Open Journal Systems

OPINION ARTICLES

Received: February 23^rd 2015

Judged: October 21^st 2015

Reflections concerning the care process in the emergency medical services

Jorge Alberto Castañón-González,^a Tomás Barrientos-Fortes,^a Carlos Polanco-González^a

^aFacultad de Ciencias de la Salud, Universidad Anáhuac, Huixquilucan, Estado de México, México

Communication with: Jorge Alberto Castañón-González

Teléfono: (55) 5407 0813

Email: jorgec@prodigy.net.mx

In this paper we share some reflections regarding the care process in the emergency medical services, as well as some of the challenges with which these fundamental services deal. We highlight the increasing amount of patients and the complexity of some of the clinical cases, which are some of the causes that lead to the overcrowding of these services.

Keywords: Emergency medical services; Crowding; Triage

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As key components of our country's health sector, emergency medical services (EMS) face numerous challenges affecting their performance. Among them, for the great impact it has on the efficiency and quality of medical care, and the steady increase in demand for this care regarding the volume of patients and complexity of cases. This demand is associated with poor interaction between this service and other components of the health sector, particularly with the other EMS in their geographical area and in general with the various outpatient and patient referral services.^1-3 This problem increases demand for beds and therefore the saturation of EMS, and runs in parallel with society’s great expectations of staff efficiency, processes of care, and patient safety, given that delays in medical attention cause frustration in them, their family, and the health team, in addition to increasing costs of medical care and especially risks to the patient.^4,5  

Although Norma Oficial Mexicana NOM-027-SSA3-2012 states that patients should not stay in the EMS longer than 12 hours for reasons attributable to health care,⁶ extended stay in those services for more than four hours is seen as a key component for saturation of the service. It is imperative that every doctor and administrator critically review the process of care in their emergency medical services and identify and correct deviations in subprocesses to improve their efficiency and effectiveness, especially those that directly impact the quality of care to prolong the time spent in the service, increasing resource use and costs of care. With this purpose in mind we present these reflections and comments.

Because EMS must guarantee patients the precise care that they need in a timely manner, these services use a risk management system called triage. This system ensures that patients are cared for according to clinical priority and not by order of arrival, as it manages the flow of patients in a safe manner even when care needs exceed the capacity of these services. The development of nomenclature, definitions, and solid methodology together make this system replicable and auditable between health professionals.⁷ The allocation, accommodation, and distribution of patients, as well as the initial medical assessment in the service, should ideally not take longer than 20 minutes.

Triage systems in the emergency department were originally more intuitive than methodical, and therefore were not replicable and auditable among professionals. Standardizing triage processes facilitated common understanding among personnel of the service, hospital, or institution on the needs of patient care; it also allowed the distribution of the workload for service providers.

As physicians, we know that diagnosis is invariably linked to the clinical priority, because this reflects the sum of a number of aspects of the particular situation in which the patient arrives, such as the diagnosis. Triage gives the doctor, nurse, or paramedic a rapid classification of the patient in terms of clinical priority and the possibility for treatment in this service, thus contributing simultaneously to the organization of the service. For this, a common system of nomenclature and definitions is used. Patient classification is done in five categories, which are assigned a number, color, and action, defined in terms of a key time for first contact with the doctor. The consensus now reached results in the triage scale, shown in Table I.

Over the past 30 years it has been established that the triage scales are five classification levels worldwide, but the wait times are locally established, influenced more by political issues than clinical ones, especially in lower priority levels; despite this, the concept of different clinical priorities remains. Broadly, the method of triage requires professionals to select the different clinical presentations of a number of signs and symptoms in each priority level. Signs and symptoms that differentiate between clinical priorities are called discriminators, and they are arranged in a diagram for each form of presentation (clinical presentation diagrams). Discriminators that indicate higher priority levels are the first to be looked for. Usually, patients are classified in a "normal" clinical priority if those discriminators do not exist. It is easy to confuse the clinical priority given to a patient and the management of their clinical episode. It is therefore important to remember that the clinical priority requires gathering the sufficient information to classify the patient into one of the five categories or levels defined above. Meanwhile, the management of a clinical episode may also require a deeper understanding of the needs of the patient and may be influenced by a number of external factors such as time of day, the availability of medical groups from different specialties, and the number of beds available. This will not affect the underlying clinical priority, which determines the priority of care and not the priority of the care circuits in the clinical service.

Proper implementation of a strict triage auditing method is critical because it must be shown to be replicated between among professionals and EMS’s.

Triage (determination of clinical needs as a method of clinical risk management) can be applied to other clinical contexts in which it is important to detect any change in patient clinical status as soon as possible, for example, in the medical hospitalization or surgery services. To take advantage of this surveillance, many centers have implemented these systems and have termed them "early warning". These are associated with "medical rapid response teams" formed by internists, intensive care doctors, and anesthesiologists who immediately respond to the alerts generated.

In summary, triage is an essential part in managing clinical risks for EMS when the workload exceeds their capacity, as it offers a system for allocating clinical priorities that is transmissible, replicable, and auditable. It is not designed to identify patients who come to the emergency room rightly or wrongly, but is geared for patients who require medical care to be treated at a suitable time interval.

In an efficient service, diagnostic evaluation and initial medical treatment in the emergency medical service should consume most of the patient's remaining time in the service, because the great concentration and availability of diagnostic and therapeutic medical equipment in emergency services in most cases allows the rapid identification and treatment of the disease or syndrome that was the reason for coming.

Many internal and external factors affect the process of evaluation and treatment in EMS, for example, the cohesion of health teams (medical and paramedical), quick access to patient information (electronic or paper medical record), the quality of information and communication systems, the rapid availability of interdisciplinary medical specialists, the nurse-patient ratio, the doctor-patient ratio, and fast access to and efficient use of diagnostic laboratory and imaging tests, among others; but the cognitive aspects of diagnosis and treatment are the physician’s cardinal functions; when these functions are suboptimal, all other health care-related processes are put at risk. 

Diagnostic uncertainty is common among doctors working in EMS, because there is not always enough objective data to establish a diagnosis and develop an effective treatment plan. Attending to patients presenting at emergency medical services with problems that may be confusing or contradictory, characterized by incomplete, imperfect, inconsistent, and even incorrect information, will always be a challenge for the clinician. Patients can present themselves in the emergency medical service and tell the doctor or nurse in charge of triage information that is "tangential" to the real underlying problem, or can simply communicate a symptom that is most bothersome or concerning but which may not be related to the underlying disease. It is worth mentioning here that throughout most of the health history of our country, support and programs for older adults were few and to some extent irrelevant, since most of the population died before getting old. Today, with the demographic transition, older adults are an age group that is in crescendo and that, because of their functional status, comorbidities, variability in social and family support, polypharmacy, cognitive impairment, and depression, demand a lot of time and care resources in the emergency department. Approximately 25% of older adults evaluated in EMS present alterations of consciousness, either due to delirium, dementia, or both. As an age group they are at increased risk of repeated EMS visits, of being hospitalized, and of being diagnosed incorrectly or incompletely; therefore, they are likely to be discharged without complete diagnostics, with unidentified and untreated conditions, so they have increased risk of death when compared with other age groups.⁸

EMS attention for patients requiring palliative care has increased substantially, which complicates the doctor’s job, because even though they recognize that medical interventions change gradually during a serious illness in this subgroup of patients, its initial purpose being properly "healing", moving towards palliative care, this transition is not always clear for the emergency physician, which frustrates family members, doctors, and paramedical staff with the "information gaps ", with aggressive and unnecessary therapeutic interventions in these patients, and poor communication and coordination between treating services.

All doctors work under time pressure, which is particularly acute in critical hospital areas such as EMS; hence the importance of carefully choosing the questions to be asked in the interview (when this can be done). Many patients do not recall key medical history information without a clinical record available (first time patients), and we lack of any kind of extra information to help fill in the "information gaps", as often happens with patients who do not remember what medications they are taking.

For each patient we make numerous decisions about their symptoms, findings from physical examination, clinical context, laboratory and radiology tests, other imaging studies, and so on. If we multiply these decisions by the number of patients evaluated in a saturated emergency service, per doctor and per shift, then they come to count in the hundreds, which increases the risk of errors in medical care.

The inability to admit patients to the hospital for lack of beds on floors or in hospital services is identified as the main cause of saturation of the service, which requires EMS to keep these patients in the area until there are hospital beds available or the patient is transferred to another hospital, an issue that reduces the response capacity of the whole service to admit and treat new patients.^9,10 This problem also causes the redirection of ambulances with patients arriving directly from the area of ​​the accident or serious clinical event, or who are referred from other clinics and hospitals. The continuous and prolonged treatment in the emergency department of patients who should be hospitalized consumes doctors’ and nurses’ time and attention and delays the evaluation and treatment of new patients. Many internal factors and others external or unrelated to EMS contribute to this problem, such as the lack of beds in the hospital's services, the inflexibility of the nurse-patient or doctor-patient ratios, lack of staff (usually nurses), isolation techniques for ill patients, delays in "administrative" discharge or cleaning beds after patients leave hospitalization, delays in planning and scheduling outpatient follow-up for patients who are being discharged from the hospital (failure of the hospital pre-discharge system), and so on. All these factors are a bottleneck that prolongs the stay in EMS unnecessarily.

The number of readmissions to these services after 48 hours of discharge is an adequate indicator of quality because it identifies inappropriate expenditures or a barrier to access to medical care monitoring and control.

Of the many factors that determine EMS saturation, some originate in the emergency room itself, others in different parts of the hospital, and some are even caused by the actual health sector. The diversity in size, location (urban, suburban, or rural), type of hospital where the service is, geographic area, coverage, infrastructure, number and training of personnel, equipment, budget, type and degree of control of its processes, among other factors, make all EMS different; for these reasons, as a physician or administrator it is useful to functionally analyze emergency department saturation from the perspective of the service itself, as it allows us a systematic understanding of the problem. This approach will allow us to measure and try to solve the problems that are rooted in the service itself.¹¹

References

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10. Moskop JC, Sklar DP, Geiderman JM, Schears RM, Bookman KJ. Emergency department crowding, part 2 - barriers to reform and strategies to overcome them. Ann Emerg Med. 2009;53:612-7.
11. Polanco-González C, Buhse-T. T, Arreguín-Nava R, Castañon-González JA, Samaniego-Mendoza JL, Villanueva-Martínez S. Respuesta: índice de saturación modificado (ISM) en el Servicio de Urgencias: ¿Otro índice más? Gac Med Mex. 2015;151(4):557-8.

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