To Shunt Or Not To Shunt?
August 6, 2019
Clarification is requested regarding Protocol 26: Sick Person (Specific Diagnosis) as follows:
An EMD on Protocol 26 who receives NEW information about the patient’s condition (Stroke symptoms present, or patient starts to seize) that is discovered in KQ 4 (Does s/he have any pain?) are directed by Rule #2 to remain on Protocol 26 for symptoms other than chest pain/discomfort (e.g., abdominal pain, back pain, or headache).
The EMD is not directed to shunt to a more appropriate Chief Complaint code when priority symptoms are indicated, i.e., Protocol 28: Stroke (CVA)/Transient Ischemic Attack (TIA) or Protocol 12: Convulsions/Seizures. Both Chief Complaints launch important diagnostic tools that assess the patient’s breathing or the presence of stroke.
Also, Rule #2 appears to conflict with Case Entry Rule #6, which states:
Protocol 26 identifies only one (1) priority symptom, Chest pain/discomfort, as cause for shunting to another protocol (10).
All other priority symptoms are not addressed leaving the EMD with limited options.
Continuous Quality Improvement Manager
Department of Emergency Management
Division of Emergency Communications
San Francisco, California (USA)
Thanks for your question.
It is common for patients without a categorizable complaint (Sick Person) to have secondary complaints such as a head or tummy ache, and even abnormal breathing, that is essentially “discovered” on Protocol 26 but not mentioned on Case Entry as part of the initial Chief Complaint Description. And we know from outcome data that conditions “discovered” on another protocol are typically not as serious as when they are part of the initial complaint. For instance, you may remember when there was a shunt to Protocol 6: Breathing Problems for when abnormal breathing was discovered on Protocol 5: Back Pain (Non-Traumatic or Non-Recent Trauma) and Protocol 26. When we looked at these outcomes, we learned that these “shunted” patients were not as ill as those with a primary complaint of breathing problems so we removed the shunt and added codes for “Difficulty breathing” (Protocol 5) and “Abnormal breathing” (Protocol 26) so that agencies can assign response codes specific to “discovered” versus primary breathing problems.
That brings us to the intent of Protocol 26’s Rule #2. The intent is limited to the discovery of incidental complaints and is NOT intended to prohibit a move to another protocol when it is clear to the EMD that s/he is in the wrong place. You are most correct that if a Sick Person interrogation discovers clear Stroke Symptoms, or the patient has a seizure, we need to move to that protocol. However, this sort of thing is relatively rare as these sorts of symptoms are most concerning to the caller and are normally part of the initial Chief Complaint.
In summary, advise your EMDs that if a move is clearly necessary (“I’m clearly in the wrong place”), and this is usually defined in protocol with Chief Complaint Selection Rules and symptom lists like Stroke Symptoms and Heart Attack Symptoms, they should move to the more specific protocol to address the more specific complaint. However, a Sick Person interrogation has nothing to gain from a move to the Headache or Abdominal Pain Protocol when these symptoms are discovered on Protocol 26 and were not part of the initial Chief Complaint. Rather, such a move only clouds the issue by changing the code to reflect something that was not part of the initial Chief Complaint.
Thank you for reaching out to the Academy.
Brett Patterson Academics & Standards Associate Chair, Medical Council of Standards International Academies of Emergency Dispatch®