Today’s correspondent is:
… a nurse working in a busy ED in Melbourne.
Something that many of your readers will be familiar with (and hopefully something that gets more public attention from the Royal Commission into aged care) is the number of older people who are transported from nursing homes to hospital via ambulance for vague and non-specific symptoms. This is often because staff at the nursing homes (through no fault of their own) often have very limited clinical referral pathways.
Some of our older citizens may be admitted to hospital but many will be assessed, found not require any medical treatment and be sent home. This process is expensive, takes many hours and can be very distressing to patients and families.
I was having a discussion with one of our emergency consultants as to whether paramedics would be able to assess a patient and then phone through to a consultant and seek advice as to whether, in that consultant’s opinion, that patient would be likely to be offered any intervention at the receiving hospital. She replied that this had been considered at one stage however due to concerns around liability for the consultant offering advice, the idea had been shelved. She said that she would happily offer such advice to a GP because that GP was able to assess the patient, consider the advice of the ED consultant and make their own decision. In this case, the liability for a decision to recommend an ED would lie solely with the GP.
Given that Paramedics are a registered profession with recognised clinical autonomy (within their guidelines) and are able to accept or reject the opinion of an ED consultant based on their own clinical judgement. Is an emergency consultant at any greater liability risk when offering advice on transport to a Paramedic than offering such advice to a GP?
I do realise that you could apply this principal to any patient however I chose older people in residential care as an example as many of these people have complex needs and are probably at higher risk of iatrogenic harm if inappropriately transported to hospital.
In principle, I do not think ‘an emergency consultant [is] at any greater liability risk when offering advice on transport to a Paramedic than offering such advice to a GP’. The law doesn’t put doctors on some pedestal above paramedics (save that in most cases involving paramedics, it is doctors giving evidence, but that is changing).
The critical issue is always who is making decisions and are those decisions reasonable in all the circumstances. Giving phone advice is always risky as the person on the non-patient end of the phone has to rely on the person with the patient to communicate the patient’s sign and symptoms and to accurately ask and answer questions. That’s true when the person with the patient is a family member, a registered nurse, a registered medical practitioner or a registered paramedic. The consultant on the phone has to try to understand what he or she is being told, form a view on the reliability of the person giving information and then make a reasoned decision based on that information. It may well turn out that the information provided was incomplete or wrong.
On the issue of liability, the question is always ‘what happened? What went wrong?’ then ‘and who was responsible for that?’ If the person with the patient is a good communicator and clinician, the issue may be ‘did the ED consultant ask all the relevant questions?’ If the person with the patient is not a good communicator/clinician, the issue may be ‘should the consultant have understood from what he or she was being told that the person relaying information was not up to the task’. Or the issue may be ‘did the person with the patient fail to properly give information that a reasonable person in that position would have given, or did they not properly understand the question and yet fail to say ‘I don’t understand’ etc in circumstances where there was no reason for the consultant to think they were not getting the whole picture’. Liability would not depend on whether the person with a patient is a nurse, doctor or paramedic but on all the circumstances.
So why might a doctor have said ‘she would happily offer such advice to a GP because that GP was able to assess the patient, consider the advice of the ED consultant and make their own decision’ but not a paramedic? I would suggest it comes down to trust. The risk of liability is like any risk – it’s a combination of the probability of a poor outcome and how bad that outcome may be. Both matters will be reduced where the person on the end of the phone can be trusted to be both a good interpreter, relaying questions and answers, and a good clinician. One doctor may feel confident that another doctor will meet both those criteria and therefore it reduces both the chance that the patient will have a poor outcome and that the outcome will be catastrophic. On a doctor/doctor basis the doctor may also be confident that the doctor-on-the-end-of-the-phone has ethical and professional duties to the patient and carries professional indemnity insurance all of which can help spread the risk.
Now that paramedics are registered much of that is also true – at least with respect to professional duties and insurance. I suggest that the issue may be that ‘it’s early days yet’. Paramedics are coming up to one year as registered health professionals. They are coming from the background of jurisdictional ambulance services and practitioners who applied ‘protocols’ rather than clinical judgment. Of course that is changing, and has changed, but not everyone including doctors will be up to speed on that or have developed the necessary trust in paramedics clinical decision making and observation to trust them to ‘make their own decision’ based on their own observations and the advice of the ED consultant.
I think that too is reflected in the sort of questions I receive or have received, about paramedics acting on doctor’s orders, the need for supervision of paramedic services by medical practitioners and the role of doctors and paramedics at accident and emergency scenes. Both paramedics and medical practitioners need to recognise, and believe, that each have their own but overlapping areas of practice – that paramedics do not have to transport everyone, that paramedics can legitimately and professionally make recommendations to patients about treatment and transport and that they may refuse to treat and transport patients who do not need further care (see for example Transport everyone or act as a professional? A question for paramedics (May 6, 2013); No adverse comments regarding paramedics following death of a woman in Ballarat, Victoria (April 3, 2017); Paramedics and recording honest advice (April 15, 2018)). Until that happens, it is likely that doctors will hold back for fear that the decision to transport or not will depend entirely on them ie that the paramedics will claim ‘once I rang the doctor it was the doctor’s decision whether I transported or not’ rather than ‘I rang the doctor and the information given was one more piece of information I considered when making my clinical decision/recommendation’.
If, by giving advice to paramedics, doctors are taking on the care of the patient and the paramedic will simply do, or not do, whatever the doctor says then yes, I would suggest that the ED consultant is facing a higher risk of liability if the patient outcomes are poor. If, on the other hand, the ED consultant comes to accept that when dealing with either a doctor or a paramedic, he or she is literally a ‘consultant’ ie someone the treating doctor or paramedic is consulting with in order to better inform the treating practitioner’s decision then the risk will become the same and doctors may then be willing to give advice to both paramedics and other doctors.
Achieving that level of trust and respect will depend on how the now registered profession of paramedicine develops, proves itself as a clinically independent profession, and creates a niche of recognised professionalism.
This would be a discussion that needs to address the electronic transfer of patient data to the ED Consultant for an informed decision to be made and conveyed back to the on-site clinician.
What if it’s just a phone call? If you start having that sort of technology and capacity that’s going to create different relationships with, no doubt, lots of contractual agreements about who’s doing what. My understanding from the question was nothing so complex – ring the ED and ask ‘do you want us to bring this person in?’
The point of my answer was that a doctor is in a different position if he or she makes an ‘informed decision’ that is then ‘conveyed back to the on-site clinician’ for action, versus the on-site clinician seeking a second opinion/advice before the on-site clinician makes the ultimate decision. And when doctors, employers and paramedics trust paramedics to be the on-site decision maker, the risk for the doctor at the other end of the phone will be much the same whether he or she is advising another doctor or a paramedic.
Is this similar to urgent care centres who are manned by nurses and seek direction from doctors electronically
No I don’t think it’s similar at all. If ‘urgent care centres’ are staffed by nurses with facilities for doctor consultations I would expect there would be clear processes and procedures and defined areas of responsibility. I suggest that’s quite different to a situation of registered paramedics making a patient assessment where they usually make autonomous clinical judgments but seeking a consult with an expert to assist in their decision making.
I think it’s impprtant to note that a lot of the transports are requested by locums and it places paramedics at risk from an organisational point of view if the doctor says I want them to go hospital and we say no and then the doctor complains to the organisation.
Often the locum makes a decision over the Phone without any direct assesment.
I would much rather see Locums assigned to aged care facilities and have to come in, actually assess the patient, then liaise with the Admitting Officer and coming up with a joint management plan.
Or a working group between local hospitals, aged care facilities and GPs to develop better guidelines on what should and shouldn’t bebe transported.
Indeed that would be difficult. Your suggested working group should also include paramedics shouldn’t it?
The solution is to ensure that Aged Care Facilities have sufficient numbers of Registered Nurses on-site to provide good nursing assessment and liaise directly with clients Physicians. Unfortunately RNs are becoming a rarity on the floor of what were once referred to as Nursing Homes.
You’ll never have more than one RN to 150 aged care residents …. because ut cyts into the PROFIT made by the owner of the facility.
I recall ‘that 70s TV show’ called
The firemen paramedics were always consulting with the ED doctor at the ficticious Ranpart Hospital via a radio phone ( see youtube clips ).
So the concept was well accepted 40 years plus ago.
Still disagree on the English terminology …..
A paramedic does not practice paramedicine.
Being a paramedic is not related to the practice of medicine.
Everyone my age remembers ‘Emergency’ (‘Squad 51, KMG365’); it inspired a generation to become paramedics. Randolph Mantooth, the actor who played Johnny Gage is now a spokesperson for paramedics (see https://en.wikipedia.org/wiki/Randolph_Mantooth#Firefighter/EMS_advocate_and_spokesperson).
But the situation depicted in that show was what I was suggesting maybe the doctor’s problem in the post I was responding too. In Emergency the paramedics were not independent practitioners, they did not ‘consult’ Rampart General as equals, the doctors on the other end made the diagnosis and prescribed the treatment (‘give D5W TKO’). Today paramedics are independent, able to assess patients, make a diagnosis and administer treatment without having to ring anyone. That is why my suggestion was that doctor’s would not be willing to consult paramedics unless and until they too recognise that they are giving information, but the ultimate decision rests with the paramedic as it does with a GP. To go back to the situation in Emergency would be to take paramedic practice back 40 years. The concept that doctors would consult with, rather than direct, paramedics was not accepted 40 years ago.