Answer: Thanks for your question.
First, let us address the Base Hospital Role in Setting Documentation Standards:
- The employer has responsibility and accountability for documentation standards, and as such, the employer is responsible for training and overseeing the application of the MOHLTC ACR documentation standards (Ambulance Act RSO 1990, c A.19, O Reg 257/00, Part V, ss 11 and 11.1). Paramedics should obtain advice from, and follow the direction of, their employer on questions of application of the standard.
- When Base Hospital auditors find what appears to be deviations from the ACR documentation standards, we forwards these comments to the employer who can determine if followup is necessary (in compliance with the Act). The BH does not directly advise paramedics on adherence to the standard except in connection with application of medical directive.
- The BH has been involved (in concert with employers) in developing regionally standardized novel codes for use in application of new procedures (King LT, CPAP etc) that can be used with e-ACRs.
The Base Hospital Role in Directing Application of Medical Directive:
- The primary role of the Base Hospital, with respect to documentation standards, is to use the ACR as evidence that the medical directive has been followed, in the chronological order defined in the directives. In cases where documentation appears to show deviation from medical directive, followup is performed directly by the BH.
- In connection with the ACR as proxy for performance, the BH has directed paramedics that documenting CPR as being continuous throughout would be acceptable in cardiac arrest cases. Since CPR documentation is not specifically addressed in the ‘standard’, the BH is free to so direct the paramedics (subject to ultimate authority of the operator).
- Vital signs documentation is entirely different for the following reason: They are specifically addressed in the standard (Pg 21 in the ACR completion manual makes reference to the requirements for vital signs documentation):
Vital signs are recorded in the Treatment/Procedure/Medication/Results section. In the left hand column, enter the time at which the vital signs are measured. Enter the vital sign code in the procedure column. Ghosted lines are used to separate vital signs entries. The vital signs section is intended to record information regarding the patient’s pulse, respiration, blood pressure, temperature, ECG, O2 saturation, Endtidal CO2, Glasgow Coma Scale and pupils. As a minimum, all patients must have an entry made regarding their pulse, respiration, skin and blood pressure. Other areas are to be completed if appropriate and available. A minimum of two (2) sets of vital signs should be taken for every pre-hospital patient. If the minimum vital signs assessment are not taken, document the reasons in the “Remarks” section of the ACR. Approximations of vital signs are acceptable if documented as such. (emphasis from original document) There are vital signs documentation requirements that arise from application of medical directives:
- Initially, the patient must be assessed as being pulseless in order to apply the cardiac arrest medical directive. This assessment of vital signs ought to be recorded. In addition, while not specifically noted in the medical directive, it seems prudent prior to obtaining a pronouncement, that the absence of a pulse be confirmed. These two events would satisfy, at minimum, the standard requirements, but more is often required by the directive.
- After a rhythm analysis that yields a rhythm other than VF/VT or asystole, the paramedic is required to confirm the absence of pulse. This must be documented.
- After securing the airway, EtCO2 reading should be taken and recorded as a proxy for underlying metabolic activity and adequacy of ventilation, These values ought to be noted.
All these additional vital signs documentation requirements are temporally specific (need to be associated with a time). This makes documenting ‘vitals taken throughout’ inappropriate. Vitals, unlike CPR, are not a single procedure, but a term used to denote a series of indicators that are considered vital to a baseline assessment. As indicated above, what is vital is sometimes variable (sP02 or etCo2 may be vital in some cases but not others), which further supports the suggestion that vitals must be documented when they are taken. As for the second part of your question relating to rhythm analysis in a moving vehicle, the concern here is twofold: the influence of artifact affecting your decision making and the actions you may take based upon that interpretation. Paramedics interpret the rhythms safely while on transport every day. This is an essential component of what you do and the Base Hospital clearly supports this activity. The concern would be acting upon a rhythm which would have been exposed to artifact by ambulance motion. Paramedics should not press “analyze” as a PCP or ACP in semi automatic mode with a vehicle in motion. It is a manufacturer’s safety recommendation and expresses limitation in the computer’s analysis of the underlying rhythm. For the same reasons, any use of energy from the defibrillator by paramedics should not be performed in a moving ambulance. We hope this helps to clarify your excellent questions!