Notes – Universal Care Guideline

Universal Care Guideline

Notes/Educational Pearls

Key Considerations

  1. Pediatrics: use a weight-based assessment tool (Handtevy, SLCH/BJC-approved dosing book, or length-based tape) to estimate patient weight and guide medication therapy and adjunct choice
    1. The pediatric population is generally defined by those patients who weigh up to 40 kg or up to 14-years of age, whichever comes first
    2. Consider using the pediatric assessment triangle (appearance, work of breathing, circulation) when first approaching a child to help with assessment.
  2. Geriatrics: the geriatric population is generally defined as those patients who are 65 years old or more
    1. In these patients, as well as all adult patients, reduced medication dosages may apply to patients with renal disease (i.e. on dialysis or a diagnosis of chronic renal insufficiency) or hepatic disease (i.e. severe cirrhosis or end-stage liver disease)
  3. Co-morbidities: reduced medication dosages may apply to patients with renal disease (i.e. on dialysis or a diagnosis of chronic renal insufficiency) or hepatic disease (i.e. severe cirrhosis or end-stage liver disease)
    1. Direct medical oversight is required to discuss dosing changes.
  4. Vital Signs:
    1. Oxygen
      1. Administer oxygen as appropriate with a target of achieving 94-98% saturation
      2. Supplemental oxygen administration is warranted to patients with oxygen saturations below this level and titrated based upon clinical condition, clinical response, and geographic location and altitude
    2. Normal vital signs (see chart below)
      1. Hypotension is considered a systolic blood pressure less than the lower limit on the chart
      2. Tachycardia is considered a pulse above the upper limit on the chart
      3. Bradycardia is considered a pulse below the lower limit on the chart
      4. Tachypnea is considered a respiratory rate above the upper limit on the chart
      5. Bradypnea is considered a respiratory rate below the lower limit on the chart
    3. Hypertension Although abnormal, may be an expected finding in many patients
      1. Unless an intervention is specifically suggested based on the patient’s complaint or presentation, the hypertension should be documented, but otherwise, no intervention should be taken
      2. The occurrence of symptoms (e.g. chest pain, dyspnea, vision change, headache, focal weakness or change in sensation, altered mental status) in patients with hypertension should be considered concerning, and care should be provided appropriate with the patient’s complaint or presentation
  1. Secondary Survey: may not be completed if patient has critical primary survey problems
  2. Critical Patients: proactive patient management should occur simultaneously with assessment
    1. Ideally, one provider should be assigned to exclusively monitor and facilitate patient-focused care
    2. Treatment and Interventions should be initiated as soon as practical, but should not impede extrication or delay transport to definitive care
  3. Air Medical Transport: air transport of trauma patients should be reserved for higher acuity trauma patients where there is a significant times savings over ground transport, where the appropriate destination is not accessible by ground due to systemic or logistical issues, and for patients who meet indications based on the State of Missouri’s Time-Critical Diagnosis system

Pertinent Assessment Findings

This guideline is too broad to list all possible findings

Quality Improvement

Associated NEMSIS Protocol(s) (eProtocol.01)

  • 9914075 – General-Universal Patient Care/Initial Patient Contact

Key Documentation Elements

  • At least two full sets of vital signs should be documented for every patient
  • All patient interventions should be documented

Performance Measures

  • Abnormal vital signs should be addressed and reassessed
  • Response to therapy provided should be documented including pain scale reassessment if appropriate
  • Limit scene time for patients with time-critical illness or injury unless clinically indicated
  • Appropriate utilization of air medical services
  • Blood glucose level obtained when indicated
  • EMS Compass® Measures (for additional information, see http://www.emscompass.org)
    • PEDS-03: Documentation of estimated weight in kilograms. Frequency that weight or length-based estimate are documented in kilograms
    • PEDS-01: Respiratory assessment. Documented evidence that a respiratory assessment was performed on pediatric patients
    • Hypoglycemia-01: Treatment administered for hypoglycemia. Measure of patients who received treatment to correct their hypoglycemia
    • Stroke-01: Suspected stroke receiving prehospital stroke assessment. To measure the percentage of suspected stroke patients who had a stroke assessment performed by EMS
    • Trauma-01: Pain assessment of injured patients. Recognizing that pain is undertreated in injured patients, it is important to assess whether a patient is experiencing pain

Normal Vital SignsGCS

References

  1. Bass, R. R., Lawner, B., Lee, D. and Nable, J. V. (2015) Medical oversight of EMS systems, in Emergency Medical Services: Clinical Practice and Systems Oversight, Second Edition (eds D. C. Cone, J. H. Brice, T. R. Delbridge and J. B. Myers), John Wiley & Sons, Ltd, Chichester, UK.
  2. Bledsoe BE, Porter RS, Cherry RA. Paramedic Care: Principles & Practice, Volume 3, 4th Ed. Brady, 2012.
  3. Gill M, Steele R, Windemuth R, Green SM. A comparison of five simplified scales to the out-of-hospital Glasgow Coma Scale for the prediction of traumatic brain injury outcomes. Acad Emerg Med. 2006;13(9):968-73.
  4. National Association of State Emergency Medical Services Officials. State model rules for the regulation of air medical services. Published September 2016.
  5. O’Driscoll BR, Howard LS, Davison AG. BTS guideline for emergency oxygen use in adult patients. Thorax 2008;63:vi1-vi68.
  6. Thomas SH, Brown KM, Oliver ZJ, Spaite DW, Sahni R, Weik TS, et al. An evidence-based guideline for the air medical transportation of trauma patients. Prehosp Emerg Care 2014;18 Suppl 1:35-44.
  7. U.S. Fire Administration. Traffic incident management systems, FA-330. Published March 2012.