Hospital settles for childs death, faults EMTParamedic

[Just Plain Ruff]

thanks for the correction Rid, I was actually going on information that I had when I was in the ER setting about 10 years ago so since then I know it has changed.

thanks for the info.

[spenac]

Actually, it is very specific that ONLY an RN or a physician representative (NP or PA) is the only acceptable persons to be able to perform triage!

If you see an LVN/LPN or even a Paramedic performing triage at a hospital setting in the ER, they might as well start writing out the checks. This is very specifically stated and described over & over in the EMTALA, COBRA regulations, in fact one example of whom that they use is for FAQ' s is a Paramedic allowed? The answer is an inequitable NO!.

R/r 911

Rid do you know the particular laws you reference as I see LVN's often. Perhaps I can share those with hospitals that do that and save them some money.

[chbare]

Hmm, we are in somewhat of a grey area. If we look at EMTALA for example, it essentially states every patient must have a "medical screen" to determine if they in fact have an emergency medical condition. However, triage is not really considered a medical screen. Triage is more like the process of determining who receives the medical screen first.

Now, when we talk about who can perform a medical screen. Again, it is a bit on the grey side. Usually, a physician will perform the medical screen; however, in some cases the physician my delegate to another "qualified provider." However, this can only lead to increased liability.

Clear as mud?

Take care,

chbare.

[Ridryder 911]

Actually this has been a standard for quite a while. Although, many attempt to circumvent around the standards. EMTALA has developed whom and what is required for a medical screening evaluation (MSE). Most states will allow RN's to perform, although there are a few that does not even allow that. JCAHO has been very firm on not recognizing anyone than an RN working in Critical Care areas. LPN/LVN's are usually titled as techs, as practical and vocational nurses are not recognized as "nurses" in those areas. They definitely are not allowed to perform triage or even "open" the chart as such as the first initial assessment, and then afterwards may document with the co-signature of a RN (as practicing under their supervision).

Again, ED is whole different environment than the field and vice versa. Yes, I welcome new RN"s that were former Paramedics.. but; they do have to adjust to it. Assuming it will be alike the field is one of the first wrong things one can do. Yes, there is a lot of similarities, but that is where it stops. Alike Critical Care is not the same as the ED.. again, similar is some ways but definitely not the same.

I forewarn those considering to pursue nursing and focus in the ED to be prepared for some changes. For example in triage, defining what can be assessed and treated in the first 30 minutes, what tests will be needed for diagnostics is one of the major proponents in triaging. Again, not knowing emergency medicine, one will not know what the initial diagnosis is, what tests will be ordered, what the average length of time for treatment and potential ability if one will be admitted or not. Again, not all Paramedics could perform...

R/r 911

[chbare]

Actually this has been a standard for quite a while. Although, many attempt to circumvent around the standards. EMTALA has developed whom and what is required for a medical screening evaluation (MSE). Most states will allow RN's to perform, although there are a few that does not even allow that. JCAHO has been very firm on not recognizing anyone than an RN working in Critical Care areas. LPN/LVN's are usually titled as techs, as practical and vocational nurses are not recognized as "nurses" in those areas. They definitely are not allowed to perform triage or even "open" the chart as such as the first initial assessment, and then afterwards may document with the co-signature of a RN (as practicing under their supervision).

Again, ED is whole different environment than the field and vice versa. Yes, I welcome new RN"s that were former Paramedics.. but; they do have to adjust to it. Assuming it will be alike the field is one of the first wrong things one can do. Yes, there is a lot of similarities, but that is where it stops. Alike Critical Care is not the same as the ED.. again, similar is some ways but definitely not the same.

I forewarn those considering to pursue nursing and focus in the ED to be prepared for some changes. For example in triage, defining what can be assessed and treated in the first 30 minutes, what tests will be needed for diagnostics is one of the major proponents in triaging. Again, not knowing emergency medicine, one will not know what the initial diagnosis is, what tests will be ordered, what the average length of time for treatment and potential ability if one will be admitted or not. Again, not all Paramedics could perform...

R/r 911

However, the lines blur when we go into small facilities that do not have JCAHO credentials. I have seen a major policy shift with many hospitals however. In fact, some hospitals have all RN staff in "critical care" areas. I am not sure where the incident in question occurred. It would be nice to look at that states' BON SOP and facility guidelines.

Take care,

chbare.

[VentMedic]

Rid do you know the particular laws you reference as I see LVN's often. Perhaps I can share those with hospitals that do that and save them some money.

I haven't seen an LVN in the acute hospital setting for about 15 years. At one time they were in the SNF attached to the hospital but that has also changed since the RNs were responsble to do the initial assessment on all patients. It was easier to hire RNs and do a different assessment and patient management approach that put the RNs more intouch with each patient rather than 1 RN trying to supervise 4 LVNs and 60+ patients as many nursing homes still do.

Sometimes the Paramedic, as evidenced by some comments in the different threads, looks more for "BS" rather than disease processes that don't initially appear as true emergencies. Some may be likely to dismiss something that is truly life threatening like a high temp in an elderly nursing home patient as a 0300 BS "fever" call. Few will know that this can be life threatening to that patient.

We had a similar case in Miami a few years ago where the paramedics wrote a 17 y/o off as having the flu and told him to get his mother to take care of him instead of them transporting him to the hospital. He died from meningococcemia.

The overview of diseases that a paramedic gets does not qualify them for triage in the hospital setting where the wait to see a doctor could be several hours.

The paramedic had nothing to do with causing this little girls death. It sounds like the doctor 2 days earlier screwed up. This little girl was so far gone she had already quit compensating, and that is an extremely late sign. This child basically was dead the minute the doctor 2 days earlier sent her home.

The fact that the paramedic did not pick up this fact or see the serious of a little girl with the same symtoms continuing for 2 days without improvement is negligence in itself and should have admitted that maybe pedicatrics is not his specialty. Any child that young that has "flu like" symptoms for an extended time needs to be at lease considered for dehydration which in itself can be an emergency. Some of the "traditional ER nursing" questions which would be necessary to fully assess this child's condition are not in a Paramedic's training.

However, the lines blur when we go into small facilities that do not have JCAHO credentials.

If these facilities are not JCAHO, do they accept medicare or insurance? JCAHO is the accrediting agency that goes out to make sure that each facility is qualified so medicare and the insurance companies don't have to. A hospital really doesn't want a "Medicare" inspection. JCAHO is even considered much gentler and kinder.

[ambodriver]

Hmm. I work my part time in a busy trauma 1 ER in Chicago and I work triage occasionally. Sometimes its just a basic or a "medical assistant". I fail to see how a paramedic couldn't triage correctly in an ER. Whether it is legal or not? Didn't have a problem when the inspectors came through. Usually if I get up and tell the charge nurse someone needs to be seen right away they trust my instinct, just like they do when I make radio reports to them from the field. I fail to see how this was the medics fault, unless he didnt understand the condition of this child, she must have looked pretty shitty though...but lets not forget that familys often given really shitty hx...although the V/S should have led to a high index of suspicion if this kid was that sick. I really don't know enough details to really pass judgment.

edit: it takes awhile before they let you into triage....but with sick younger children with flu like symptoms we will usually draw blood and send labs per an order sheet during triage and send them to fast track with a PA and nurse. Usually the very young and very old do not wait long with any kind of complaint.

[medicv83]

As AmboDriver said, we here as well have paramedics working triage, amongst many other portions of the ER. They triage, and if needed will fast track a patient, as well as obtain an EKG as needed, and line and lab the patient if need be. The functioning medics in the ER here are generally indistinguishable from the staff nurses usually. As a matter of fact, the paramedics are generally the only ones assigned to triage, However, Im fairly certain that a nurse accompanies them, and is responsible for their actions.

[Ridryder 911]

Again, if one does not know how it would be problem, I foresee a problem. Sorry, what maybe occurring and what is legitimate is a different story. Sorry, Paramedics are not adequately taught about medical conditions and treatment regime to make determination under the standard triage of emergent, urgent and life threatening. It is much more complex than .. who is sick and not.. Sorry, if your ER is doing such, they have not been caught .... yet!

Just await, there will be someone who will notice and yes, someone will sue and yes you will loose. (Now it is a documented case, it will be used as a standard of care). It is also clearly defined in the EMTALA (Federal) regulations.. as well as in JCAHO and standard of care in most States.

We all realize of Hospitals and EMS that do not do perform and do the right thing, but it does not excuse them...

R/r 911

[VentMedic]

edit: it takes awhile before they let you into triage....but with sick younger children with flu like symptoms we will usually draw blood and send labs per an order sheet during triage and send them to fast track with a PA and nurse. Usually the very young and very old do not wait long with any kind of complaint.

Our Fast Track is for minor boo-boos that can be taken care of quickly and released. Children and the elderly rarely get sent there for medical problems because they can be many times more complex as well as needing observation after some treatments. They are taken in quickly though because both age groups can decompensate quickly. A physician also sees them. We also don't draw labs on kids in the triage area since it can be a traumatic scene for the child and anyone near the area.

medicv83

However, Im fairly certain that a nurse accompanies them, and is responsible for their actions.

Our ER Techs (EMTs and Paramedics) can do vitals in triage but the RN does the questioning and determining how fast and where the patient goes.