EMS Hospital Alerts


This is a follow up to Handling the Under-Triaged Patient.

Because some patients require time-dependent interventions more than others, certain ones are assigned an “alert” designation.  This creates a streamlined process to minimize delays in triage and registration.  Specialists from other areas of the hospital, or possibly at home, come to the emergency department to assess these patients so that they can receive definitive care faster.

This was adopted from the Golden Hour approach to trauma. Although the hour part has been debunked, severely injured patients still do best when treated at a few specialty hospitals that can get them to the operating room quickly.  The challenge has been identifying which ones truly are severely injured. Stroke and STEMI alerts have since followed, and EMS plays an integral role in getting patients faster care after we drop them off.

I think that EMS sepsis alerts are the next big thing.  Sepsis is a body-wide infection that presents with vague symptoms, which progresses to septic shock.  Many septic patients do not appear acutely ill, and by the time they do it is often too late.  Sepsis can be detected by obtaining a venous lactate level from a device similar to a glucometer.  Sepsis alert patients are treated with IV fluids and antibiotics before shock symptoms appear, which has been shown to reduce mortality.  For more about sepsis, read Steve Whitehead’s excellent EMS World article here.

Ultrasound is another tool making its way into EMS.  We may soon be able to diagnose some causes of abdominal pain and identify patients who need emergency surgery.  This would allow us to make better decisions about what hospital to transport to, both by identifying patients who need a specialty center and safely directing others to community hospitals. This was discussed on the latest EMS Garage Podcast, and on a post by Rogue Medic.

Some skeptics believe that assessment findings are only useful if they can be managed with a needle, drug, tube, or electricity. This was evident when 12-lead ECG’s were first introduced to EMS.   Since all chest pain patients were assumed to be having a heart attack and received same treatment, some ask why they were necessary.  Even if our treatment does not change significantly, lives are saved by us creating a path to the cath lab in the hospital.

We need to embrace that EMS is getting to be less about skills and more about directing patients to the right facility.  Saving patients from being transferred between hospitals is a good thing.  Directing patients away from specialty centers who don’t need to be there is also good.  And hopefully some day we can safely direct patients to resources other than a hospital.

Comments

  1. Agreed about sepsis alerts. Barring toys like bedside lactate, this may really be an example of making a difference by nothing more or less than being the one to say, “Hey, I’m worried about sepsis. Can we put him on THAT treatment pathway?” rather than letting them fall through the cracks. It seems meaningless but it is real.

    • emspatientperspective says:

      Brandon,
      There are signs in triage that address this. Lots of sepsis patients are transported BLS, so triage nurses and BLS crews are reminded to pay special attention to patients who have a fever, respiratory rate above 20, pulse above 90, and a suspected infection.

      • Would it matter if they went ALS, though?

        • In my area, yes. An abstract in Prehospital Emergency Care from an area hospital showed that sepsis patients transported ALS reached hospital treatment goals faster than ones transported BLS. This was before we got lactate monitors and did prehospital sepsis alerts.

          Preliminary data shows that our lactate meters correlate with hospital lab values for venous blood, but not capillary. For now, at least, patients need to have an IV started to find out. If they are septic, we bolus fluid even if they are normotensive. While the amount of fluid we infuse during out transport times is probably not significant, the lactate measurement is.

          Lots of patients have a fever, infection source, and are tachycardic, but most aren’t septic. Sepsis alerts trigger an overhead hospital page, clear a room, and notify a pharmacist and infectious disease specialist. The cost of false alarms is high, so you need the lactate.

  2. Impressive! I haven’t spoken to anyone directly who’s using the lactate monitors. Interesting that you suggest one of the main reasons it’s an ALS tool is that only a medic can “access” venous blood for sampling. How has your experience been with these devices overall?

    The tenets of early goal-directed therapy seem to suggest that, other than early recognition and resource activation, the main things we can do in the field are provide fluid and perhaps draw blood for labs. I’m not sure how much the latter can expedite things but I support the former. I believe some areas with long transport times (I assume yours must be such a system) are playing with prehospital broad-spectrum antibiotics as well.

    I suppose the question here is how to reliably raise the flag for true sepsis vs a simple infection, as you say. But to a certain extent I question how critical this distinction is. Let’s say we have an elderly, immunocompromised patient with many comorbidities and a frank infection. Although their current status is certainly relevant to their treatment and priority, I would suggest that in many cases it’s more of a question of “how far along” they are rather than “how sick” — because if they’re high enough risk, we might as well go ahead and assume they’re going to GET very sick — they’re not going to fight this off with no problems. Whether it progresses to true septic shock is something to find out retrospectively; if we treat aggressively, it’ll never get there, but if we ignore it, we’ll miss our window to nip that cascade in the bud. I’m not saying every infection we see should get “the works,” but there’s a spectrum here, and I think the relative risk calculation supports bias on that spectrum toward high suspicion and early, aggressive therapy. In other words, maybe we can make some of these calls based on risk stratification rather than solely clinical presentation.

    I do think these folks should have medics — as long as the medics are willing to be aggressive too!

    • emspatientperspective says:

      Actually our transport times are relatively short (10-15 minutes average). The amount of fluid we can infuse is probably not significant, and we aren’t talking about antibiotics yet. We are a tiered system, so some patients now get an IV started who would not have in the past. There have also been cases where ALS was cancelled for sepsis patients who deteriorated in the hospital. The push for lactate monitors came after several patients looked fine initially but suddenly crashed. STEMI patients can look fine also, but the ECG triggers a heart alert. Some either has sepsis or they don’t.

  3. That’s a strong statement. So you don’t think there’s any role for clinical diagnosis of sepsis (in the field or otherwise)?

    • emspatientperspective says:

      Not sure what you mean by that. Most STEMI patients are pale and diaphoretic, some are not. The ECG tells us if they need to go to the cath lab. Some septic patients look ill, some do not. Lactate monitors give us a number to tell us how urgent it is for patients to get fluid and antibiotics. More about the hospital system driving this is here.

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