June 22, 2015
By Art Braunschweiger
Ever find yourself jumping from one protocol to another, unable to decide which one’s the most appropriate? You’re “protocol surfing”—something that has nothing to do with the beaches of California or Hawaii. In this column we’ll look at why this happens and how to avoid it.
In our call reviews, our ever-vigilant Qs are constantly reminding us to make the appropriate protocol selection. As many of you have learned, failure to choose a correct Chief Complaint Protocol is a Critical Deviation—so the pressure is on. At the same time, our calls don’t always neatly fit into one protocol or another. Let’s apply a little common sense along with the performance standards that we’re all being held to (and yes, your Qs have to follow those standards as well). Since this is not intended as a remedial training article, I’ll assume that you already know all Chief Complaint selection rules found in Case Entry and elsewhere. Instead, I’ll point out a few things that aren’t as frequently considered.
In the November/December issue of The Journal, Brett Patterson, Medical Council of Standards Chair, wrote: “We have learned through outcome analysis that priority symptoms ‘discovered’ during interrogation on a different protocol are generally associated with less acuity than the priority symptoms that are part of the Chief Complaint.” The protocols have been programmed to “think” this way with many combinations of signs and symptoms. For example, if you’re on Protocol 19: Heart Problems/A.I.C.D., there’s a Key Question that asks: “Does s/he have chest pain?” If the answer is yes, there’s not an automatic shunt to chest pain. Why? Because if the caller didn’t mention it upfront when asked what happened and reported something else instead, such as “her heart is racing, and she can feel it beating irregularly,” then any chest pain reported after that is, statistically, less likely to be as serious than if it was reported upfront.
Another sign or symptom that frequently adds uncertainty is abnormal breathing. Abnormal breathing is just that—any rate or quality of respiration that differs from the norm. But even when the medical event that prompted the call to 9-1-1 is causing difficulty breathing, that doesn’t automatically make it the Chief Complaint. Breathing difficulty is often the secondary complaint, regardless of the ABCs (Airway-Breathing-Circulation). Chest or abdominal injuries, for example, can make it more difficult to breathe easily, so it’s not uncommon to have a patient with some trouble breathing even if the Chief Complaint is unrelated to the respiratory system.
In most cases, selecting the Chief Complaint Protocol is best when based on what happened, and is the most logical choice. If the patient is having a seizure and isn’t breathing normally, Protocol 12: Convulsions/Seizures is still the correct choice, not Protocol 6: Breathing Problems, which assumes a respiratory issue above all else. Over time, you should build your knowledge and understanding of what certain signs or symptoms are commonly associated with other Chief Complaints even though they might otherwise be a high-priority on their own.
And remember that ProQA is pretty smart (programmed with logic paths to make it that way). If ProQA doesn’t shunt, there might be a good reason for it. The protocols have been structured to consider what other problems are commonly associated with each Chief Complaint, and react accordingly—or not—if one of those is found.
“Protocol surfing” can usually be avoided if you focus on the Chief Complaint or its cause, and not what followed. There should rarely be more than one shunt on any given call. Use your judgment and shunt if a truly high-priority condition requires it, but otherwise, leave the surfing to the beach.