Thirty years ago, ambulance and emergency medical services (EMS) had shifted from the old “Scoop & Scoot” practice that was focused on just getting a patient to the hospital as quickly as possible, to providing initial care and stabilization at the scene ( “stay and play”).
In the new “stay & play” world, the EMS aim was to deliver a stabilized, cleaned up, prepped, and evaluated patient to the receiving ED or care facility. EMS teams were therefore performing a range of monitoring, care, and documentation services previously only done by hospital staff. These included taking vitals; using technology such as electrocardiograms (ECGs); documenting according to standards such as the Glasgow Coma Scale (GCS); conducting detailed inventories of signs, symptoms, and injuries; monitoring progress; and attending to the airway, bleeds, breaks, and more at the scene or enroute to the hospital.
EMS teams were administering certain medical treatments, including gases and IV fluids. They could intubate and bag to protect the airway and perform artificial ventilation, or use equipment to defibrillate where necessary.
However, contact between the EMS teams and the receiving hospitals was often limited to occasional brief radio transmissions relayed from the ambulance to the home fire station and passed on to the receiving hospital.
At early adopter hospitals, a certain amount of advanced contact was possible, and an ED receiving a call from admissions saying, “Victor-Bravo Four was lights and siren with single MVA, bagged and intubated, ETA 12” could react by clearing a high acuity bed, rolling in a crash cart, and alerting surgery and imaging. They would assume that if the EMT team believed it necessary to be skipping traffic lights and running over the speed limits and had intubated the patient that the patient arriving in 12 minutes was an acuity one and in need of immediate attention. Often, the arriving ambulance would be guided in as a priority and met at the receiving door by nurses ready to rush the patient to the cleared bed.
In many cases, however, the receiving hospital would be unaware of the case until it arrived in the loading bay, behind all the other ambulances that were dropping off anything from recently deceased patients to routine admissions and transfers. As a result, there were many delays in care, many important facts were lost in the handoff, often wasted time getting the ambulance crew turned around, and many missed opportunities for the hospital to be better prepared or for EMS to initiate specific treatment during transport or on-scene based on feedback from the hospital ED physician. Likewise, in many cases, the EMS teams would lose sight of the patient after handoff and had no way to use patient outcomes, diagnosis, or physician feedback to improve EMS methods or policies.\
Three categories of risks and issues could be identified:
The transition from “Scoop & Scoot” to “Stay & Play” did not meet with the approval of all emergency medicine physicians or hospital management. Some viewed the emerging role of emergency medical technicians and paramedica with reservations that often bordered on outright disdain. The EMS teams were viewed more by some physicians as upstart laypeople than authentic members of the emergency medicine process.
Although radio-frequency modems and toughened personal computers were available, data transmission rates were low, error rates were high, and there was no world-wide web or internet access as is typical today. Cellular networks were sparse, and the ability to transmit patient data over them was possible, but difficult. There were often no practical means to interface the hospital computer systems (where these existed) with external data sources. While some hospitals attempted fax or teletype solutions for remote admissions data, these were often not robust or reliable.
Thirty years ago, the care workflow interface between EMS teams and receiving hospitals was manual and required a physical face-to-face patient handoff from the EMS team leader to an attending physician. As a result, EMS teams often had to wait in the ED with their patient before physically transferring them to an ED bed and giving an oral handoff to the attending. There was often no documented procedure for two-way communication with an EMS team at the scene or in transit. In some cases, individual physicians and EMTs would establish processes for calling from the ambulance via CB radio and later by cellular phone. However, these often relied on personal relationships and might not survive if either changed roles or moved.
We want to hear from YOU! Please take a minute to answer some or all of the following questions by commenting below. And please feel free to comment on your related experiences! Then come join our live #PWChat Tweetchat on this very topic on February 28 at 3:00pm ET.
- How have attitudes changed in 30 years?
- Are EMS members now part of the EM team?
- How has technology changed in 30 years?
- Is the accumulated patient data transferred intact to the receiving hospital
- How has workflow adapted to including EMT activities?
- Is the ED alerted to case specifics in enough time to be prepared, can the ED talk to EMS while they are still on scene?
- Is there a feedback loop to the EMS crew with outcomes and advice on process improvement?