no say. Their agencies or companies might get no say as well.

There is no reason to feel bad because a higher care echelon removes your measures or rechecks your findings. You wouldn't accept a patient from a first-aider without rechecking and correcting/updateing care and history plus vitals. Same for further up the line.

If you can't forge relatonships with yor receiving facilities, then at least make like a swan in a hurry: be unflappable, keep on paddling. If you're steamed and something seems like a very satisfying thing to say to a receiving staff member, probably you ought to skip it. Be sure to invite feedback and give thanks and congratulations and ask professional questions.

And doughnuts.

 

[Aidey]

She then proceeded to break off both of his teeth and miss twice before placing the tube, to the point where one of our supervisors called me to confirm that I hadn't attempted to intubate.

BOTH of is teeth? As in the only 2 teeth he had left? :blink::blink::blink:

 

[mycrofft]

Vene, one of the most-used hospitals in my area is a teaching hospital. They've got capacity for everything and get quite a few of our critical patients. The only thing that I would say is that a few of their individual doctors are a little bit snide, unwilling to educate, and quite arrogant. One of their residents chewed me out over not intubating a GCS 8 maintaining-airway ETOH head bleed (simple reasoning I didn't- too active to take the tube, resisted nasal attempt, maintained his own airway quite well, nonvomiting, and last but not least, no etomidate or paralytics and only 10mg of Versed available). Honestly, I didn't feel like I could quickly or accurately place the tube, so I left it alone(and it worked fantastically). She then proceeded to break off both of his teeth and miss twice before placing the tube, to the point where one of our supervisors called me to confirm that I hadn't attempted to intubate.


I think that this is not an EMS area to correct, but that EM physicians should better QI their transfer-of-care procedures in terms of how changing interventions are handled. As you said, I don't see a huge reason to change an IO line in the ER when you know that patient is going to ICU and will simply be changed again. I don't get offended when my interventions are discontinued (except tourniquets, those are on there for a reason!). I do think that it is more appropriate to properly replace a tube (potentially wth a bougie or something to maintain placement) than it is to simply deflate, pull and reintubate.

Here's a question sort-of related: when receiving a transfer patient from another facility, are those patients interventions redone?

The ED staff are probably not responsible to anyone for what they say. And as Vene said before, the emergency sector was a place (and is a place) the less-socially adept doctors will tend to gravitaten or be sent. (NOT, not all!!).

Talk to your boss about how to handle these chewing-outs. It really can be a "hostile work environment" issue but the chastising staff member will think of it as "teaching"...which may be why they aren't teachers. Having been torpedoed by a rotten orienter once, I can appreciate that. See if your boss wants you to ask them to tell him their concerns, or if you are to just say "yessir", or what. (If the latter, either suck it up, or work away from that hospital).

And the hard point...maybe they have a point.

 

[Shishkabob]

What I mean by this is, for example, hospitals that pull all field lines if the patient is going to be admitted and replace them with their own. I see very little reason to pull a perfectly good line

Money. That's it. They get to bill for starting the IV and saying they did more.

There is no study that shows pre-hospital IVs are more prone to infections than hospital ones, yet there are a couple that have shown the opposite might be true. But infusion nurses are the ones making the noise about possible infections... even though 2 holes are more likely to cause an infection than just one hole.



As far as pulling ET tubes... if they can be confirmed as working and in place, there is no reason to pull them, and infact pulling them increases risks, such as the patient having been a difficult airway, tracheal swelling, or inducing / furthering tracheal trauma.

I would especially love to hear some input from a medical director (if anyone would feel like raising this issue with them). I find it hard to believe that the medical director is completely on board with the hospital redoing everything that EMS does (especially since many medical directors work as ER physicians as well).

And that's probably the biggest part of it. At a place like mine, where my medical directors work at the 2 biggest trauma centers, and most of the other ER physicians have done some sort of ride time with us, partake in protocol creation, or have a direct relationship with the medical directors, they know what we are expected to do to work as independent providers at the agency, and know what our limitations are, therefor less likely to question what we did.

 

[mycrofft]

" At a place like mine, where my medical directors work at the 2 biggest trauma centers, and most of the other ER physicians have done some sort of ride time with us, partake in protocol creation, or have a direct relationship with the medical directors, they know what we are expected to do to work as independent providers at the agency, and know what our limitations are, therefor less likely to question what we did."

SWEET!

 

[Rialaigh]

Money. That's it. They get to bill for starting the IV and saying they did more.

There is no study that shows pre-hospital IVs are more prone to infections than hospital ones, yet there are a couple that have shown the opposite might be true. But infusion nurses are the ones making the noise about possible infections... even though 2 holes are more likely to cause an infection than just one hole.



As far as pulling ET tubes... if they can be confirmed as working and in place, there is no reason to pull them, and infact pulling them increases risks, such as the patient having been a difficult airway, tracheal swelling, or inducing / furthering tracheal trauma.




And that's probably the biggest part of it. At a place like mine, where my medical directors work at the 2 biggest trauma centers, and most of the other ER physicians have done some sort of ride time with us, partake in protocol creation, or have a direct relationship with the medical directors, they know what we are expected to do to work as independent providers at the agency, and know what our limitations are, therefor less likely to question what we did.

This was my understanding (limited at best) of these situations. Vene however seems to think that pulling or redoing everything is in the best interest of the PT (whether it is in the ER, a procedural area, or the floor).

This is where I think a great debate is.

What do the studies show about EMS lines, tubes, or otherwise invasive procedures, causing infections in the field (rate and severity) compared with the infection rate in a hospital by redoing the same procedure over again.

It really makes no sense to me to place a perfectly good IV that will be in the PT's arm for 12-24 hours only to have it pulled 48-72 hours early because it is a "ems" iv. Wouldn't the risk of infection through that IV after 12-24 hours be close to zero if an infection has not already popped up? Seems like all we are doing is putting the PT at greater risk here..


Also on the note of central lines. If a PT is admitted (at the hospital I work at) and the nurses can't seem to get a good IV after 4-5 tries and the PT does not have a good EJ site then it is almost always an automatic central line. I have seen them put in a central line for PT's that have a planned discharge in 2 days but need 2-4 more doses of IV antibiotics...I'm not talking about sick people here...they just pop PIC lines in for no reason all the time here...

I am of the opinion that if the ER or the floor is going to pull my IV 12-24 hours in then I don't really feel like starting an IV in the field unless the PT is going to die or otherwise suffer very greatly during the 5-10 minutes it takes to transport to the ER...

 

[VFlutter]

Here's a question sort-of related: when receiving a transfer patient from another facility, are those patients interventions redone?

Yes, if they are from an outside hospital. If they are an internal transfer from one of the smaller hospitals in our system we will leave it. In my experience some of the transfers from rural hospitals are worse off then when EMS does them.

Ultrasound IVs really cut down on our central and PICC lines. Our NP/PA rarely can not get a peripheral line with ultrasound.

 

[Rialaigh]

Yes, if they are from an outside hospital. If they are an internal transfer from one of the smaller hospitals in our system we will leave it. In my experience some of the transfers from rural hospitals are worse off then when EMS does them.

Oh and ultrasound IVs really cut down on your central and PICC lines. Our NP/PA rarely can not get a peripheral line with ultrasound.

we probably have this capability at our hospital (288 beds I think) but I don't think I can recall them doing one in the 3 years I have been working float the the hospital. Pic lines are the new stylish thing..

 

[Shishkabob]

In my experience some of the transfers from rural hospitals are worse off then when EMS does them.

Huh?

 

[Veneficus]

What do the studies show about EMS lines, tubes, or otherwise invasive procedures, causing infections in the field (rate and severity) compared with the infection rate in a hospital by redoing the same procedure over again..

I have seen no studies of any reasonable amount or power.

However, I have played both sides of the field, hospital and prehospital. In my experience, for every 1 highly competent EMS provider there are dozens who will do things 1/2 assed.

I have also seen all manner of crazy justified with "in the field..."

But I think of it basically like this...

There is emergency care and definitive care. Both providers need to set themselves up for success. As I said, it is not just about infection rates. It is also about what is going to work out best for the patient, including things like mobilty and ease of treatments.

It is not just a cost factor, in societies that have government funded systems and the financial side of medicine is much less than in the US, they still maintain these procedures.

I think it would be foolish to deny that money doesn't play a large part in it, especially in the US, but there are also regulatory mechanisms in place EMS doesn't have to deal with. For example, joint commision requires a host of things that are utter BS. But if you want medicare money, you need to play ball with these regulating agencies.

I have explained several times, the primary mechanism for infection in any invasive procedure is the patient's own flora, you don't have to take my word for it, it is in every surgical text ever printed. It also makes sense physiologically, sick person, not at peak more suseptible to opportunistic infection, invasive devices bypassing natural defenses. An environment where only the strongest pathogens survive. It is predisposed to things going wrong.

However, by maintaining vigilance, reducing potential problems before they occur, and erring on the side of caution, you will prevent the most complications.

I will be the first to tell you, the extreme sterile environment practice is seriously flawed. It is what creates these "superbugs" But we know the more often you remove invasive devices the less often infection happens. We can debate how often is too often, but using the IV example, how many medics legibly time and date their IVs? How many EMS agencies make sure their locks and tubing are compatible with the transporting hospital? How many EMS providers or systems make sure they meet regulatory requirements hospitals must adhere to for things like standardized blood tubes?

How many providers start IVs that are not needed at all "just in case?"

How many choose a site on what they think they can get over what might be most helpful later?

How many are aware of the differences in similar procedures like intubation? The ICu nurses here can tell you, there are not many baloon inflated ET tubes there.

I used the OB example before, but I will add to it...

I can give meperidine through a peripheral IV to a woman in labor. It is much safer and less side effects than spinal anesthesia. It doesn't require an anesthesiologist. (aka another provider)But when you put that IV in the AC. Then I need another one that is not in a joint to prevent occlusion or extravasiation, so that I can provide reliable and effective treatment. So no matter how good you think it is or how clean, it is not a good line.

No matter how clean or perfect your line is, if it doesn't connect with my equipment, then it is no good.

If the patient during their stay is constantly yanking on it as they go about their activity, then the line is no good.

These are just some examples, but I think you get the point.

It really makes no sense to me to place a perfectly good IV that will be in the PT's arm for 12-24 hours only to have it pulled 48-72 hours early because it is a "ems" iv. Wouldn't the risk of infection through that IV after 12-24 hours be close to zero if an infection has not already popped up? Seems like all we are doing is putting the PT at greater risk here..

I do not understand this timetable?

If a line is normally replaced every 24 hours, at least everywhere I have been it is, how could it be pulled earlier than 23:59?

Infection is not so simple a pathophysiology. The initial inflammatory response may not contain an infective organism, so the symptoms will show up over time. You also have an issue of synergistic and symbiotic infective organisms, just like synergistic drugs. Some organisms actually have defenses against body defense mechanisms.

Opportunistic infections from the body's own flora are caused my migration of existing mechanisms, sometimes through deep skin layers. (acne is a great example of this) The act of selecting and cleaning another site permits wound closure at the initial site. Denying the organism passage past host defense.

Then, somethings, like teflon, no matter how sterile it is, harbor any orgaism that attaches to it in a very effective way. Basically your own body flora migrates to the teflon no matter what you do and creates a biofilm on it. Overtime, it defeats host defense and local and possibly systemic infection ensues. Which is why hospitals do their best to take out these kinds of catheters often. Especially central ones. There are some strategies to leave them in longer, but they are exceptions, not normal procedure.

You can even create chronic infections with things like foley's. Infective prostratitis is usually chronic, is very hard to eradicate, and might end up being life long.

Equally problematic are abceses at remote locations from infective organisms introduced via invasive device. (especially places like the brain and heart)

Also on the note of central lines. If a PT is admitted (at the hospital I work at) and the nurses can't seem to get a good IV after 4-5 tries and the PT does not have a good EJ site then it is almost always an automatic central line. I have seen them put in a central line for PT's that have a planned discharge in 2 days but need 2-4 more doses of IV antibiotics...I'm not talking about sick people here...they just pop PIC lines in for no reason all the time here...

I am sorry. I hope I never wind up in that facility.

I am of the opinion that if the ER or the floor is going to pull my IV 12-24 hours in then I don't really feel like starting an IV in the field unless the PT is going to die or otherwise suffer very greatly during the 5-10 minutes it takes to transport to the ER...

Why? It is common to pull it in 24. What about patients who walk in the front door of the ED on their own power, get an IV in the ED, then get admitted? The ED staff doesn't go crazy (or even care) as soon as they get to their destination the IV is likely to be pulled and restarted. Why should EMS get any special consideration?

 

[RocketMedic]

The ED staff are probably not responsible to anyone for what they say. And as Vene said before, the emergency sector was a place (and is a place) the less-socially adept doctors will tend to gravitaten or be sent. (NOT, not all!!).

Talk to your boss about how to handle these chewing-outs. It really can be a "hostile work environment" issue but the chastising staff member will think of it as "teaching"...which may be why they aren't teachers. Having been torpedoed by a rotten orienter once, I can appreciate that. See if your boss wants you to ask them to tell him their concerns, or if you are to just say "yessir", or what. (If the latter, either suck it up, or work away from that hospital).

And the hard point...maybe they have a point.

Oh, it wasn't a chewing-out as much as it was a failure to understand that I did not have the needed drugs to knock the man down and intubate safely, nor the expertise to improvise, nor the stupidity and arrogance to do a half-assed job.

My supervisor was simply covering EMSA's *** and confirming that I hadn't tried to intubate the patient. I did right by our QA/QI staff and FOS, which mattered to me more than a resident ER doctor (employment = good).

 

[VFlutter]

Vene however seems to think that pulling or redoing everything is in the best interest of the PT (whether it is in the ER, a procedural area, or the floor).

I strongly agree. We do not redo EMS/OSH lines in the ER we wait until they hit the floor. It is a more controlled environment.

In the ICU they routinely swap out ET tubes over a bougie, in uncomplicated cases, if they were intubated in the field or flown in from an OSH.

Last quarter our CLASBI/VAP rates were very low and well below the national average so I think we are doing something right.


If it was myself or a family member I would expect the same treatment.

What do the studies show about EMS lines, tubes, or otherwise invasive procedures, causing infections in the field (rate and severity) compared with the infection rate in a hospital by redoing the same procedure over again.

I do not know of any definitive study. Most are flawed or weak studies for a number of reasons. If anyone has one please let me know.

Just some basic info...

There are two main mechanisms for venous catheter infections, Extraluminal and Endoluminal.

Extraluminal is basically direct migration of the organism along the skin-catheter interface or insertion site. A common cause is improperly prepped skin. My favorite is when you see someone cleanse and prep the site then palpate the site again before inserting, most likely with a glove that they have been wearing since jumping getting off the ambulance. Then you slap a tagaderm on the site and trap those organisms right at the insertion.

Once a catheter is removed and the site has clotted the chance of infection from that point on is pretty much nil so you are really not adding more risk to the patient by removing a potentially contaminated line and starting a new one under better conditions.

Endoluminal is contamination at the catheter hub. How often to you see a provider, especially in EMS, properly cleanse the hub prior to use? The current recommendation is 30 seconds with an alcohol wipe. Count it out..it seems like forever. Now how often do you honestly see that happen.

It really makes no sense to me to place a perfectly good IV that will be in the PT's arm for 12-24 hours only to have it pulled 48-72 hours early because it is a "ems" iv. Wouldn't the risk of infection through that IV after 12-24 hours be close to zero if an infection has not already popped up? Seems like all we are doing is putting the PT at greater risk here..

Like Vene said we make sacrifices in emergency medicine. If they need an IV then they need an IV. An infection can be treated. There is still a risk for 7-10 days if the skin was improperly prepped and colonization has occurred. Bacteria grows and leaving the catheter in can potentially allow adequate time for that organism in migrate.

No offense but I find that hard to believe that any respectable institution would allow that to occur. Central lines should not be be used lightly and with the various alternatives there is much less of a need for them. That should not be happening.The choice of antibiotic may be playing a large role in those decisions.

We are very liberal and aggressive with PICC lines. They are relatively low risk and is generally more comfortable for the patient. It is not uncommon for a patient to request one. For a patient with multiple incompatible drips is is a great alternative to rotating multiple IVs every few days. Imagine having 3 peripheral IVs being changed every 72 hours (soon to be 96)

I am of the opinion that if the ER or the floor is going to pull my IV 12-24 hours in then I don't really feel like starting an IV in the field unless the PT is going to die or otherwise suffer very greatly during the 5-10 minutes it takes to transport to the ER...

I guess if that is the way you want to look at it. You probably won't make your local ER very happy.

It sounds like you are taking issue with this personally when it is really just best practice not an insult to your ability as a provider.