Patient-Centric Practices

     Customer service is a concept familiar to consumers. We purchase products and services, have good and bad experiences, then decide which merchants we continue to patronize. Those rules don't apply to regional monopolies like EMS--patients usually aren't able to choose which agency will provide their emergent treatment and transport. In many cases, the decision to dial 9-1-1 is the first and last time callers participate in planning their own prehospital care.

     The absence of competition can promote top-down corporate complacency, a sign of which is employees who allow their own preferences to supersede customers' needs. We who deliver prehospital care should occasionally remind ourselves that EMS is about providing services, not serving providers.

     Patient-centric systems discourage "cookbook" medicine and recognize that patients and their families are valuable resources during assessment and diagnosis. Our tone and body language can reinforce patience, empathy and a desire to be of service. By discussing rather than dictating treatment options, EMS personnel can encourage a team approach to problem-solving, including shared responsibility for prehospital care decisions.

     Let's see what it would be like to ride in such a system.

ON THE ROAD AGAIN

     Dispatch receives an alarm for a 28-year-old female complaining of shortness of breath. The patient's chief complaint and brief medical history are transmitted to the closest ALS unit, whose GPS receiver directs the driver to the correct address. En route the providers prepare, psychologically and strategically, for a patient who has been taking amiodarone for an unspecified arrhythmia.

     Pattern recognition is responsible for many of our prehospital conclusions, correct and incorrect. Limited by time, pressured by patients and peers, yet emboldened by experience, we confront and process decision points--sometimes superficially--in mental flow charts of differential diagnoses.

     Even when we lack sufficient data to make informed decisions, we still try to fit scenarios to familiar patterns. Sometimes we discard conflicting or ambiguous details prematurely to "confirm" a match. When we hear "28-year-old, short of breath," what patterns come to mind? A respiratory scenario, such as asthma? Anxiety? A lot depends on what types of calls we've handled recently, and the extent to which our diagnoses were reinforced by outcomes.

     Knowing the patient has a cardiac history should make a big difference in our evaluation of differentials. The unspecified arrhythmia certainly is worth noting. It could be atrial or ventricular; amiodarone is prescribed for both. Also, we know myocardial ischemia occasionally presents atypically--with shortness of breath, for example, instead of chest pain.

     We'll have to wait for an on-scene assessment to narrow our diagnosis for this patient, but at least we've chosen a plausible pattern: cardiac instead of respiratory.

     The ability to review patient profiles can be an important element of en route preparation. The technology is not complicated. Database management systems permit storage and retrieval of medical history documented on patient care reports. Some agencies use "homegrown" software developed with generic packages such as Microsoft's Access. Others have purchased large-scale CAD systems. Both should offer not only priorities and locations of alarms, but also summaries of previous calls, including presenting problems, treatment, transport decisions and outcomes.

     Limitations of electronic data are as old as computers. Patient details must be updated promptly and accurately to reap the benefits of prearrival profiles. A realistic goal for the next decade would be to share patient information between EMS, medical facilities and private practitioners. Administration, cost and confidentiality--not technology--are the impediments.

     Voluntary releases signed by patients or their proxies during initial encounters would allow responders to prepare for future visits by storing patient demographics, presenting problem(s), medical histories, treatment and outcomes after calls. If the 28-year-old subject of our scenario had not been treated previously by the same agency, had moved to a different address, or had declined to release her medical history, there wouldn't have been any alert about her cardiac condition.

ADVICE AND CONSENT

     Upon arrival, EMS finds the 28-year-old to be asymptomatic. She confirms that she had some trouble catching her breath, accompanied by palpitations, but only for a few minutes. She recounts one similar prior episode last week, when she was transported by the same agency to the community hospital for evaluation. Initial vitals are: HR 90 and regular, RR 18 and unlabored, BP 118/80, and SpO₂ 98% on room air. She says she feels fine.

     The paramedic asks the patient about her arrhythmia. She doesn't remember its name, but says it was discovered several months ago during a routine EKG. Later, at the hospital, a doctor told her she'd need a procedure to correct the problem, but it would have to wait until she got rid of an upper respiratory illness. He prescribed amiodarone--an antiarrhythmic--and sent her home. Meanwhile, she began taking an unspecified antibiotic her sister gave her for her URI.

     The paramedic recalls that amiodarone can cause many side effects, but doesn't remember all the details. Using a company-provided handheld computer, she discovers that some antibiotics, when combined with amiodarone, can delay depolarization of the heart. Having just read an article about long QT syndrome, she wonders if the patient had a run of ventricular tachycardia.

     Our medic knows she's still lacking important details about the events preceding the patient's illness. However, her conscientiousness about staying current in her field gives her and her patient important advantages. Instead of focusing only on the patient's asymptomatic presentation, she considers underlying etiologies that could cause sudden decompensation.

     Given the unpredictability and uncertain origin of this possibly life-threatening arrhythmia, the medic has a bias towards transporting her patient to a hospital for definitive care. However, the crew senses that this asymptomatic woman probably won't accept the cost and inconvenience of a hospital visit without a more definitive on-scene assessment.

     "We're concerned about the shortness of breath you had before we got here," the paramedic explains to her patient, pausing to make eye contact with family members too. "While you're feeling fine now, there's a chance you'll have another episode. I'd like to do an EKG to see if we can figure out your arrhythmia. It's painless and will only take a few minutes. Are you OK with that?"

     Many healthcare providers have been patients too. When I suffered a job-related injury, my perspective on EMS and hospital practices changed. Suddenly I felt trapped in a system that was processing, rather than caring for me. If I'd been less concerned about being obnoxious, I might have expressed some of these frustrations to a few colleagues:

• I'm a person, not a social security number.
• I know you're busy, but pay attention to me sometimes.
• Don't assume you know what's wrong with me before we talk.
• Answer my questions, give me some options, keep me informed and be accessible. I promise not to monopolize your time.
• Don't subject me to tests or procedures that will degrade my quality of life unless you have my informed consent.
• Meet commitments you make, and don't make commitments you can't meet.

     The conventional approach to emergent care encourages EMS providers to "take charge" of patients, many of whom are assumed to be poor judges of their own health. Time and resource constraints pressure caregivers to rapidly select treatment modalities from generic protocols, initiate care, and transport. This is appropriate only when patients are unstable, unaccompanied and unable to communicate.

     This patient seems reluctant to proceed with the EKG.

     "I'm not sure I really need that," she states. "How much does it cost? I have a big deductible on my insurance." The paramedic accesses a price list of prehospital procedures on her computer. "We charge $75 for an EKG," she advises. "Of course it's up to you whether we proceed, but there are two reasons I think it's important: One, I'm concerned about whatever arrhythmia you might have had, and two, I want to make sure your breathing difficulty wasn't caused by another type of heart problem I might be able to find."

     Is this call progressing too slowly? Should the crew have transported or released their patient already? Are resources being wasted? Not in patient-centric systems. Our goal should be to treat each patient encounter as a unique opportunity to be of service. Yes, resources are limited in EMS, and there will be occasions when we have to delay or abbreviate care. However, the ambiguity and potential severity of this patient's initial complaint justify more time on scene. If the patient were pressured to make a transport decision, she might decline further care. Although expedient, a refusal could jeopardize the patient's health.

     As medical insurance deductibles rise, the cost of prehospital care is becoming a bigger issue for patients. Yet we continue to minimize the importance of itemized charges to patients by telling ourselves, "You can't put a price on good health," or "We're not the ones paying the bills." Both statements contradict patient-centrism by substituting efficacy for service. Our medic's ability to link a distinct purpose to a modest price enhanced her argument that a prehospital EKG was prudent.

     With this persuasion, the patient agrees to undergo a 12-lead EKG. It shows a sinus rhythm in the 80s without ectopy or signs of ischemia. However, after routine transmission of the strip to medical control, a physician spots the delta wave and short PR interval that are classic indications of Wolff-Parkinson-White syndrome (WPW), an abnormality that can lead to very rapid supraventricular arrhythmias. The paramedic and doctor discuss the possibility that the patient may have had episodes of atrial fibrillation accompanied by WPW.

     After speaking with the medical control MD, the patient consents to be transported for further assessment.

HANDLE WITH CARE

     En route there's still uncertainty about the patient's underlying condition, but also a growing suspicion that she suffers from a paroxysmal, tachycardic arrhythmia. Facing a 10-15-minute ETA, the medic retrieves an IV set, notices that the patient's veins are not particularly prominent, then explains that she'd like to establish a route for medication "just in case."

     "What kind of medication?" the patient asks.

     Sometimes we use the term multitasking to describe management of a heavy workload. The connotation is that we can train ourselves to perform several activities simultaneously, a talent that would be particularly useful in a short-transport prehospital environment. In fact, we are not wired that way. Our brains are not able to focus on more than one task at a time. We are serial, rather than parallel, processors of information.

     Patient-centric systems prize good communicators almost as much as skillful practitioners. Providers must be able to discuss Procedure B with patients and their families while performing Procedure A. Since we can't concentrate on both simultaneously, the best we can do is engage in "time-slicing"--alternating rapidly between two tasks and making progress during each iteration. People who are hailed as superior multitaskers actually excel at not forgetting where they left off between "slices."

     Our paramedic's preference to establish an IV at the beginning of transport leaves one less critical task to complete if the patient becomes unstable. This sort of "What if...?" anticipation is a key element of patient-centric practices.

     Now it's time to address the patient's question about the IV.

     "If your heart starts beating very fast again," the paramedic counsels, "we might be able to slow it down with some medication." She is also thinking about sedation, should cardioversion become necessary, but doesn't want to risk alarming a patient who is still asymptomatic.

     After obtaining the patient's consent, the medic establishes IV access with a 20-gauge angiocath.

     When I was in paramedic school, some of our preceptors urged students to "go big or go home." Translation: When starting IVs, use the biggest catheter that will fit in the vein, regardless of the presenting problem. The logic was that it was better to have a large-bore IV in place in case fluid had to be infused rapidly. For asthma? Hypertension? Please. I doubt any of my instructors would have wanted to be on the receiving end of a 14-gauge needle for no particular reason.

     The medic in our scenario selected a 20-gauge catheter, even though she might have succeeded with a larger one. Her rationale was that nothing bigger than a 20-gauge would be needed en route. Her concern about minimizing the patient's discomfort was evident in both her choice of catheter and her inclusion of sedation in her contingency plan.

     The last few minutes of transport are uneventful; there are no further episodes of respiratory distress or signs/symptoms of an arrhythmia. The paramedic presents her patient at the ED, but is concerned that the triage nurse seems distracted by other cases. A crew member waits with the patient until she is transferred to a treatment area.

     Approximately 20 minutes later the medic has a second opportunity to discuss her case with ED staff--this time a nurse and a resident. She summarizes the patient's history, accentuates the unspecified arrhythmia, produces a copy of the EKG and relates her conversation with the medical control physician. She concedes her uncertainty about the etiology of the patient's illness.

     Emergency departments are challenging environments for assessment and diagnosis. Most patients are strangers to their ED nurses and physicians, who are pressured to make quick treatment decisions and then move on. In patient-centric systems, EMS personnel are patient advocates. It is our responsibility to penetrate the ambient "noise" of the ED with the headlines about each patient's condition. The paramedic in our scenario sought the ED staff members who would be directly responsible for her patient, then repeated her presentation. She highlighted aspects of her objective assessment she felt were important, and did not hesitate to admit uncertainty about underlying conditions or speculate about possible etiologies. Even if she didn't get much of a response from the doctor or nurse, she may have stimulated their consideration of differentials.

AT YOUR SERVICE

     Patient-centric practices are not quick fixes. Implementing them successfully requires, at the very least, three initiatives cited by authors Tom Peters and Robert Waterman in their 1982 best-seller, In Search of Excellence:

1. Top-down devotion to customer service. Managers can't just preach patient-centrism; they have to demonstrate passion for those ideals. Call it "management by example."
2. A people-oriented workplace. Often the best way for companies to validate a commitment to their customers is to display equivalent appreciation of their employees. This could be very effective in EMS, where prehospital personnel have so much to do with customer satisfaction.
3. An obsession with measuring and improving quality. Is there anything more important in EMS than quality of care? I don't think so. Surveys and tools such as PET (Prehospital Evaluation Technique) allow us to benchmark our services, give feedback to providers, then close the QA/QI loop by quantifying improvement.

     In most of the U.S., if a patient is dissatisfied with EMS, there is no competitor to call next time. The alternatives are to self-treat, drive oneself to a medical facility or forego care. These options are risky, often impractical and occasionally life-threatening. There isn't a direct relationship between patient satisfaction and profitability.

     By making our care patient-centric, we offer the public flexible, proactive, cost-effective services--not because we have to, but because it's the right thing to do.

The Philosophy of Patient-Centric Medicine

     When we acknowledge the primacy of our patients, we begin to embrace a patient-centric philosophy that offers customers many things:

     Education-We demystify delivery of emergent medical care by describing procedures, offering therapeutic options when possible, discussing risks and benefits, and answering questions. It is easier and safer to share responsibility for treatment decisions with informed patients.

     Flexibility-Prehospital protocols are guidelines, adaptable to patients' special needs within providers' scopes of practice. There are no presumptive agendas for treatment and transport of verbal patients.

     Advocacy-Empathetic caregivers help patients communicate their concerns and preferences to other medical professionals during transfer of care. As facilitators, EMS personnel protect patients and preserve their rights.

     Empowerment-A sense of self-determination encourages patients to act as "chairpersons" of their own "care committees." In a participatory environment, satisfaction is accentuated, and risk is reduced.

Bibliography

     Roughan J, White E. Making disease management patient-centric. Health Mgmt Tech 21(6):46-48, Jun 2000.

     IBM Healthcare and Life Sciences. Patient-centric: The 21st Century Prescription for Healthcare, July 2006.

     Peters T, Waterman R. In Search of Excellence. Harper & Row, 1982.

     Integraph, www.integraph.com.

     Groopman J. How Doctors Think. Houghton Mifflin, 2007.

     ZOLL Data Systems, www.zolldata.com.

     Rubin M. What not to do in EMS. Emerg Med Serv 36(10):105-113, Oct 2007.

     Glatter R, Martin R, Lex J. How Emergency Physicians Think. Medscape, www.medscape.com.

     Wikipedia. Wolff-Parkinson-White Syndrome, https://en.wikipedia.org/wiki/WPW.

     Medina J. Brain Rules. Pear Press, 2008.

     Rubin M. One for good measure. Emerg Med Serv 37(12), Dec 2008.

     Mike Rubin, BS, NREMT-P, is an EMS educator and consultant based in Nashville, TN, and a member of EMS Magazine's editorial advisory board. Contact him at mgr22@prodigy.net.