PROTOCOL 33

By Brett Patterson

Brett: 

I have several questions related to the 33 card (Transfer/Interfacility/Palliative Care).

• What type of facilities would you consider medical?

• Does it require a certain level of staffing or equipment such as a crash cart?

• How do you classify an assisted living center with certified nurse assistants?

• What about an independent living facility with a nurses’ office?

I also have a question about private ambulance companies.

• Is it your interpretation that a private ambulance company should be EMD certified? The company in question does mostly nursing home to direct appointment transfers but does also receive direct admits and some urgent/emergent calls for service requiring the ambulance to respond lights-and-siren.  

Thank you,

Brenda Farlow

EMD Program Director

Loyola University Medical Center

Maywood, Illinois, USA

Hi Brenda: 

Thank you for your questions about interfacility transports and calls from private ambulance companies. I will do my best to address them, and please don’t hesitate to call me directly if my response is incomplete.

Protocol 33 was designed to make the EMD’s interrogation of medical professionals more appropriate to the needs and knowledge of these callers and eliminate some of the frustration that is sometimes evident when the standard protocol is used for these types of calls. The protocol was not designed for any specific type of facility, but rather a type of caller. In fact, this protocol is often used for home health patients where an on-scene nurse is requesting transport for further evaluation, treatment, or relocation. However, some agencies restrict the use of this protocol to specific types of facilities by internal policy from local medical control, which is perfectly appropriate.

In the first generation of this protocol, which was Protocol 33, no specific definition of “nurse” or “doctor” was included, and this prompted agencies to define these terms by local policy. Another concern involved the fact that this single protocol pathway was being used to process two distinct requests: transport for evaluation and transport for scheduled treatment or simple relocation. These issues, and several others, prompted the creation of a second-generation interfacility protocol, Protocol 37: Interfacility Evaluation/Transfer (Medical Priority Dispatch System (MPDS) v12.1).

Protocol 37 is available in ProQA only. It includes a Medical Control authorization section to define and authorize the terms NURSE and DOCTOR locally, and it restricts Key Question 1 to an evaluation by a NURSE or DOCTOR within the past two hours. Additionally, Protocol 37 provides separate pathways for the now-defined terms EVALUATION and TRANSFER. Protocol 37 also provides more response options and more leeway for EMDs to confer with professional callers about the response needs. Agencies with ProQA may now choose to use Protocol 37, Protocol 33, or both, depending on their needs. Protocol 37 can be enabled in ProQA’s Configuration Utility.

Regarding your question about private ambulance companies: The Academy does not discriminate regarding what type of agency is taking calls for ambulance service, but rather sets standards for all agencies taking such calls. There is a fine line between emergent and non-emergent calls, as I’m sure you are aware. Many calls to 9-1-1 are non-emergent. Likewise, calls are received on standard telephone lines that turn out to be emergent. Perhaps a better way to classify a request for an ambulance is as described above—EVALUATION (patient has an acute medical or traumatic problem) or TRANSFER (patient requires simple relocation). In either case, but especially the former, the Academy recommends (as do other standard-setting organizations), a protocol-driven interrogation that ensures an appropriate response and appropriate instruction, if needed. In essence, the different needs of these distinct requests, often made by medical professionals or their associates on behalf of medical professionals, is why the two separate pathways of Protocol 37 were developed.

In the absence of a standardized protocol for calls requesting transport for evaluation of an existing problem, agencies that normally accommodate simple transfers should create policies that dictate when and how such calls for evaluation are handled/referred in an effort to prevent inappropriate responses and patient care, or the lack thereof. The Academy’s position is that processing such calls without a protocol introduces variance, which is associated with increased risk regarding response decisions and patient care.

Please let me know if I can be of further assistance.

Brett A. Patterson

Academics & Standards Associate

Medical Council of Standards Chair

Brett: 

I’m hoping you can help us out with a question. We were going over scenarios, and our Q’s have different opinions about the correct path. Here’s the scenario: Caller reports that grandma just fell, and she is not breathing. Here are the paths: Do you work this under Protocol 9: Cardiac or Respiratory Arrest/Death or Protocol 17: Falls? On one hand, Rule 2 in Case Entry states, “If the complaint description involves TRAUMA, choose the Chief Complaint Protocol that best addresses the mechanism of injury.” According to that Rule, the dispatcher should go to Protocol 17 and ask the three Key Questions, which would lead to a DELTA-2 response. This would be no different than a traffic accident or any other trauma case.

However, the caller volunteered, “not breathing.” Per Case Entry instructions for ineffective breathing, this statement, when volunteered, directs the EMD to use an ECHO-level determinant and, in this case, 9-ECHO. Rule 1 in Protocol 17 states, “Always consider that the patient’s fall may be the result of a medical problem (fainting, heart arrhythmia, stroke, etc.).” 

The discussion centered on this: A fall is a trauma, but the EMD can’t rule out a cardiac arrest as the cause of the fall. Which protocol is correct?

Thanks for your help.

Tim Hawkinson

Communications Supervisor

McPherson County Communications

McPherson, Kansas, USA

Tim: 

What came first, the chicken or the egg?

We know that there is a very high percentage of cardiac arrest cases in the 17-D-2 & 3 codes. This is because the caller sees the fall and doesn’t initially realize the cause—cardiac arrest. The problem here really isn’t trauma; it’s cardiac arrest, and the fastest way to help the patient is to follow the cardiac arrest pathway. The exception to this scenario would be a long fall where it is clear that the cause of the arrest is the fall, and not the other way around.

In Medical Priority Dispatch System (MPDS) Version 13.0, we are introducing a new “Fast Track” from Case Entry Question 3 (“Okay, tell me exactly what happened.”) that takes you directly to Pre-Arrival Instructions (PAIs) for the obvious medical arrest. This is in an effort to get hands-on-chest as quickly as possible, which we now know has a critical role in survival from out-of-hospital cardiac arrest. 

Please encourage your EMDs to err on the side of patient care and get hands-on-chest as fast as possible, and don’t use the Agonal Breathing Tool when the caller is UNCERTAIN (now a defined term) about breathing. Use it only when the caller tells you the patient is breathing but YOU are unsure, i.e., ground level fall and unresponsive, caller says “yes” or “I think so” when asked about breathing. Tell your EMDs it’s OK to be wrong [about getting hands-on-chest so quickly]; the patient will object to the compressions and you start over. No problem.

And start measuring how long it is taking to recognize cardiac arrest, and then to get to hands-on-chest. The new v13.0 software will measure this and provide real-time feedback after each case. The ED-Qs need to lead the charge on this one. If it looks like a duck, smells like a duck, and tastes like a duck, get hands-on-chest! Don’t worry if it turns out to be a chicken!

Brett

ABOUT THE AUTHOR:
Brett A. Patterson is an Academics & Standards Associate and Medical Council of Standards Chair for the IAED.

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