I’m not sure I really understand today’s question which is:
Our company employs varying levels of medical professional personnel. Patient Transport officer, EMT, Registered Paramedic, RN and ICP.
There seems to be a dispute between hospital staff and the registered paramedics [RP] on shift and whether or not the RP has a right to take a baseline set of vitals prior to accepting patient care from definitive care, then transporting them to various locations – I.e home, nursing home, hospital, specialist clinics.
At present, the process that most of the RPs are taking is taking a baseline vitals, and if anything is out of the “normal parameters” they question for altered calling criteria, resuscitation plans and history.
This has become an extensive discussion within our workplace, in regard to registration, as I’m sure you could imagine, and we have now received a fairly unofficial email regarding whether or not we have the authority to take vitals.
So for the time being, the question I have for you is this.
If, as a registered paramedic, we accept care of and take a patient from the hospital, a place of definitive care, without getting a baseline set of observations, and the patient was to deteriorate due to an underlying condition that could have been detected by taking those vitals, are we then held as accountable for that patients deterioration, and would we be risking registration as a result?
Does this change if we are to use the last set of vitals that the ward nursing staff give us during handover, whereby these vitals could have been taken 5minutes ago, or 8 hours ago?
As I say I don’t really understand the basis of the question as I don’t understand how anyone could think they could ‘direct’ a paramedic not to take a set of obs if the paramedic thought they would provide useful information that would enhance patient care, or why one needs to have a ‘right’ to do so. In short the question makes no sense and that’s no reflection on the person asking the question but on whoever it was who suggested anything other than ‘of course you can take a set of obs if you think you need to, and if the patient consents’.
The obligation of a paramedic is to provide good paramedic care. The Paramedicine Board’s Code of Conduct-Interim says (at [2.1]):
Care of the patient or client is the primary concern for health professionals in clinical practice. Providing good care includes:
(a) assessing the patient or client, taking into account their history, views and an appropriate physical examination where relevant; the history includes relevant psychological, social and cultural aspects
(b) formulating and implementing a suitable management plan (including providing treatment and advice and, where relevant, arranging investigations and liaising with other treating practitioners)
(c) facilitating coordination and continuity of care
(d) recognising the limits to a practitioner’s own skills and competence and referring a patient or client to another practitioner when this is in the best interests of the patients or clients, and
(e) recognising and respecting the rights of patients or clients to make their own decisions.
I would think taking a set of obs is necessary for (a), (b), (c) and (d) above, based on the paramedic’s assessment of the task at hand, the relevant history etc. Taking a set of baseline obs and then asking about them if they are out of the ordinary is reflective of patient centred care and working together as part of the health team (Code of Conduct [4.2]). It helps understand the treatment plan during transport and to ensure that the paramedics can make decisions about whether a patient’s condition is deteriorating or not.
It’s not for me to say, as I am not a paramedic, whether a set of obs is required in every case and even if I had a view, I don’t know the specific circumstances of where my correspondent works or the type of patients they are transporting. What that means is the question of whether a set of baseline obs is necessary or simply ‘would be helpful’ is a clinical question for the treating paramedics. But if the treating paramedic forms the view that a set of obs will enhance the care that they can provide then they have both a right and a professional obligation to take them and anyone telling them they cannot is simply speaking non-sense. On the other hand, if they think the obs will be of no value, then they should not be taken just to be seen to take them ie for the paramedic’s benefit. Putting the patient to the albeit minor inconvenience of another blood pressure cuff etc can only be justified if it is necessary in the patient’s best interests. The inconvenience may be minor, so the benefit need not be much to justify it, but there has to be, in the paramedic’s mind, some benefit to the patient from taking the obs.
Let me turn to the questions:
If, as a registered paramedic, we accept care of and take a patient from the hospital, a place of definitive care, without getting a baseline set of observations, and the patient was to deteriorate due to an underlying condition that could have been detected by taking those vitals, are we then held as accountable for that patients deterioration, and would we be risking registration as a result?
A registered paramedic will be accountable for the decisions they make in providing paramedic care. If the paramedic thinks a set of baseline observations will enhance patient care, then he or she will be accountable for their decision not to take them. Imagine you are sitting as a panel of the Paramedicine Board assessing a paramedic’s conduct where indeed the patient’s condition did deteriorate and there was a delay in noticing that because of no baseline obs. The Panel might ask the question ‘why did you not take a set of obs?’ How would you judge the answer: ‘Because the hospital staff said I was not allowed to’. Would that fit your definition of good paramedical practice?
If you think taking a set of clinical obs, given the circumstances is warranted and you don’t take them and then fail to detect that the patient’s condition is deteriorating I think you would be accountable, negligent and unprofessional.
Does this change if we are to use the last set of vitals that the ward nursing staff give us during handover, whereby these vitals could have been taken 5minutes ago, or 8 hours ago?
It depends on all the circumstances. You work with nurses and as the Code of Conduct says ‘Good care is enhanced when there is mutual respect and clear communication between all health professionals involved in the care of the patient or client.’ You don’t have to second guess the staff, if as part of their handover they tell you that obs have just been taken and give you those details as part of the handover then that may well be sufficient. I doubt if it is sufficient if they were taken 8 hours ago.
You can understand the nursing staff may be annoyed if as part of getting the patient ready for transport they have taken obs in the hope of making your job easier and you then insist on taking your own set; it may also annoy the patient. But at the end of the day, just as nurses at an ED will probably take a set of obs when a patient is delivered by an emergency ambulance so too you may choose to take a set of obs. The issue is not about ‘not offending the nursing staff’ but providing patient centred care. If you think you need your own set of obs, taken with your equipment to give you a baseline and to give a second opinion, then do take them (providing the patient consents). If in all the circumstances you think the obs taken 5 minutes ago and which are within normal parameters or if not there is an adequate treatment plan, then fine. It’s a matter of clinical judgement for each paramedic – that is what it means to be a professional. No-one can tell a registered paramedic that they are not ‘allowed’ or don’t have the ‘right’ to take a set of obs if the paramedic thinks that will help them to provide good patient care.
Conclusion
A registered paramedic has an obligation to provide good paramedic care and it is their obligation to determine what that means in the particular circumstances. If it means taking a set of baseline obs, take them.
Australian Emergency Law 
So many confusing things with this question. Thank you very much Michael for attempting to answer.
One thing that I hope we can avoid in paramedicine is reference to the title ‘Registered Paramedic’. Since Paramedic is a protected title, that can only be used if one is registered it would appear redundant to use the prefix.
There was, and is still, a sound reason for RNs to use the ‘registered’ prefix as there are many levels of nurse: Assistant in Nursing, Enrolled Nurse, Registered Nurse, etc. Paramedicine does not need to go down this path. In the post above the correspondent refers to registered paramedics and ICPs. The ICP would also be registered. But yet they did not state ‘Registered Intensive Care Paramedic’ (please no one start doing this).
I agree, registered paramedic is an oxymoron.
We as paramedics form part of the chain of care and often play a role in the pt’s journey through the health system. As we know the health world is a huge machine with multiple facets, varied requirements, increasing performance based pressures and ofcourse the human factor. I understood from the question that the baseline vital acquisition was the topic. As I like to say “ our forefathers “ created a patient report form with the fields for the entry of all the vital signs, I guess they were onto something ie: having a baseline on assessment, a transfer of a patient also includes the transfer of their care. As a paramedic you cannot provide adequate care unless you know what you are dealing with ( for wont of a better term). I think we often transfer patients without recent baseline vitals, this I believe is a risk, employment aside, but a risk to the patient outcomes. Its fair and really good practice to get these baseline vital signs before accepting any patient because the buck stops with the last person caring for the patient if a full picture was not noted before accepting a patient. The risk of error especially with a chain of care sometimes being challenged by transfer from one facility to the other, one ward to the other or a myriad of health professionals who change every shift. I guess being asked in front of a legal audience why you didn’t have a set of baseline vital signs will hurt more than requesting these before transport