Pre-Hospital Care Reports A Quality Improvement Program

1. Pre-Hospital Care ReportsA Quality Improvement Program Karl W. Klug, B.S., EMT-CCDeputy Chief of OperationsSuffolk County EMS

2. Remember when? Leah, did you fill out a PCR on that guy? Patchogue, please report to Triage with your patient….Brookhaven out. Ummm, no Ron, I thought you were going to…

3. What’s the PCR’s Purpose? • Statewide data collection system • Serves as a confidential and legal medical record • Quality Improvement instrument • Standardized format for all providers • Instrument to provide continuity of care between prehospital and hospital settings • Recently revised as Version 5 (2/04)

4. Housekeeping Rules • NYS-DOH states agencies need to have written policy dictating guidelines for completion, storage, access, and release of PCRs • Medical Records can only be released on certain conditions (more later!!!)

5. When should a PCR be completed? • One PCR for: • Every patient on every call • Treated by one unit transported by another (004) • RMA w/ informed consent (005) • Call canceled (006) • Stand-by only (007) • No patient found (008) • Every event i.e. Lift assist … (010) • To document every request for EMS that your agency receives, whether you handle the call, or not, or whether there is a patient or not

6. Other Response • A PCR is to be generated for every request for ambulance response • Call canceled enroute by PD, MedCom, or chief • No crew shows up and you 24 the call • Fire standbys for the local FD • Ambulance response to fires within your own FD

7. Who gets which copy? • WHITE (original) retained by the EMS agency • PINK stays with the patient in the emergency department • YELLOW is forwarded to Medical Control For screening, local quality improvement, and submission to Statewide data processing • May be exceptions for regionally-approved studies, i.e. intubation confirmation, AED use, etc…

8. What about “No Transports”? • DOA or Field Discontinuance of Prehospital Resuscitation • Cancelled while enroute by PD / Chief • Unfounded • RMA • Treated but refused transport • Stand-by

9. What about “No Transports?” • On “no transports” the Agency is responsible to mail the yellow copy to Medical Control by the 20th of EVERY month to: Stony Brook University Medical Center Department of Emergency Medicine - EMSSUNY at Stony BrookStony Brook, New York 11794-8350 Attn.: PCR Inspection

10. Tiered Response • For every patient, for every leg of the trip From same agency = 1 PCR • NYS DOH 02-05 (supersedes 93-05 and 85-01) • When flycar arrives at scene before ambulance –in old BLS manual, has been changed From different agencies = 2 PCR’s • Each documents only what their service did

11. PCR’s are....... • Medical Records - Permanent part of the patients chart • Legal Documents - Proof of your assessment and treatment • Standardized Records - Statistical collection of Statewide information

12. Confidentiality • The form and information contained on the form is confidential • EMS providers have a legal obligation to protect the confidentiality of patients • EMS Providers must comply with new federal HIPAA requirements

13. HIPAA • Promulgated in 1996, Compliance effective April 14, 2003. • Covered entities include • All providers of health care services • billing clearinghouses • insurance plans • Effects our • PCR retention schedule • use of PHI as part of the QI process • release of PHI that you collect

14. The PCR should be a reflection of... • Assessment of patient and scene • Care rendered by crew

15. And should include... • Pertinent +/- findings • Interventions • Changes in status • Response to those changes

16. And should include... • OPQRST • SAMPLE • All Vital Signs • Head-to-toe exam, vectored when appropriate

17. SOAP • Subjective: what the patient tells you, history of the present illness • Objective: P/E, +/- findings • Assessment: prehospital impression and differentials • Planof treatment: what you did and the patient’s response to the treatment

18. What To Write • Chief Complaint - in the patients own words • Subjective Assessment - history of present illness • events leading up to..., secondary complaints, MOI • Presenting Problem - simple check-box format • PMH/Meds/Allergy - document all pertinent history • be aware of heart/lung disease, diabetes, seizure

19. What To Write • Objective Physical Exam - Systematic approach, cover all body areas and don’t forget pertinent negatives How you found the patient, what problems you found, what you did to fix the problem, and the response to your efforts to fix the problem

20. What To Write • Treatment Given - simple check-box format • Continuation Form for ALS suggested but not required (with the exception of controlled substances) • Disposition - Don’t forget the code • Crew - Names and State EMT numbers only! Badge/member numbers are UNACCEPTABLE!

21. Why The Need For A Comprehensive PCR? • Enhance patient care • Enhance your position as a health care professional • Ensure that your EMS agency has satisfactory legal evidence documenting the response

22. Limit Your Liability • September 2002- EMS crew in New Jersey transported a patient to local ED after suffering a blow to his head • Hospital discharged patient after concluding that injury was not serious • Patient developed seizures, became comatose and was declared brain dead 4 days later and died • ER Physician stated he “would have ordered CT scan if [he] knew patient had vomited” • EMTs were found to be negligent and liable for wrongful death for FAILING to document prehospital episodes of vomiting

23. Writing Styles • Divergent • Takes into account all aspects of a complex situation Patient fell down a 30 foot embankment with multiple injuries • Convergent • Focus on the most important aspects of the situation Patient is apneic with a pulse

24. What about ALS calls? • Pre-Hospital Care Report Continuation Form • Anytime a medication is administered, the Continuation Form should be used • Controlled Substances require the use of the Continuation Form

25. What about Albuterol and Epinephrine? • EMTs may administer nebulized Albuterol and Epinephrine via auto-ejector; the administration of these drugs must be documented on the PCR • Patient-assisted medications (i.e. nitroglycerin and/or bronchodilators)must be documented on the PCR

26. NY State Trauma PCR For all patients who’s presenting complaint is traumatic in nature, regardless of severity or cause, and regardless of whether or not the patient is transported to a trauma center. (some still around…data points captured in RescueNet TabletPCR)

27. Yep…I’m braggin’ here ! • Good documentation may protect everyone • Poor documentation protects no one Which would you rather have on the stand with you?

28. What About Mistakes? • Change on all copies - strike with line and initial OR • Re-write and destroy white and pink copies; retain yellow copy, void it and submit to Medical Control

29. Who should have access to completed PCRs? • Agency officers • QA Committee • Training Coordinators • System/Service Medical Director • NY State EMS Representative • Other Agencies that participated on the call • Patients / Legal Guardians of Patients

30. As a Medical Record, PCRs should only be released when presented with a: Subpoena Medical release form signed by the patient, guardian, or estate (for legal purposes) When requested by a patient or legal guardian (routine purposes) EMS Division QI follow-up request Medical Record

31. Legal Record • As a Legal record, all PCRs should be completed before : * Copies are separated * Leaving the receiving hospital

32. Lets Clear Up the RMA Issue In the event that an ambulance is dispatched to call where both individuals at the scene and EMS personnel believe that no injuries exist and that there are no individuals requiring or requesting EMS assistance, the appropriate PCR code 008 (gone on arrival) or 009 (unfounded) shall be used. An RMA signature is not required, but may be obtained if desired. A PCR, however must be completed. A physical assessment may be necessary to make a “no patient” decision. Also, remember to consider High-Risk Criteria before making a “no patient” found decision. If in the judgment of EMS personnel there is a patient at the scene who requires treatment and/or ambulance transport, but refuses, Medical Control must be contacted in an attempt to convince the patient to permit appropriate care.

33. Lets Clear Up the RMA Issue In the event that a patient receives treatment, but refuses transport by ambulance, and the EMS provider agrees that ambulance transportation is not warranted, then medical control need not be contacted. This becomes a “treat and release”, or a “refuses further medical assistance.” This decision and any recommended follow-up should be noted on the PCR and an RMA signature obtained. In the event that the EMS provider believes that ambulance transport is indicated, Medical Control must be contacted.

34. Review of High-Risk Criteria • Altered Mental Status or suspected head injury • Glasgow Coma Scale less than 15 • Less than 18 or older than 70 • Neurological, cardiac, or respiratory signs and symptoms • Abnormal vital signs • Alcohol or drug use • CO exposure • NO RADIO CONTACT FOR RMAs

35. Bottom Line • Very few situations turn out to be “unfounded” • If all parties neither require nor requested EMS and there is no mechanism of injury • Inadvertent personal / home medical alert alarms • There are no protocols or procedures in NY State that allow for EMS provider-initiated refusals • Your duty to act begins when you accept the 911 call

36. Common Weaknesses • No record of patient status after treatment given • Focused assessment does not match presenting problem • No Documentation for reasons something can’t be done

37. Common Weaknesses • Pertinent negatives omitted • Incomplete physical examinations • Lack of Repeat Vital Signs, when indicated • Use of non-standard medical abbreviations

38. Some Beauties… • Spontaneous Idiopathic Fernoquadriplegia or Spontaneous Idiopathic Strykerquadriplegia: The condition in which the patient suddenly develops total body paralysis while transferring them from your Ferno or Stryker stretcher onto the hospital bed (usually affects patients over 350 lbs). • Economically Challenged Urban Outdoorsman – politically correct term for a homeless person • Gravity Storms – causes of a rash of falls and fall-related injuries

39. More Beauties… • Anti-Gravity Storms - The cause of accidents with ejections • NKDA – Not Known, Didn’t Ask • Vitals WNL – We Never Looked • TMB – Too Many Birthdays • ART – Assuming Room Temperature • CTD – Circling the Drain • Just Kidding!!!

40. Common Omissions • Date • Agency Code • Type of Alarm • Response Times • Presenting Problem • EMT Number • Location Code (Geocode) • SSN - Last 4 digits only vs 0000 or all 9 digits

41. Rejected PCRS • Will be returned to you for completion • May inhibit your QA/QI efforts • Increases liability • Agency does not receive credit for number of responses • Reduced future delivery of PCRs

42. Karl’s Pet Peeves • “Sluggish Pupils” (is that before or after algebra?) • Measuring the depth of lacerations (hopefully that ruler is BBP compliant!) • Using the dispatch data as the chief complaint (I didn’t think the person said “I’m having an MVA”) • The term “neuro deficit” (were you able to measure that?) • The A&O x 3 scale (wasn’t that a Railroad in Monopoly?) • If you use a medical word - know what it means and how to spell it (hey- Anna Falaxis, is that you?)

43. Yes, I actually saw these... Please help me... • John Dow • Posed Dictal • Sinkable • Groinal Area • Consous • Reveils • Difrederick • Antiobiodack • Glue Coast

44. Helpful Hints Your PCR should be like a math problem….. • Subjective Interview + • Objective Examination • =Treatment Plan Prehospital Impression Interventions Response

45. Helpful Hints • If you want to do it, and the patient doesn’t let you - tell them why they need it, and what may happen if you don’t do it - and DOCUMENT IT AND GET A SIGNATURE • If the protocol calls for it and the patient doesn’t want it - tell them why they need it, and what may happen if you don’t do it - and DOCUMENT IT AND GET A SIGNATURE

46. Helpful Hints • If the protocol says you need to do it - and you can’t do it - DOCUMENT IT on the PCR.

47. Supporting Documentation • Public Health Law Article 30 • NYCRR Part 800.21 • NY State EMS Policy Statement 02-05 • Suffolk County Operations Policy 2-001

48. What about changes after the PCR is submitted? • Complete an addendum for the original record • NEVER alter the original service copy • Provide copy of changes to hospital and State for their records

49. Let’s Look at a Few PCRs…(The Good, The Bad, and The Ugly)

50. The Good…