Emergency Treatment Guidelines: An Introduction to Care Maps & Protocols

Transcription

1 Introduction EMS Branch / Office of the Medical Director Emergency Treatment Guidelines: An Introduction to Care Maps & Protocols The Land Emergency Medical Response System Regulation and the Air Emergency Medical Response System Regulation require that patient care is to be provided in accordance with procedures and functions as set out in the Manitoba Emergency Treatment Guidelines... published by the Minister. Welcome to the Emergency Medical Services Branch (EMSB) /Office of the Medical Director (OMD) Patient Care Maps & Procedures! These new patient care tools are the equivalent of the clinical sections of Emergency Treatment Guidelines (ETG), formerly developed by the Manitoba Emergency Services Medical Advisory Committee (MESMAC) and distributed by the Emergency Medical Services Branch. The new care maps and procedures will be created by the OMD and authorized by the EMSB, on behalf of the Minister. There have been dramatic changes to format, as well as updates to clinical content. The new formats have been developed to support best patient care, education design and delivery, quality assurance and continuing maintenance of competency. All new material is current, evidence-based, consistent with national standards, and aligns with the 2011 National Occupational Competency Profiles (NOCP). Look at A00 Emergency Treatment Guidelines and you will see four categories: A00.1 Patient Care Maps A00.2 Medications A00.3 Clinical Procedures A00.4 Regulation and Administration A00.1 PATIENT CARE MAPS: The concept of a care map incorporates elements of both a guideline and protocol. The care map allows for flexibility within some established parameters. They are strictly prescriptive for those with a basic scope of practice such as those licensed at the Technician level. However, they allow for greater clinical discretion for those with more experience or a broader skill set, such as those licensed as Technician- Advanced Paramedic. They will be applicable for all license categories, all provider skill levels, primary response and interfacility transfer missions, and for air as well as ground platforms. Look at the table of contents A00.1 Patient Care Maps. Every care map will have a version date. The updating, maintenance and revision of the care maps will be a continuous process and the version date will help authors and providers remain current and organized. The clinical care maps are divided into eight categories: A - General Assessment B - Airway & Breathing Management C - Resuscitation & Emergency Medical Conditions D - Child Birth & Newborn Care E - Medical & Non-traumatic Conditions F - Traumatic & Environmental Conditions G Transport & Interfacility Transfer Intro to Care Maps & Clinical Procedures Page 1

2 H - References & Clinical Support Each care map will have a unique alpha-numeric identifier code. For example, care maps outlining general patient assessment will have an identifier beginning with the letter A, while care maps for airway management will have identifiers beginning with the letter B, and resuscitation care maps will begin with the letter C, and so on. For many clinical conditions, there will be different versions of the same care map for patients of different ages. Some of these versions will have numerous differences, while some may be imperceptibly different. The age categories are clearly identified on each care map but will also be noted by a different letter after the final digit in the alpha-numeric care map identifier. As an example, C02A is the resuscitation map for adults while C02B is the care map for adolescent resuscitation; and C02C is for child resuscitation, and so on. PCM with no suffix letter will be applicable to all age categories. The standardized age categories are as follows: Suffix Category Age range A Adult 17 years of age and older B Adolescent 10 up to 17 years of age C Child 1 up to 10 years of age D Infant 0 up to 12 months of age E Neonate Newly born up to 72 hours post-partum None All ages 72 hours post-partum and older Near the top of A00.1, is the following statement, highlighted in yellow: License holders are responsible to maintain satisfactory knowledge and appropriate psychomotor skills for the safe application and performance of these care maps, and are required to be familiar with all relevant updates as distributed by the EMSB / OMD. The OMD will eventually be moving away from the current process of annual recertification for all transfers of function to one of continuous maintenance of proficiency for clinical procedures where appropriate. This puts more responsibility on the individual provider to continually maintain their skills, and self-identify areas that need improvement, consistent with the expectations and responsibilities of all self-regulated professions. Initial entry into the care maps for all patients of all ages is by way of one of the following standard assessments: A01 Medical Assessment A02 Trauma Assessment These outline the standard scene and patient assessment for all medical patients or trauma victims. They are the entry point into the more specific patient care maps, and sometimes may be a returning point, as well. The standard assessment care maps will eventually lead into one or more specific care maps, usually by way of the chief complaint or identified clinical condition (H03 - Care Map Entry by Chief Complaint). Intro to Care Maps & Clinical Procedures Page 2

3 Some specific care maps directly accessed from the assessment care maps are utilized for assessment and management of critical situations and include: Resuscitation (C01 & C02) Airway & Breathing Management (B01) Hypotension & Shock (C07) Traumatic Hemorrhage & Shock (F09) Head Injury (F11) Unstable Bradycardia (C05) Unstable Tachycardia (C06) Two additional care maps are often used as adjuncts to the standard medical or trauma assessments. A04 Load & Go will help paramedics differentiate patients who require rapid transport with continuing assessment and treatment en route from those who can be safely assessed and treated on scene and then transported. A03 Multiple Casualty Incidents will be of help in situations where patient number and needs exceed initial resources. Take a look at any care map. Immediately to the right of the MHHLS logo and bison icon is the identifier code and the main clinical category of the care map, such as B01A Airway. Beneath this is the version date of the care map which, if you are holding the most current version, should correspond to the date in the table of contents (A00.1 Patient Care Maps). Beneath this is the age category that this care map applies to. Next to the right, you will see the EMS Branch / Office of the Medical Director. This indicates that the care map has been created within the EMSB by the OMD and its Executive Practice Committee (EPC). However, authorization of the care map must come from the EMS Branch. Below this is the title of the care map. Finally, to the extreme right is a group of icons (see appendix A). These icons each have a different shape, outline, filling and font color and identify which provider can perform which steps in the PCM. For example, all providers can perform steps identified by the white rectangular box, (with appropriate delegation for medications and procedures) while only those with the advanced skills set or greater can perform steps identified by the blue oval box (with appropriate delegation). Each care map will usually be in the format of a flow chart, followed by several boxes. These boxes will contain the INDICATIONS for the use of this particular care map; the CONTRAINDICATIONS to the use of part or all of this care map; and NOTES pertinent to the application of the care map. Some care maps may have one or more appendices containing readily accessible important clinical information, such as common causes of a certain clinical conditions. With many of the new care maps commonly used drug dosages will be included in a red box beneath the flow chart. At the bottom of each care map will be a running title and its identification code. Some sections found in the previous Emergency Treatment Guidelines and Protocols are noticeably absent from the new care maps. This information can usually be found in standard reference texts or EMS journals. While such information is important in preparation and training for patient care it is not usually required at the point of patient care. Specific information on medication administration or clinical procedures will now be found in A00.2 Medications or A00.3 Clinical Procedures. Intro to Care Maps & Clinical Procedures Page 3

4 A Few Words about the Flow Charts: Performance studies show that flow charts are often easier to utilize at point of care compared to wading through pages of text. In regards to the flow diagrams themselves, you will notice boxes with different shapes, outlines, filling and font colors. These boxes align with the provider skill sets as indicated in appendix A. The white ones contain decision points (questions) or imperatives (actions) that all providers at all license levels will undertake (with appropriate delegation for medications and procedures). These actions include the administration of basic medications and performing one or more of the universal set of procedures. The pink rectangles contain actions for all paramedics with the primary skill set, or greater. The green boxes contain actions for providers the intermediate skill set and above. The blue rectangles outline actions for advanced level providers, while the red octagons indicate those for critical care paramedics. If you look at C02A Advanced Resuscitation Adult as an example, there are two greyed-out boxes where the basic and primary boxes are usually located. This indicates that this particular care map applies only to those with the Technician-Advanced Paramedic license level or to those Technician- Paramedics under special considerations. One way arrows indicate a forward progression of steps, such as doing another action or referring to another care map. Bidirectional arrows indicate that one is to move on to a different step or care map that may, or will, eventually return to the original referring map. If you look at A01 Medical Assessment as an example, the white rectangular box Assure patent airway & adequate breathing leads to another white rectangle with a two-headed arrow. This means that either you refer to the Airway & Breathing Management care map (and may be returned to A01), or use them concurrently as appropriate. Although as an educational strategy we talk about steps occurring sequentially, experienced providers recognize that multiple steps in patient care are often occurring simultaneously or nearly so. Looking at A01 Medical Assessment again, you will notice that references to care maps appear in bold-faced print ( Load & Go ) while actions are not emboldened ( Contact legal authorities ). In keeping with the OMD philosophy (and supported by a burgeoning body of evidence) that providers at the scene are often best situated to determine patient needs, we are building discretion into many of the care maps. For example, if you look at the VF/VT Algorithm in care map C02A Advanced Resuscitation - Adult (algorithm A) you will see the phrase Consider hyperkalemia in a green rectangle. This word consider enables providers with an intermediate skill set and above to use their own clinical judgement. And although we may not always be correct in our judgements (health care providers are only human) we can design tools (such as our care maps) that create a safe process for providing good patient care. Although these changes in design, format and process may seem a little daunting, we hope that as users work through our new care maps, they will work for you and your patients: these are your tools. We will always welcome any suggestions for revision or improvement. Intro to Care Maps & Clinical Procedures Page 4

5 A00.2 MEDICATIONS : The second major category of patient care tools are the protocols for medication administration. These will replace many parts of the previous Emergency Treatment Protocols. These are grouped into five sets (see also supplement Z05.2 Delegated Acts Medications): Emergency Care (Basic) Medications (white rectangle) Primary Care Medications (pink rectangle) Intermediate Care Medications (green rectangle) Advanced Care Medications (blue rectangle) Critical Care Medications (red octagon) A00.3 CLINICAL PROCEDURES: The third major category of patient care tools is the protocols for clinical procedures and they too will replace much from the previous Emergency Treatment Protocols. These are also grouped into five sets (see also supplement Z05.1 Delegated Acts Procedures): Emergency Care (Basic) Procedures (white rectangle) Primary Care Procedures (pink rectangle) Intermediate Care Procedures (green rectangle) Advanced Care Procedures (blue rectangle) Critical Care Procedures (red octagon) Initially, the OMD will work with all Regions and Services to ensure that their existing clinical protocols are in adherence to the standards as set by the Minister. Eventually, the OMD will become the sole authorizing agent for Manitoba. Rather than continuously re-inventing the wheel, the OMD hopes to leverage the good work that already exists throughout the province for the benefit of all providers and patients At the OMD we intend to move away from the current so called current merit badge approval process for delegation of reserved medical acts (transfers of function) to a standardized scope of practice that includes a uniform group of skill. These skill sets will be in accordance with the 2011 NOCP. Although allowances will be made for unique regional needs and operational realities, we intend that providers at particular provider and / or licensing level will have the same skill set throughout the province (appendix A). For example, if a provider can do an IV start in one region, they will be able to do so in another region of the province, without the need for a formal recertification process. Unlike the care where paramedics with appropriate delegation will have discretion as to whether or not a particular skill is performed (ie. what is done), the Medication or Procedures will prescribe how that skill is to be done. These will become the standards expected by the OMD (and the employer, and the Regulator) for any clinical procedure or medication administration. If you look at A00.2 Medications or A00.3 Clinical Procedures you will again see that every protocol has a version date and an alpha-numeric identifier code. Medication administration protocols will begin with the letter M, N or O; while clinical procedure protocols will begin with the letter P, Q or R. And as with the care map, there may be different versions of the same protocol for patients of different ages. For Intro to Care Maps & Clinical Procedures Page 5

6 example, while M14 Resuscitation Medications contains the protocols for all age categories, P06 Tracheal Intubation is divided into adult (P06A), adolescent (P06B) and child (P06C) versions. The new Medications and Procedures are quite different from the previous Emergency Treatment Protocols. Many of them will have only three or four sections. These include: INDICATIONS The medication can be administered or the procedure performed in these clinical situations. CONTRAINDICATIONS - The medication or procedure is not appropriate in these situations or under these conditions. DRUG DOASGES This is self-explanatory. NOTES Other pertinent information that can be helpful at point of care. Some procedures will have flow diagrams analogous to those featured in the care maps. Some medications or procedures will have one or more appendices containing helpful or frequently used information, such as age-relative equipment sizes. Specific details, such as the actual steps to perform a procedure or administer a medication (for example, how to position the leads in acquiring an ECG) will be covered by other supplemental materials and by undergraduate education and post-employment training. Look at the highlighted statement at the top of A00.2 Medication or A00.3 Clinical Procedures. License holders are responsible to maintain satisfactory knowledge and appropriate psychomotor skills for the safe administration of these medications and performance of these procedures, and are required to be familiar with all relevant updates as distributed by the OMD. The individual license holder will now be required to play a greater role in continuing professional development and maintenance of proficiency in the performance of clinical procedures or administration of various medications. A00.4 REGULATION & ADMINISTRATION: This section will generally contain information, policies and procedures required for you to carry out your professional responsibilities Materials, such as destination policies or documentation requirements that overlap between clinical care and operations will be included here. As an example, when we develop a pan- Provincial STEMI strategy, the clinical components will be in the Care Maps and / or Clinical Procedures sections, while procedures for bypass to a cardiac capable facility will be found here. Z01 is a code of ethics that all personnel are required to follow. Z02 - Z05.2 are the documents that outline requirements/responsibilities related to delegation of reserved medical acts. Intro to Care Maps & Clinical Procedures Page 6

7 Z19.2 Cross References to Care Maps and Medications / Procedures will help providers, managers, and educators correlate all new OMD materials with existing guidelines and protocols. Over time this document will be phased out. Z19.1 Revisions Log will be maintained to allow for forward tracking of significant changes to the care maps and clinical procedures. CONCLUSION: The updating and revision of the patient care tools will be an ongoing and dynamic process. Our intent is to keep them as current as possible in the rapidly changing world of EMS. We welcome any suggestions, corrections, additions or deletions. Please contact the OMD ( tony.herd@gov.mb.ca) or EMS Branch (Susan.Dyck@gov.mb.ca). We are also most eager to benefit from the collective expertise out there. If any provider, service or medical director has protocols that they have created or come across otherwise, we would be happy to consider placing a bison in the corner and turning them into a Provincial resource. Intro to Care Maps & Clinical Procedures Page 7

8 APPENDIX A: ICON SKILL SET or PROVIDER LEVEL CURRENT PROVIDER LEVEL CURRENT PROVINCIAL LICENSE LEVEL NATIONAL PROVIDER LEVEL Basic Basic EMR Technician EMR Primary Primary PCP Technician - Paramedic PCP Intermediate Intermediate ICP Technician- Paramedic PCP Advanced Advanced ACP Technician Advanced Paramedic ACP Critical Critical ACP Technician Advanced Paramedic CCP Not available at that license / provider level Intro to Care Maps & Clinical Procedures Page 8