EMS Innovations 2009: A Five-Part Series

Part 2: Have It Your Way

London's patient-specific protocols deliver care on a case-by-case basis

School officials didn't want to administer the rectal paraldehyde.

The child suffered from epilepsy, but the usual treatment for seizures in London, Diazemuls (an injectable emulsion of diazepam), had been linked to respiratory depression on a previous use. The preferred treatment was instead the paraldehyde, kept at the school. But who could give it? Backed by the child's doctor, the school approached the London Ambulance Service for help. They didn't carry the drug, but could they administer the child's own medication in a pinch?

"It was clear the child wasn't going to get the medication otherwise," says LAS Medical Director Fionna Moore, MD. So LAS did something counterintuitive for a service of its imposing size and call volume (more than 3,500 a day): It wrote an individual protocol for use only with this child.

Then came the Addison's patients, suffering from chronic adrenal insufficiency. Although they often carried their own hydrocortisone for their fast-onset adrenal crises, they could become too unwell too quickly to self-administer it. They, too, asked if LAS crews could give them their meds.

That's how the service's patient-specific protocols were born.

"It snowballed from there," says Moore. "I think the speed with which it became known surprised us a bit, particularly within the pediatric community. We expect that as people within these various groups talk to each other, it will continue to grow."

The PSPs are intended to alert crews to special medical histories and unique aspects of individual patients' care. Around 250 have been written since the idea's inception in 2007, of which 186 were still active in the LAS database as of Moore's Eagles presentation in February. These cover a broad range of conditions and circumstances, the largest of which concern end-of-life care, use of steroids, preferred places of care and transplants. Also represented are patients with seizures, LVADs, respiratory failure and more.

The service maintains a high-risk database in which it flags addresses of patients with PSPs, among others. When a crew is called to one of these addresses, it's automatically alerted and linked to the PSP. Copies, on official LAS letterhead and signed by Moore and each patient's treating physician, are also given to each patient or their caregiver, their physician, the local ambulance station and the LAS clinical support desk, which has experienced medics available 24/7 for consultation and troubleshooting.

This kind of thoroughgoing support--clear authorization from the service's top physician, plus online backup at all times--has made deviations from the comfort of standard care easier for medics to swallow.

"I'm not aware of a crew ever ringing up and saying 'I have this protocol and don't know whether I should use it,'" says Moore. "If they're presented this paper with the London Ambulance Service crest on the top that's something they recognize and is signed by me, they know I'm taking responsibility for their actions. So it seems to have gone down well." Not without certain challenges, however. One child had a PSP kept with her mother, but a father who knew nothing about it. When she needed assistance while with dad, the crew didn't get the information. Another frequent caller with significant chronic pain could be given morphine without transport to a hospital, but as his calls mounted, crews were devoting large amounts of time on scene just trying to keep him comfortable. "That was a risk not so much to the patient, but just because that vehicle was then unavailable to answer other calls," says Moore. "So the challenge there was trying to balance the needs of one individual with service delivery in the area."

The solution in the latter case was a case conference with the various clinicians involved in the patient's care (e.g., primary care, pain consultant, orthopedist) to discuss more appropriate avenues for handling his pain. These are increasingly common for people who call frequently without true emergencies.