Patient transport codes give paramedics options
EDs in Akron, OH, have created a novel, tiered transport program that allows paramedics to rate patients according to how urgently they require care. When paramedics respond to a 911 call, they call medical control and recommend a transport option using one of three codes. "They may say, We have a 6-year old who fell and hit his head, with brief loss of consciousness. We feel a code 3 transport is appropriate,"’ says Kim Jetter, RN, EMT, pediatric EMS coordinator at Children’s Medical Center in Akron.
If the paramedics believe the patient doesn’t need immediate transport, a different code is used. "The paramedics can [make] that patient to a Code 2 transfer, which frees up the paramedics to get back into circulation," explains Norman Christopher, MD, FACEP, director of emergency and trauma services at Children’s.
They also have the option to not transport the patient at all. "Code 1 transport is actually a non transfer, because an emergency does not exist. They may feel the child is fine to drive to the hospital or doctor’s office. This protects a valuable resource," says Christopher. "Our paramedics are getting back into circulation more quickly, instead of being tied up with non-emergency work."
The following codes are used:
Code 1: No transport. "Those are your really minor injuries, such as a cut hand," says Roger Hoover, district chief for EMS at the Akron Fire Department. "In that case, we will dress it, wrap it up, and call it in. But the patient is made a code 1, meaning they do not need an ambulance for transport."
The decision is always jointly made by the paramedics and the physician at med control, says Jetter. "They both need to be comfortable with the code 1 status," she adds.
Code 2. Transport by private ambulance. "Once it’s determined a patient is a code 2, a private ambulance is called. They are supposed to guarantee a 15-minute response time," says Hoover. "We stay until they assume care of the patient. The patient is then transported to the hospital, and the team is freed up and back in service. This way, they are able to immediately respond to another call."
Examples of code 2s include post-seizure patients, diabetics who need to be observed, and most orthopedic injuries. "These aren’t life- or limb-threatening conditions, and they don’t need a lights-and-siren ride. The extra time won’t make a difference in care, and they will likely be waiting in the ED for several hours before they are evaluated," says Hoover.
Code 3: Transport by ambulance. "This is the highest level of transport, for life- or limb-threatening conditions, such as severe trauma, chest pains, uncontrolled seizures, imminent childbirth, and strokes," says Hoover.
Paramedics freed up
Patient care is improved because delays are reduced, says Jetter. "The last thing we want to do is needlessly tie-up a squad, especially if the whole city is busy. If we have med units unnecessarily tied up, their response time is longer and that can be detrimental to a patient," she notes.
The system ensures that patients are treated appropriately. "A lot of non-urgent care isn’t dumped on the hospitals, and the public is educated that EMS is not a taxi service," says Christopher. "The impact that it has on ED care delivery is incredible. Because our paramedics remain in service, our EMS staff isn’t twice as large as it needs to be. They are doing what they are trained to do, instead of providing a carpool service for families."
A smaller force is able to focus its resources on patients who need its level of skill, says Christopher. "This ensures availability of higher level providers in the field, and better triage," he notes.
The arrangement with private ambulances also helps when there is a catastrophe, notes Hoover. "By allowing them to generate the revenue from Code 2s, we have a built-in backup system when we need it. The worst thing is to not have anybody to respond. We had a couple close calls on very busy days," he explains. "For example, if we have a bad car accident, and several units are out on other calls, there may not be enough units to handle it. If we need a few private ambulances, they will drop anything else to respond to our requests."
Failsafe system
If there is a disagreement about which code should be used, the higher code always prevails, says Hoover. "If the paramedic says to the physician, Based on our evaluation we feel this can be a code 2, but the physician feels it’s a code 3, the physician wins, or vice versa," he explains.
A failsafe system ensures that a decision is never made to downgrade a patient’s status without a physician consult. "If for some reason med control cannot be contacted, then no matter how minor the problem, the patient is transported Code 3 by the ambulance," Hoover explains. "A perception exists that the paramedics make the decisions by themselves and if they don’t want to bother to transport a patient, they’ll make it a code 2, but that’s never the case."
Strict controls are used. "The paramedics would never make a decision to not transport a patient without contacting medical control first," stresses Christopher. "If they explain that a child vomited two weeks ago and it doesn’t appear to be anything urgent, I have the option to ask more questions or not agree with their decisions. The onus is on us to review our medical control decisions."
The Code 1 patients are harder to track than Code 2s since the patients who aren’t transported may not come in, notes Christopher. "However, we can follow to see if they come in the next day. That way we can ascertain if a bad decision was made and they wind up sicker," he says. "But from our research, we have every indication to believe that our field triage is accurate. The system is very conservative."
Of 450 calls in a recent month, 160 were made Code 1s. "Roughly one-third of the patients were not transported," says Christopher. " Of that group, about half didn’t wind up coming in. It’s a little troubling that we don’t have accurate follow-up for patients who don’t come in at all."
Patients are never told they don’t need to go to the hospital, says Hoover. Even with Code 1 patients, they are advised that this situation does need further evaluation, wherever the patient chooses to go," he notes. "Paramedics never tell anybody You don’t need further evaluation,’ because that would be a dangerous practice. These are transport modes, not treatment modes."
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