[buffettrn]

Coming from the adult world where just about everything wa done by protocal, I have found that in the Pedi world things seem to be done by Medical Command (at least in this area of the country). I would like to know more about this and maybe get some protocals from others so that I might be able to impliment a more protocal driven program.

I thank everyone and anyone that responds to this poll and would be glad to help anyone I can in this area.

Thank you

Jeff

[buffettrn]

I thank everyone that has looked at my post especially those that have responded to my poll. Just want to add a question for your thoughts. Why do Pedi programs tend to utilize Medical Command over protocals?

[Michael Collins]

Its likely based on the history and development of the program. Many pediatric specialty teams don't perform scene flights and many don't employ paramedics, or historically don't. The model was not developed from EMS, but for a "mobile ICU." This nursing model didn't embrace comprehensive protocols and standing orders. Since the transfers were all interfacility, the additional time required to contact medical control for each transport was non-critical.

Probably not as eloquent as I'd like to be, but I haven't had my lunch yet.

buffettrn, on Apr 30 2008, 07:15 PM, said:

I thank everyone that has looked at my post especially those that have responded to my poll. Just want to add a question for your thoughts. Why do Pedi programs tend to utilize Medical Command over protocals?

[Mike MacKinnon]

Hey yer missin a choice We didnt have to call for a chest tube either.

[flightnursesarah]

We don't do chest tubes, but we can do pericardiocentesis without Medical Control. Where do we put that? We are also RN/RN, RN/EMT-P, and RN/MD. I need more choices!

[buffettrn]

flightnursesarah, on May 7 2008, 03:51 PM, said:

We don't do chest tubes, but we can do pericardiocentesis without Medical Control. Where do we put that? We are also RN/RN, RN/EMT-P, and RN/MD. I need more choices!

Mr Wade limited my choice options sorry, but I understand. I used Chest tubes as an example of advanced procedures suchh as pericardiocentesis.
what determines your team composition? WE use RN MD or RN PA/NP for unstable neonates.

Thank you fot looking

Jeff

[Loydster]

At my company we run adult and peds calls the same. We have protocols for both as well as extensive continuing education and skills every month. I believe protocols are good but should be used as references not guidelines. Guidelines take the thinking out of pt care and crews just follow the protocols and don't think about what is going on and what may happen if they do a certain intervention. We allow our crews to deviate from the protocols as long as they have sound reason and judgment. All of transports are reviewed by peers 100% as well as 100% through our CQI process that looks specifically at how the crews follow our protocols and if they deviated was it appropriate for the pt. A prefect example is a hypotensive trauma pt in pain. The protocol states give 1mcg/kg of Fenatnyl. But knowing the pt is shocky a 1/2 dose maybe more appropriate to see how they do with it. (IE in California the Drs cannot write MD orders for drug ranges they must be a set dose).

We also have a medical director on call 24 hours a day and can be reached by land or air if we have a question/problem.
There are certain pt in which we are required to make contact with the accepting MD. These are Neo, peds, OB, and spinal injuries. This is based upon state requirements as well the accepting facilities request. These calls are more for getting the actual assessment and pt info correctly to the accepting MD and not the possibly skewed assessment from the sending MD who just wants the pt out of their hospital.

[mjcfrn]

Michael Collins, on May 1 2008, 07:27 PM, said:

Its likely based on the history and development of the program. Many pediatric specialty teams don't perform scene flights and many don't employ paramedics, or historically don't. The model was not developed from EMS, but for a "mobile ICU." This nursing model didn't embrace comprehensive protocols and standing orders. Since the transfers were all interfacility, the additional time required to contact medical control for each transport was non-critical.

Probably not as eloquent as I'd like to be, but I haven't had my lunch yet.

I think another piece of it is that Peds and Neo have historically tended to have more hands on involvement from the MDs. When I worked in adult ICU's I had protocols that covered many things but they were very rigidly cookbook and allowed no deviation, no judgment, no thinking. I have a lot of autonomy when I work as a staff nurse in PICU, but differently than the autonomy I had as an (adult) ICU RN. The docs stay very involved. The trend to have hospitalists physicians is and has been much more common in Neo/Ped than in the adult world. Also, there is increased legal liability (statute of limitations) in most if not all states.

Our protocols are very broad and cover most everything, but our intensivists (who are our med control) expect a call not so much to get orders as to get an update on the patient's condition. I think they are preparing for what the infant/child will need once we arrive to NICU/PICU. I think it also may be that the physicians have confidence in our assessments because we have worked closely with them, while the referring doc's level of skill may be unknown to them.

There's probably other factors, too, but since I'm post-shift I'll stop before I get too eloquent. (I talk more but think less when I'm tired)


How was lunch?

[mjcfrn]

I couldn't answer the "protocols good or bad" question because I think it depends. I've worked under well-written protocols and poorly-written ones. The same team which had very cookie-cutter rigidly defined protocols also had a med control doc who was very hands off. He would let you know if you had done something wrong, but no case reviews, no skill maintenance. I think that's a bad way to run EMS /transport teams.

Right now, our protocols are very broadly written: we can "consider" most of our interventions and decide whether or not they are appropriate for this particular pt. Often, we have our choice of several agents for analgesic, sedative, paralytic, anti-hypertensive, etc. as well as dosage ranges in many agents. There is a caveat at the beginning of our protocols saying these are only "guidelines" and that they "do not replace clinical judgment." [Obviously, I understand the definition of "guideline" a bit differently from one of the other posters.

Our med control doc meets with us frequently and we review most cases. He expects us to have a reason for each of our decisions. He also plays the "what if?" game with us a lot - it keeps us thinking and learning. Working from broadly-written protocols which allow clinical judgment necessitates a med control doc who is very involved in educating the team/maintaining team skills, etc, It's got to be better for the patients to be able to individualize their care.

[MSDeltaFlt]

buffettrn, on Apr 30 2008, 09:15 PM, said:

I thank everyone that has looked at my post especially those that have responded to my poll. Just want to add a question for your thoughts. Why do Pedi programs tend to utilize Medical Command over protocals?

The ones I've seen, it depends. I think that the younger the pt, the more they uttilize medical command; not to mention the more problems the pt has.

[Flightgypsy]

I think a lot of it is to do with the liablilty and the fact that you have so much less room for error in pediatrics. It is also a well known fact that unless you have experience with pediatrics many providers really aren't comfortable taking care of pediatric patients. You also have such a range of providers in even one company that one person may have a lot of pediatric experience while the next person may have very limited experience. So the doctors may not know how much experience the person transporting really has. We all know kids are NOT little adults but a lot of adult experienced providers don't always know what they don't know. (For example doing heelsticks for glucose checks on infants instead of fingers). The majority of providers that I know are very active and accountable in increasing their pediatric knowledge but it is still not quite the same as having actual experience.

Of course this is not including Specialty Pediatric/NICU Teams. The PICU/NICU teams out of our hospital that just do interfacilities run a lot on protocols but they still have to keep in close contact with the receiving MD and I think they have to call him before they do a lot of things but I am not familiar with exactly how they run.

My flight program runs on protocols and they are really closely following pediatric transports at the moment. We are required to attempt to make physician contact on all IFTs and especially on pediatric transports. Receiving docs usually want a report from the crew on how the pt really is.

To be perfectly honest some of the nurses in our company would know pediatrics better than the majority of the sending physicians and I have mostly found the receiving docs very amenable to suggestions and more willing to accept your interpretation of the patient condition than the sending docs.

The KEY is education, education, education!!!

Keep safe all,

[flightnursesarah]

buffettrn, on May 18 2008, 10:30 PM, said:

Mr Wade limited my choice options sorry, but I understand. I used Chest tubes as an example of advanced procedures suchh as pericardiocentesis.
what determines your team composition? WE use RN MD or RN PA/NP for unstable neonates.

Thank you fot looking

Jeff

We use whatever crew composition is working that shift. We are mostly RN/RN, but also have paramedics. We have Emergency Medicine Resident physicians that fly with us as part of their residency program. They have to follow our protocols, though, unless they are 3rd year and independently licensed.

We have to have an RN on every flight, then whoever else is there that shift takes the flight with the nurse. When the residents are just starting out, we try to fly with 3 crew members if weight allows. It is pretty scary to have a first year resident in their 3rd month as a doctor as your partner when you have a sick kid or a really bad airway. It is nice to have an experienced partner there to have your back!

Our preemie team flies RN/RT.

[cbaker4481]

I am going to answer the pedi/neo question from the eyes of a pedi/neo provider. I have always been on a dedicated childrens team, but for a while worked for a program that did big people, but had a very heavy pedi/neo volume, and we did not carry a specialty team, we did it all. We made contact with the ICU docs on every trip, but the vast majority of the time, at least for me, the conversation consisted of "Kid looks great, I am just folowing protocols and will see you in a few". For the other 10%, there would be more of a discussion, but those were the more complex patients (congenital hearts, septic shock, DKA, unrecognized abuse...). To be honest, I loved this discussion, as there were times that I learned a thing or two from the discussion and it only made my practice better. As well, the docs learned about what we did. I remember a little girl that we flew that had HUS. The doc wanted everything thrown at her before we lifted. I had the frank discusion with him and said "if you don't let me go she's going to f'in die!" and he learned that there are times in peds to pack and go. I agree completely with all of the previous answers to this, but I will add, that at times it is difficult to run cookbook protocols for kids. A lot, it is their firts time with whatever they have (new diabetics, congenital hearts,...) and you do not know what or how much will work for them, as much as you do for the adult with recurrent CHF. I will admit that we saw an equal volume of complex adults, but they were able to be managed easier based on history and protocol than the kids were.
The other issue is that some states (I am in Ohio) do not allow nurses to work from protocol. Ohio is VERY clear and just posted an interpretive statement that states that RN's CAN NOT work from protocol, they must have contact with a physician prior to initiating any orders.
My rule was always ABC's first. I never called back until I was comfortable that the kid was not going to die while I was on the phone. All of the docs were comfortable with that and as I said, from that point my callo back was more of a report to get them ready than to receive orders.
I am done babbling, not sure I answered the question, but just my two cents!

[justlookin]

cbaker4481, on Jun 21 2008, 08:34 AM, said:

The other issue is that some states (I am in Ohio) do not allow nurses to work from protocol. Ohio is VERY clear and just posted an interpretive statement that states that RN's CAN NOT work from protocol, they must have contact with a physician prior to initiating any orders.

Would you be able to post a link to this rule/reg, or the interpretive statement?

[cbaker4481]

The link for Ohio is http://nursing.ohio....latory_stmt.pdf
I will say that they state that in the case of a true emergency, you can use protocols, but the definition of emergent is not clear. I would imagine that most scene calls could be called emergent, but specialty teams for the most part do not do scene work. Most interfacility work would probably be seen as routine, as they are being managed in a health care facility, therefore you would not be able to use protocol. As I said before, if I needed to manage something like seizures or an emergent intubation, then I would follow protocol, if the patient could be maintained while I made a quick call, then I did it.

[ljoestlein]

cbaker4481, on Jun 25 2008, 03:54 AM, said:

The link for Ohio is http://nursing.ohio....latory_stmt.pdf
I will say that they state that in the case of a true emergency, you can use protocols, but the definition of emergent is not clear. I would imagine that most scene calls could be called emergent, but specialty teams for the most part do not do scene work. Most interfacility work would probably be seen as routine, as they are being managed in a health care facility, therefore you would not be able to use protocol. As I said before, if I needed to manage something like seizures or an emergent intubation, then I would follow protocol, if the patient could be maintained while I made a quick call, then I did it.

I have called the Ohio Board of Nursing about this. They were very clear that as a RN, you cannot act on protocols alone in the state of Ohio unless it was emergent. I asked for clarification of "emergent". The example I received was if a child was seizing, I could secure an airway (ABC's) and give an anticonvulsant such as ativan to stop the seizure. I could not load the child with fosphenytoin until after I called Med Control as that was considered not an emergent action. Actually the Ohio Medical Board, the Ohio Pharmacy board and the Ohio Board of Nursing wrote a regulatory statement about this (Joint Regulatory Statement Regarding the Use of Protocols to Initiate or Adjust Medications). In the statement, there is a list of questions and answers. One of the questions asks if drugs on a list of drugs be administered using protocols: "to administer a listed drug using protocols would be the unauthorized practice of medicine, which is a felony in this state." Another question asks what is an example of a "true emergency." "for purposes of this rule, examples of true emergencies would be cases such as heart attacks, severe burns, cyanide poisoning, electrocutions or severe asthmatic attacks." That was when I asked for clarification of what treatment is considered emergent vs. non emergent and received the seizure example. I would suggest that if you have questions about acting on protocols, to contact your state board as I'm sure this can vary from state to state.

[BackcountryMedic]

ljoestlein, on Jul 1 2008, 04:42 PM, said:

I have called the Ohio Board of Nursing about this. They were very clear that as a RN, you cannot act on protocols alone in the state of Ohio unless it was emergent. I asked for clarification of "emergent". The example I received was if a child was seizing, I could secure an airway (ABC's) and give an anticonvulsant such as ativan to stop the seizure. I could not load the child with fosphenytoin until after I called Med Control as that was considered not an emergent action. Actually the Ohio Medical Board, the Ohio Pharmacy board and the Ohio Board of Nursing wrote a regulatory statement about this (Joint Regulatory Statement Regarding the Use of Protocols to Initiate or Adjust Medications). In the statement, there is a list of questions and answers. One of the questions asks if drugs on a list of drugs be administered using protocols: "to administer a listed drug using protocols would be the unauthorized practice of medicine, which is a felony in this state." Another question asks what is an example of a "true emergency." "for purposes of this rule, examples of true emergencies would be cases such as heart attacks, severe burns, cyanide poisoning, electrocutions or severe asthmatic attacks." That was when I asked for clarification of what treatment is considered emergent vs. non emergent and received the seizure example. I would suggest that if you have questions about acting on protocols, to contact your state board as I'm sure this can vary from state to state.

This is the dumbest thing I have ever heard.

I'm not from OH, so I have no facts - but these people are idiots. This is poor patient care and dangerous. It is also an insult.

[Macgyver]

BackcountryMedic, on Jul 1 2008, 04:05 PM, said:

This is the dumbest thing I have ever heard.

I'm not from OH, so I have no facts - but these people are idiots. This is poor patient care and dangerous. It is also an insult.

So, aside from hospital based specialty teams, how do most HEMS programs manage to operate - the Medic runs the call with the RN "advising"? Sweet!