THE SAFETY NET IN PROTOCOL 26
July 30, 2015
By Art Braunschweiger and Brett Patterson
In the Medical Priority Dispatch System, perhaps no other protocol appears more straightforward yet causes more confusion than Protocol 26: Sick Person (Specific Diagnosis). There’s more to Protocol 26 than meets the eye, and understanding its intent and structure is key to using it correctly.
It’s worth a moment to review the proper use of this protocol, i.e., when should this protocol be selected? As defined in the Additional Information section, a Sick Person is described as “A patient with a non-categorizable Chief Complaint who does not have an identifiable priority symptom.” The first half of that definition is easy; it makes Protocol 26 a medical “catchall” when nothing else fits. In the second half of the definition, Priority Symptoms refer to the presence of Abnormal breathing, Chest pain (any), Decreased level of consciousness, and SERIOUS hemorrhage.
If the Chief Complaint (as determined in Case Entry) is a breathing patient who’s unconscious, has fainted, nearly fainted, or is not fully responsive, Protocol 31: Unconscious/Fainting (Near) is most appropriate—unless the caller’s information points to a possible cause available as a Chief Complaint Protocol such as a Seizure, Stroke, or Diabetic Problem. That’s why it’s critically important to find out exactly what happened, not merely “What’s going on.” But not every complaint is that specific. A good example is the caller who tells you that her elderly mother hasn’t been eating and she might be dehydrated. When you attempt to clarify what prompted the call to 9-1-1, the caller says, “Because she’s not doing well the last day or so, and I think she needs to be seen at the hospital.” Having made two attempts at this question, you select Protocol 26 and move on. For calls like this, Protocol 26 shows its real value, because the first four Key Questions act like a safety net: They’re intended to catch any Priority Symptoms that weren’t reported up front. They also allow the calltaker to code the call to reflect those symptoms when they’re not the Chief Complaint.
While three of the four Key Questions regarding Priority Symptoms result in shunts to more specific protocols, the “breathing normally” question does not, but rather it results in a CHARLIE-level code on Protocol 26. This is because data has revealed that the acuity of patients tends to be less when this symptom is “discovered” rather than presented as part of the Chief Complaint. The separation of this code on Protocol 26 allows for appropriate local response assignment that may be differentiated from the codes on Protocol 6: Breathing Problems.
Thinking of the first four Key Questions as a safety net also helps explain the list of descriptors within the definition of ALTERED LEVEL OF CONSCIOUSNESS (ALOC) on Protocol 26. There are no less than 17, all of which are answer choices to Key Question 1 in ProQA. While you wouldn’t choose Protocol 26 when a decreased level of consciousness is reported in Case Entry, if you end up on this protocol because of a non-specific complaint, the above list of descriptors allows you to code a patient identified in Key Questions, or elsewhere, as less than fully alert. But why all the descriptors? Why not just consider any of them a “no” answer?
Brett Patterson, Chair of the Medical Council of Standards for the International Academies of Emergency Dispatch, explains: “The intent of this protocol addition is to stop patients from falling through the cracks when a caller answers ‘yes’ to Key Question 1 but actually describes the patient using a conflicting term. Through extensive call review, in an attempt to evaluate the acuity of patients coded in the ALPHA level, we were hearing EMDs essentially talk the caller out of saying ‘no’ when asked about alertness in Key Question 1. This was mainly an issue in centers where EMDs seemed pressured to stop over-triage and, with only ‘yes’ and ‘no’ answer choices available at the time, this question seemed a bit of a culprit. What we noticed was a disturbing trend on the part of EMDs when the caller was ambiguous or hesitated in their response to the initial, first-line question. EMDs would often hurriedly reply to the hesitant caller with something like ‘Well, is s/he responding appropriately?!’ in a tone bordering on impatience in a rather obvious attempt to get the caller to say something like ‘Well, I guess so.’ What we decided to do was create a safety net to capture those patients who were technically reported to be ‘alert’ but the caller also used a term that suggested otherwise. Incidentally, the list of ALOC descriptors was obtained through our call review. In other words, these terms were actually being used to describe patients who were reported to be alert at Key Question 1.”
That’s a key point that helps to explain the difference between a yes and no answer to this important question. A straightforward “no” will code out at the DELTA level (Not alert), whereas a “yes” answer that is obtained with the addition of one of the ALOC descriptors will code at the CHARLIE level. However, it’s the “yes” or “no” answer, not the descriptor alone that should “drive” the Determinant Code. Patterson adds, “If the caller says ‘no,’ that’s ‘Not alert’—period. If the caller says ‘yes’ but describes the patient using one of the listed descriptors, use that descriptor to code the call as ‘ALTERED LEVEL OF CONSCIOUSNESS.’”
Unfortunately, callers don’t always give a yes or no answer. It’s not uncommon to ask “Is she completely alert?” only to have the caller say something like “Well, she’s kind of lethargic.” As Patterson explains, “That’s the perfect time to use the clarifier. And if you don’t get a ‘yes’ answer, it’s ‘no’ by default. That way you’re being risk averse.”
As always, proper coding depends on both the accuracy of the information provided by the caller and how the EMD interprets that information. As Patterson concludes, “We can’t always provide black-and-white choices when we develop these protocol concepts because of the tremendous differences in patient presentations. For example, ‘She’s a little lethargic’ is obviously different than ‘She’s semi-conscious.’ To me, the latter means ‘Not alert’ while the former may need the clarifier. My hope is that the Q’s who review these calls will understand the intent of both the process and the EMD, and evaluate accordingly. Latitude can be prudent when appropriate.”
The Academy continues to study this very diversified group of patients in an effort to safely improve the triage methods found in Protocol 26. In the meantime, when used compliantly with sound judgment and good intent, this protocol will continue to provide a safety net as we assess the patients we can’t see.