Poor response times "killing patients"

[melclin]

melclin, on 22 December 2009 - 12:18 AM, said:

To be clear, I wasn't saying that poor response times are killing people. Quote

Poor response times "killing patients"

I wasn't me that they are "killing patients", it was a heading for the post, paraphrased from the articles; a sentiment that I happen to disagree with. The quotation marks at the very least suggest that I am quoting/paraphrasing someone else, and also infer a certain amount of sarcasm, which I would have thought would be obvious given the context.

REGARDING THE ARTICLE POST

Now, sure, there are a handful of of conditions that are truly 'seconds count' time sensitive (cardiac arrest and respiratory arrest are the archetype examples). However, it's a fairly safe bet that most other conditions, including serious conditions like MIs, are not a 'seconds count' emergency. 2 minutes, in reality, isn't that much time.

You may argue though that since a person experiencing an MI (or other serious consitions that are not necessarily 'seconds count' problems) has a significantly elevated chance of suffering cardiac arrest compared to a random member of the population, such that the standard of care should be that they are, as quickly as possible, provided with medical professionals who have the ability to deal with that situation, given the higher likelihood that a genuine 'seconds count' emergency might arise. I'm just saying it could be argued. Whether or not it actually is realistically beneficial may be another matter.

However, I will say that there comes a point where response times matter and it's most likely not what's being researched. Saying 'well, there wasn't a difference in outcomes between the 5 minute and 8 minute response time groups, therefore response times are meaningless' isn't very helpful and is probably giving the data too much credit. 5 minutes vs 8 minutes probably won't make a difference, but how about 5 minutes and 15? 5 minutes and 30? 10 minutes and 45? Sure, the vast number of emergency responses aren't going to fall into the 45 minute mark, however you still see a 23 minute first response and 38 minute transport unit response times. Trying to apply a study comparing a short response time (6 minutes) vs shorter (4 minutes) to a long time (23 minute or 38 minute) response time is not a valid application of the research data.

I think given the different types of cases seen in EMS, its difficult, if not impossible to suggest certain single response times are better overall. As you have said, different conditions may require different 'ideal' (what ever that means) times and I think it may be worth putting a greater emphasis on response times to different conditions. Putting "respiratory distress" in the same category as "MI" and as "cardiac arrest" is probably not the greatest of ideas. But then how you apply all that to practical issues like whether or not you should spend the money on ambulance station 1.5 when 1 and 2 can't cover their areas, I don't know.

One thing I do think is that it is completely impractical to spend the money on putting enough ALS ambulances around a given area to provide adequate response times for satisfactory (what ever that may mean) cardiac arrest survival (probably..what? 2-4 minutes). That's just impossible in most modern cities, let alone rurally. This, I think (especially with the new emphasis on good compressions instead of drugs/intubation etc), is where better public CPR education and more initiatives like Community Emergency Response Teams/Workplace Response teams (O2, AED, Aspirin, Albuterol - first aid) would be better than adding to the professional emergency Ambulance compliment. eg maybe it is okay to have a 25 minute response time to a (?)AMI, if the work place response team can get there in 3 minutes to be there to give ASA/resuscitation should the person peg out; maybe a 15 minute cardiac arrest response time is acceptable if the School First aid team get to the teacher in 1:30 with a pair of hands and an AED. How you get evidence to validate or disprove that kind of idea, however, seems like an ethical and methodological nightmare.

As an aside I always thought the idea of the golden hour was an.. ah, metaphor isn't the right word (but you know what I mean) for the fact that reducing scene/transport time for trauma patients was often an important consideration. I was so surprised when I started coming on these forums and people talked about the golden hour like 60 minutes was literally the amount of time a 'trauma pt' (specifics and severity of their injuries be damned) had before their injuries got the best of them. Then that people felt the need to refute the idea. Was it ever seriously suggested that specifically 60 minutes was the be all and end all (I mean by educated people, I can certainly see some 'EMT instructor' somewhere suggesting that to be the case)?

stcommodore - I think you're right to a certain extent. The problem though is that they do call for those things. So how do you reduce the unnecessary waste of resources without sacrificing patient care.

- Firstly I think public education is a good idea. There is almost no decent education out there to teach people when calling an ambulance is appropriate. You get those adds from time to time that say "If chest pain dial 000" but that's not really what I'm getting at. They need to know that they won't be seen faster if they go in on an ambulance. They need to know that we are not a taxi service for the mildly unwell and barely injured. At the same time they need to know that when grandpa's left arm stops working and he can't speak properly, that they shouldn't make a Dr's appointment for three weeks down the track. I don't want to turn everyone into MDs but people should be provided with the education to manage their own healthcare to some degree. How exactly, I'm not sure, that's one for the public health boffins.

- Secondly, an evidence based (not litigiously based) primary care referral system via 911/000 would also be good ie, "Sir, do you feel that the back pain you have had since 1972 would be better addressed by your GP tomorrow instead of by an L/S Ambulance right now? You do? Good. Now here's an appointment with your GP and don't hesitate to call again " (we have one now to a certain extend, but you'd never know it from the paramedic point of view).

- Thirdly, increased scope for paramedics to refuse transport, perhaps not in the US yet, but here, increasingly paramedics have enough education such that we really should be protected if we say, "Look I'm sorry you fell over an grazed your knee yesterday, but this is the only emergency ambulance in the rural-town-of-where-ever and it will take ~40minutes to transport/hand you over/do your paper work, time in which we will not be adequately prepared or positioned to deal with a more serious case. You can walk well and there are three people here who can drive you to hospital/your GP, have a nice day and don't hesitate to call again". (again we have this sort of, in theory, partly, maybe. We aren't specifically allowed to say NO to a person who really wants to go to hospital, but we can convince them (with varying degrees of enthusiasm, depending on who you talk to) that they don't need us. It seems, though that most paramedics just don't want to put up with the arse kicking they'll get from their SO if a complaint is made and that's fair enough, nobody wants to sacrifice their career progression over it).

The third is something that needs to happen more often in health care in general. People need to suck it up, and health care professionals need to be able to tell them that, politely of course, without suffering from the repercussions of complaints or, god forbid, litigation. You grazed knees, you sore throats, your itchy arms your flus etc. I must say that, while I agree with universal health care one of the problems in our system is that patients and HCPs alike seem to think that because they never see money change hands, that the $1000 worth of blood tests they ordered for a pt with the flu are actually free, but that's another discussion.

[2wheelinemt]

to me there is a no greater abuse of a any other system then the 911 (ems system) we do our best every time we make that decision to be part of the 911 system. people call for all types of problems. and most of them dont even need to be seen at a hosp never mind an ambulance. i also thought that an ambulance was used for someone having a heart attack. some bleeding that cant be controlled. i would thing if you were injured and no one was with you and you couldnt drive your self them 911 is called. not iv had a sore throat for 3 days and my g/p cant see me to tomorrow. no that is not what 911 is for! but will we change that? i dont think so..about 2oyrs ago things were not as bad as they are today with people calling 911 to be seen at the hosp. part of it is that they have learned that if you went to the er per ambulance you were seen above every one else.

well things have changed but the people dont realize that. they still they are going to be seen in front of every one else.

our hosp triage those pt back into general pop..and not given a bed right off the bat. but it still delay treatment of say someone walking in with chest pain..i walked in to the er with chain pain, diff breathing,heart rate of 28. i had to wait half hour due to the amount of ambulances that came in and where triaged back to general er. is it a tax on the the ambulances and the er staff.,you bet..the pts that dont abuse system? you got it.

our response time are always the topic, not how we treat the pt,not that we need to do our best, but the response times..

crazy things have come to this!!!!!!!! hang in there everyone things will change again.....

[Timmy]

It's so hard to educate people on their own health, I've done community health promotion and I'll tell you now... Not many people give a crap. When I did diabetes education and community health promotion I think I suffered from hypertension my self over the general lack of interest or effort people would put into optimising their health even though they have a chronic health problem.

I'd have ten tone tassy come in who has uncontrolled diabetes, hypertension and cholesterols up the creek. There nutritional intake is not at all desirable for diabetes, they were none compliant with medications, sat around on there fat ass all day, smoked and generally couldn't give a stuff what I was telling them, they were just there because they had a referral. You give them reading material, talk to them, give them lectures, show them a movie, tell them the ways to improve there lifestyle habits and the detrimental effects but at the end of the day only YOU can make that difference.

After you put in all this time and effort into improving their health guess who presents next week to A&E with a headache and you find there in hypertensive emergency... But don't worry, I'll just put a GTN patch on, IVT you some Labetalol and get an order to increase your regular beta blockers and its all sweet yeah?

Its the same with the programs they run like FAST, Slip/Slop/Slap, QUIT... How many people actually take notice?

Everyone has to do the best they can, I have seen 2 deaths this year that resulted in lack of resources and staffing to get them the help they needed. We have one ALS truck in my town and the paramedics do an awesome job under the trying conditions. They can be extremely busy (most of the time) and not so busy (some of the time) They have an one hour trip to the base hospital with a 3 hour around time. That's 3 hours our town is uncovered, backup is at least 30mins off.

Were coming into peak holiday season with campers flocking to the river. Starting next week and into new years they will give the hospital and ambulance a flogging because the towns population boosts by about 20,000 and no further health resources are added. We have a 4 bed ED with 3 to 4 RNs on each shift, no xray after hours, only on call GPs after hours and 2 paramedics who go on call after 1830, not a great deal to deal with what comes in and when does stuff start getting busy and hitting the fan? After hours, when our resources are at it's lowest.

[Kiwiology]

Let's be objective and clinically rational here.

1) The public deserve, expect and are entitled as a) people with basic human needs and b ) tax payers, an acceptable standard of response and care

2) There are few (and we're talking fingers on one hand here) truly life-threating, time critical emergent cases that justify zipping round lit up like a Christmas tree playing Traffic Twister.

I think personally you aren't going to die or have significantly increased M&M in 7:59 (or applicable response standard) unless you have:

- Cardiac or respiratory arrest or near arrest (things like your life threatning asthma, anaphylaxis, poorly perfused VT, epiglottitis, croup, significant APO/CPE)

- Choking

- Seizure (clonic, tonic annoxic event type seizures)

- Uncontrolled exsanguination / shock

Nana with known history of CHF who has a few basal crackes eh she's a bit unwell but the kid on the ground who is unconscious and contionously seizing is pretty crook and that should be first priority but does not mean we have to drive like Juan Pablo Montoya!.

Although we can be cold and clinical and say "you are not dying" we must also consider M&M, splinting, analgesia etc and good quality human centred care which people deserve regardless of be they a crank addict with no nasal septum and a history of seizures, hypos and getting into fights or not.

Response times are a good way of whipping up public and funder fear and getting a bit more money out of the Government when infact it's probably a symptom of a broken funding system or a system built on half-truths and conjecture - just look at the UK and it's obsession with "call connect".

They are required, however, are not probably clinically significant in terms of M&M if you have the right level of response in place and we don't get all zany and say "well, half an hour is acceptable". Nor should they a bearing on budget (I come from a country with universal, public healthcare so the budget of the Ambulance Service is largely derived around compliance of key performance indicators as opposed to degree of payment by private insurance) if anything, poor resoinse times should be a reason to increase funding and resources not take them away!

We must be very careful not to lower the response standard as this will increase morbidity; the trauma patient who has to wait longer for pain relief, nana on a cold floor with a NOF who has to wait longer to be picked up, the parents freaking out coz little Timmy skinned his knee and they don't know what to do etc etc etc.

Edited December 22, 2009 by kiwimedic

[melclin]

Timmy,

Yes public health is difficult. Its a long hard slog, but it does work. I would dispute you evaluation of the efficacy of slip, slop, slap and a few others. 15 or more years ago, it was just a given that when you went to the beach you got burnt. I think for the most part now, people use sunscreen much more, in no small part due to things like the cancer and slip,slop slap campaigns. I think they work, but that's not the only thing I was talking about. I mean long term strategies like teaching appropriate ambulance use in schools. AV currently provides day seminar type things for school kids of different ages, which is good, but I'd like to see more than that. Understanding the role of all the emergency services is important. Maybe it should be part of a "now you've turned 18/21 and you're a real person here's a stupid course/test (cert 2 first aid, P's driving test, knowledge of welfare/health and governmental systems, including appropriate activation of 000 services, resume writing, making sure you can bowl properly so you don't end up making a d**k of yourself when you become a politician and visit the troops in Afghanistan, you know .. the basics). Until you pass it, you don't get to be an adult (drink, drive, be a bloody idiot). It could be quite a significant milestone to pass, like VCE/HSE etc and probably more useful to some. Probably a stupid idea, I'm not sure, I'm no educator, but I'd like to see more educations on the fundamentals of our society in high schools.

PS Sounds like great experience in the ED. Mind PMing me your location, just out of interest?

Kiwi,

I agree with you mate, and we've talked about this before. What I was getting at was how you apply an evidence base to figuring out what the balance is between, as you say, 1, the fact that few things really require an L/S type quick response; and 2, not letting the previous notion become an excuse to degrade the quality of services. Actually having a system of response time based on evidence, seems immensely difficult to me. Not saying its impossible, but I sure wouldn't like to have to write the ethics approval forms for the studies required, that's for sure.

Edited December 22, 2009 by melclin

[Kiwiology]

I'd love to see how long people wait in ED to be treated, like if we said on the phone "oh your condition is (immeadiate/urgent/non-urgent) the ambulance will be there within X" people freak out and say "oh but it's an emergency!".

Well you go to ED and tell look at you and say, go sit in chairs the nurse will be out when they can.

Nana who goes to ED with a good story, history of CHF and eh, sort of SOB but few crackles will probably wait what, 30 minutes? If that job comes down the pipe to ambo it's immediate priority one, lights and sirens off we go! See the disparity?

My bet is that this "poor response time" blowup is to whip up a bit of fear and get some more money.

Here's what I'd like to trial:

Immeadiate life threat - Category red, ten minutes 90% from time of dispatch

- Cardiac or respiratory arrest

- Choking

- Life threatning asthma or anaphylaxis

- Undifferentiated chest pain with no cardiac history

- All trauma that is not "obviously simple"

- etc

Potential life threat - Category yellow, fifteen minutes 90% from the time of dispatch

- Chest pain with cardiac history

- Uncomplicated known seizure patient with single seizure < 5 minutes now stopped

- Known diabetic history that is altered but no recent history of non compliance

- etc

Unlikely life threat - Category green, thirty minutes 90% of the time

- Isolated trauma

- Flu

- Controlled, minor bleeding

- The "not sure you should be ringing us but we'll see what we can do for you anyway" crowd

Five Key Questions

- Address

- Phone number

- Is the patient conscious (NOT "is the patient completely awake?")

- Is the patient having difficulty breathing (NOT "is the patient breathing normally?")

- Has this happened before?

The goal of the category green's would be to funnel them out of having to send the ambo's and having some sort of alternate referral pathway.

[tniuqs]

I think you'll find this article describing no link between patient outcome and response times interesting.

-be safe

Interesting Topic:

First comment is one can not compare in any way shape or form rural vs urban vs arrest vs CP vs trauma vs CVA vs asthmatic vs anaphlaxis vs multi trauma well (feel free to add the call of your choice) this is again reinvention of the media EMS wheel by a commentator who is getting paid to generate controversy based on dated information/misinformation.

So with all these studies we ALS providers are not "cost effective" and we should hang up our kits in the lock up and go back to the scoop and run and yet once again perpetuate the myth of the "Golden hour" maybe in the rural areas we should introduce the "Silver 4 hours"

Just my take ... INJURIES SUSTAINED are causing DEATH.

The main page article does suggest that the criteria for the past research and statistics is flawed, no kidding, bring into the mix a plethora of "situations" even the huge abuse of the EMS systems. The global conclusion is that the vast majority of poly trauma patients, GSW and Stabbing Patients actually die, wow rocket science ! So drive drunk or be "texting" on the highway and paste a semi have 2 systems affected, well things are not looking good no matter how fast EMS responds. Then with advanced life support skills attempted the truly DND dang near dead are worked instead of being called on scene one is throwing into that study soup. Then legal duty to act and is the patient actually potently salvageable in the first place ? or are we just forced by legal system to everything because we observed one ataxic breath, with brains leaking out ears ? This ends up being "classified DER vs DOA" the old data base (BLS only)and done by the ER MDs seldom were those patients called DER too just much paperwork. ie Patient had no pulse on arrival.

Out of Hospital Arrest OK, well throw the OPALS studies in the garbage can they are very dated and flawed in many ways based on old standards and in a under funded ALS system and justify continuation of under funding of ALS.

The conclusion was the sooner CPR is started the better the chances of survival WOW that cost 2 million (I was informed) and now in Toronto the IAFF has jumped all over "response time" to pad their budgets and justification to put and AED and respond a Pumper with 4 men instead of funding EMS ... sheesh.

Search OPALS Out of Hospital arrest it is discussed in depth and extensively with comments from those that were actually involved.

The OPALs Trauma studies, well the base line patients in inclusion criteria alone is in error, no RSI, only N/S available (same as BLS) then the extremely narrow margin of difference <cough> ie READ the ENTIRE STUDY and come to your own conclusions.

http://www.emtcity.com/index.php?app=core&module=search&do=quick_search&search_filter_app[forums]=1

Look to the newest of research data out of Seattle and Vancouver and it becomes quite obvious that bystander CPR is making the difference not the plastic flash boxes but after jumping on the AED bandwagon could this have been huge waste of money.And based on the "OLD" heart foundation standards of 15:2 not 30:2 then concept of early electricity, never to mention of life threating arrhythmia interventions hence preventing an arrest interventions as in cardioversion, electrically or chemically or pacing oddly enough, or thromolyics, not to forget that pain relief is never mentioned ANYWHERE! So just how does one quantify those issues ?

Excerpt from the By Margot Sanger-Katz

The Concord Monitor

In passing a reporter no mention of any medical education ?

Multiple quotes from many sources, some based on EBM, most based on conjecture and opinion only.

An error, either in judgment or technique, while performing advanced life support skills, can have catastrophic consequences. "At the basic level, it's pretty difficult to kill someone. At the medic level, it's pretty easy," said Weare EMS Capt. Bob DeStefano, who recently completed paramedic training.

Permission to slap this rookie ?

Oddly enough the last too paragraph's is stellar and suggest that more bystander CPR be done perhaps forgetting that one actually needs an ambulance to move that patient to the ER ?

I would love to see a "cost efficacy study" now on the Pubic Assess to AEDS (get it right these are not defibrillator's they are plastic brains dealing with ONE arrhythmia )then too door discharge, the cost of putting flash boxes everywhere is astronomical. Then in addition to this study completely eliminate the BLS level entirely then study the under 8 min of ALS arrival vs over 8 mins arrival?

I would conclude just based hypothetically if the moneys used ie Public access to AED costs was redirected to improve to ALS EMS services and the "perfusing patient to the ER door" would be vastly different situation.

cheers

<edit for data base error and foolish scrambled thoughts>

Edited December 22, 2009 by tniuqs

[melclin]

Immeadiate life threat - Category red, ten minutes 90% from time of dispatch

- Cardiac or respiratory arrest

- Choking

- Life threatning asthma or anaphylaxis

- Undifferentiated chest pain with no cardiac history

- All trauma that is not "obviously simple"

- etc

Potential life threat - Category yellow, fifteen minutes 90% from the time of dispatch

- Chest pain with cardiac history

- Uncomplicated known seizure patient with single seizure < 5 minutes now stopped

- Known diabetic history that is altered but no recent history of non compliance

- etc

Unlikely life threat - Category green, thirty minutes 90% of the time

- Isolated trauma

- Flu

- Controlled, minor bleeding

- The "not sure you should be ringing us but we'll see what we can do for you anyway" crowd

Five Key Questions

- Address

- Phone number

- Is the patient conscious (NOT "is the patient completely awake?")

- Is the patient having difficulty breathing (NOT "is the patient breathing normally?")

- Has this happened before?

The goal of the category green's would be to funnel them out of having to send the ambo's and having some sort of alternate referral pathway.

That's not terribly different to what we have now. Our Red ('priority zero' is only for cardiac arrest to my knowledge), and there is too much in our Yellow (Code 1). It would be good to see one or two things moved from Code 1 to P0, and from Code 1 to Code 2. I feel like Code 3s are the domain of the NEPT people/primary care referral and for the most part they seem to be. The ambulance service doesn't seem to get that many code 3, not so many that it cripples us. Although there are a great deal of Code 2 that should be Code 3s or nothing at all. I went to a job recently, where the guy had fallen over and grazed his knee the day before at the market, he got up finished his shopping, drove home, put a band aid on it and took some panadol. The next day at about 13:00 one of his friends calls the ambulance (I get the feeling she thought they'd get in quicker if she did). No pain, no dangerous body area, no problems with mobility and ample opportunity to to seek help themselves. He could drive and he had three other people there who could drive. How is that a Code 2?

I would love to see a "cost efficacy study" now on the Pubic Assess to AEDS (get it right these are not defibrillator's they are plastic brains dealing with ONE arrhythmia )then too door discharge, the cost of putting flash boxes everywhere is astronomical. Then in addition to this study completely eliminate the BLS level entirely then study the under 8 min of ALS arrival vs over 8 mins arrival?

I would conclude just based hypothetically if the moneys used ie Public access to AED costs was redirected to improve to ALS EMS services and the "perfusing patient to the ER door" would be vastly different situation.

I would very much agree with this although I think it depends what you mean by public access. I think AEDs have a place on first aid teams at big events, with life guards at big beaches etc. As for having one tucked away in the first aid cabinet at a shopping centre...I cant see that helping to be honest. In any case I think this will become less of an issue as AEDs become cheaper. Eventually they'll be so cheap that diverting money away from them would be a drop in the ocean when you added it to the budget of the an an ALS service. In that case what little benefit they do have may become worth it if each unit only sets you back an insignificant amount of money.