M01 Flashcards
Clinical Approach Care Objective
To ensure all patients receive a structured and comprehensive assessment of their health status that
leads to their healthcare needs being addressed.
Clinical Approach Intended Pt Group
All patients
Clinical Approach Pre-Arrival Special Notes
Cognitive bias and human factors have a significant impact on decision making and should be
considered and discussed frequently throughout the entire process of patient care.
Early diagnostic closure based on dispatch information presents a particular risk to patient safety.
Patients from marginalised populations are at greater risk of harm from unconscious bias.
These risks include low socioeconomic status, culturally and linguistically diverse, Aboriginal or Torres Strait
Islander, substance affected, have a mental health related presentation or behaviours of concern.
Human factors and their potential impact on patient care should be considered and acknowledged
prior to arrival and throughout patient assessment:
Clinical Approach HALTS
Hungry Angry Late Tired Stressed
Clinical Approach Rapid Assessment
Immediate impression based on the presence of altered conscious state, increased work of
breathing and obvious skin signs (e.g. diaphoresis, cyanosis) that informs:
The need for a formal primary survey
The urgency with which the patient should be assessed and the need for simultaneous
collection of information
Clinical Approach Primary Survey
If a patient deteriorates the default position should be to return to the primary survey for
reassessment.
Clinical Approach Exposure
Refers to both exposing the patient for assessment (e.g. to locate possible major
haemorrhage) and exposure to environmental conditions. Patient dignity should be maintained as
much as possible while managing the risk of potential life-threatening conditions. Prevent
hypothermia following exposure
Clinical Approach Hx of Presenting Illness Mgx
Avoid interrupting or redirecting the patient where possible during initial history taking.
Appears well / non-serious complaint: Avoid concurrent vital signs and other assessment elements
where possible to allow for uninterrupted, thorough history taking.
Appears unwell / serious complaint: Concurrent assessment as required (e.g. 12 lead ECG in chest
pain, SpO2
in acute SOB).
Clinical Approach Attendant Roles
Attendant 1: Assess the patient directly, taking the lead in history taking and physical examination.
Attendant 2: Observes assessment and scene with minimal cognitive load, collects information and
identifies missed information, errors or opportunities.
BSL must be taken in Pts:
Altered conscious state
History of diabetes
Medical patients with undifferentiated acute illness
Clinical Approach Physical Examination
Focussed examination: found in specific CPGs indicated for particular complaints (e.g. ACTFAST/MASS, AEIOUTIPS, Spinal neurological examination, etc.)
General physical examination (Secondary Survey): Any other physical assessment informed by the paramedic’s
evolving understanding of the patient’s presenting illness
Clinical Approach Social/environmental factors
May present a range of hazards and health risks which influence their care plan as much as the
diagnosis or clinical problems.
Clinical Approach Diagnosis
Diagnosis: Any clinically useful characterisation of the patient’s health status that leads to a care
plan that meets the patient’s needs. This includes a likely underlying pathology and/or a simple
statement of clinical problems to be addressed.
All stages of the diagnostic process should be discussed between AV staff and with the patient /
family where possible and appropriate
Clinical Approach Risks
The identification of risk and the subsequent escalation of care is more important than a precise
diagnosis and allows for safe decision making where there is diagnostic uncertainty (this is expected
to be frequent).
Initial assessment captures a single moment in time. The patient’s trajectory or expected clinical
course should be considered despite an unremarkable initial assessment.
Clinical Approach Differential Diagnosis
Diagnostic uncertainty is common and should be acknowledged. Where the underlying cause is
uncertain, a care plan may be based on clinical problems (e.g. hypotension) and/or risks (e.g. elderly
and frail).
Clinical Approach - Clinical Judgement
Clinical judgement is a subjective process to establish the most appropriate and accurate
characterisation of the patient’s condition that leads to a safe and effective care plan.
Most appropriate diagnosis based on a balance of the urgency and likelihood of possible
conditions
A hierarchy of clinical problems requiring management
The risks to patient safety
Expert consultation and/or the escalation of care (e.g. transport) is recommended where clinical
judgement does not lead to a satisfactory diagnosis, clinical problem and risk profile (e.g. staff on
scene cannot agree).
Clinical Approach Care Pathways
Treatment: Apply the appropriate CPG, CWI, direct care (e.g. wound dressing) or the patient’s own
care plan as required (e.g. palliative patients, medically prescribed crisis medications)
Clinical Approach Escalation of Care
Escalation of care should occur as soon as possible after recognition of deterioration. This may
include transport to ED or specialist facility, MICA, HEMS, PIPER, expert consultation, etc.
Family members / carers may be able to identify deterioration earlier in the patient’s course. Family /
carer concern should be considered in decisions relating to escalation of care.
Care can be escalated at any stage and for any reason at the judgement of the paramedic.
Clinical Approach - Refferal
A referral resource containing a summary of the assessment, care plan, safety netting and referral
instructions MUST be provided and explained to the patient in all instances of non-transport
including refusal.
Safety netting: A plan to address unexpected but possible adverse events or deterioration. Apply
the concept of safety netting in all patients who are not transported to hospital.
A patient treated with the intention of referral away from ED must be reassessed prior to departure. If
the patient has deteriorated or has not responded to treatment as expected, then revise the care
plan and transport them to ED.
Clinical Approach - Access to care
In order to be safe and effective, the care plan must be feasible and the patient must have access to
the resources necessary to enact the plan. The following barriers should be considered:
- Socio-economic status & health literacy
- Logistic issues (e.g. opening times, transport)
- Patient’s location in relation to health services
- Linguistic or cultural barriers
- Disability related barriers
Clinical Approach - Reassessment
15-minutely VSS reassessment is the minimum standard. Where it is impossible or clinically
unnecessary, the rationale MUST be documented. Where a patient is considered unwell or
deteriorates, reassessment should be performed more frequently and care escalated as appropriate.
Reassessment should include:
SpO2
, HR, BP, RR, GCS and any other observation that was initially found to be abnormal (e.g.
haemorrhage, pain, SOB)
The efficacy and safety of any treatments (e.g. tourniquets, CPAP, splint, thoracostomies, ETT)
Clinical Approach - Transfer of Care
Where the patient is referred into the community, the effective transfer of information from
paramedics to other healthcare professionals is as important as handover in an ED.
Attempt to make direct contact with the healthcare professional and include relevant information
regarding the patient’s presentation in the referral resource.
Avoid the transmission of bias to other healthcare professional by the use of biased language at
handover or in documentation.
PSA take in context with
These observations and criteria need to be taken in context with:
The patient’s presenting problem.
The patient’s prescribed medications.
Repeated observations and the trends shown.
Response to management.
BP alone does not determine perfusion status.
Perfusion definition
The ability of the cardiovascular system to provide tissues with an adequate oxygenated blood supply to
meet their functional demands at that time and to effectively remove the associated metabolic waste
products.
PSA other factors
ambient temperature
anxiety
any cause of altered consciousness.
PSA adequately perfused
s: WPD, P: 60-100bpm, BP: >100SBP, CS: AO TPP
PSA Borderline
s: CPC, P: 50-100bpm, BP: 80-100SBP, CS: AO TPP
PSA inadequate
s: CPC, P: <50->100bpm, BP: 60-80SBP, CS: AO TPP or ACS
PSA extremely poor
s: cpc, p: <50/>110bpm, BP: <60SBP/unrecord, CS: acs/uncon
PSA no perf
s: cpc, p: nil palp. BP: unrec. CS uncon
RSA Normal Resp Distress
GA: Calm, quiet Speech: Clear and steady sentences BS: usually quiet, no wheeze. No crackles or scattered fine basal crackles eg postural RR: 12-16 R Rhy: regular WOB: normal HR: 60-100bpm Skin: normal CS: alert
RSA Mild Resp Distress
GA: Calm or Mildly Anxious Speech: Full sentences BS: Able to cough. ASTHMA: mild exp wheeze. LVF: may be fine crackles RR: 16-20 R Rhy: asthma: may have slightly prolonged exp phase WOB: slight increase HR: 60-100bpm Skin: normal CS: alert
RSA Moderate Resp Distress
GA: Distressed or anxious Speech: short phrases only BS: able to cough. ASTHMA: expiratory wheeze +/- ins wheeze. LVF: crackles at bases to midzone RR: > 20 R Rhy: asthma: prolonged exp phase WOB: marked chest movements +/- use of accessory muscles HR: 100-120bpm Skin: pale and sweaty CS: may be altered
RSA severe resp distress
life threat
GA: distressed, anxious, fighting to breathe, exhausted, catatonic
Speech: words only or unable to speak
BS: unable to cough. ASTHMA: exp wheeze +/- insp wheeze, maybe no breath sounds (late). LVF: fine crackles - full field with possible wheeze. UAO: insp stridor
RR: > 20 or bradypnoea < 8
R Rhy: asthma: prolonged exp phase
WOB: marked chest movements with accessory muscle use, intercostal retraction +/- tracheal tugging
HR: >120 bradycardia late sign
Skin: pale and sweaty +/- cyanosis
CS: altered or unconscious
GCS eyes
4: spontaneous
3: voice
2: pain
1: none
GCS verbal
5: orientated
4: confused
3: inappropriate
2: incomprehensible
1: none
GCS motor
6: obeys
5: localises
4: withdraws
3: flexion
2: extension
1: none
Actual time critical
At the time the vital signs survey is taken, the patient is in actual physiological distress.
Potential time critical
At the time the vital signs survey is taken, the patient is not physiologically distressed and there is no significant pattern of actual Injury/illness, but there is a mechanism of injury/illness known to have the potential to deteriorate to actual physiological distress.
Emergent time critical
At the time the vital signs survey is taken, the patient is not physiologically distressed but does have a pattern of injury or significant medical condition which is known to have a high probability of deteriorating to actual physiological distress.
Transport time for major trauma
Patients meeting the criteria for major trauma should be triaged to the highest level of trauma care
available within 60 minutes transport time of the incident with notification
Major trauma pregnant pts
maternity patients who meet the time critical trauma criteria, or any patient who is > 24 weeks gestation
with any trauma or potential harm to the unborn child, should be transported to the Royal Melbourne
Hospital if within 60 minutes. If > 60 minute travel time, transport to the nearest alternative highest level of
trauma service. Pregnant women must not be taken to The Alfred Hospital unless in cardiac arrest and the
Alfred is closest.
Major trauma MOI
A patient under the Trauma Triage Guidelines meets the criteria for major trauma if they have a combination of MOI and other co-morbidities constituting:
Systemic illness limiting normal activity / systemic illness constant threat to life. Examples include:
- Poorly controlled hypertension
- Obesity
- Controlled or uncontrolled CCF
- Symptomatic COPD
- Ischaemic heart disease
- Chronic renal failure or liver disease
Pregnancy
Age < 12 or > 55
