Re: Closest vs. Most Appropriate Facility

April 28, 2005

> Does any one have any research on Closest vs. Most appropriate facility?

> Should patients be transported to the facility more capable of

> addressing their illness \ injury even though there is a much closer

> facility that will only begin treatment, many times available on the

> ambulance, then transfer out to the other facility hours later? If so

> what criteria should they meet to justify the bypass? I have my own

> opinion but have not seen any studies, thanks in advance.

>

> Drew Bohn NREMT-P

>

Drew:

There is a ton of literature on this subject. Have you done a pubmed search

for bypass/destination determination?

Literature, in general, supports the idea of transport directly to facility

capable of definitive care in a handful of patient types, including hearts,

pedi & trauma. There are some caveats....unable to manage ABC's for the trip,

for example, warrants stopping somwhere closer.

Search around on here:

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi

Good luck,

, BS, LP

Director, & White Pre-Hospital Services

www.swphs.org

Member, Air Medical Committee of

the Governor's Emergency and Trauma Advisory Council (GETAC)

Associate Faculty:

Texas A & M Health Science Center (Medical School)

Temple College EMS Program

TEEX EMS Leadership Academy

EMS Consultant and Instructor

April 28, 2005

> Does any one have any research on Closest vs. Most appropriate facility?

> Should patients be transported to the facility more capable of

> addressing their illness \ injury even though there is a much closer

> facility that will only begin treatment, many times available on the

> ambulance, then transfer out to the other facility hours later? If so

> what criteria should they meet to justify the bypass? I have my own

> opinion but have not seen any studies, thanks in advance.

>

> Drew Bohn NREMT-P

>

Drew:

There is a ton of literature on this subject. Have you done a pubmed search

for bypass/destination determination?

Literature, in general, supports the idea of transport directly to facility

capable of definitive care in a handful of patient types, including hearts,

pedi & trauma. There are some caveats....unable to manage ABC's for the trip,

for example, warrants stopping somwhere closer.

Search around on here:

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi

Good luck,

, BS, LP

Director, & White Pre-Hospital Services

www.swphs.org

Member, Air Medical Committee of

the Governor's Emergency and Trauma Advisory Council (GETAC)

Associate Faculty:

Texas A & M Health Science Center (Medical School)

Temple College EMS Program

TEEX EMS Leadership Academy

EMS Consultant and Instructor

April 28, 2005

Have your checked your regional RAC trauma plan? TSA-A addresses this issue

in the plan. Kay , RAC A Program Manager

Closest vs. Most Appropriate Facility

>

> Does any one have any research on Closest vs. Most appropriate facility?

> Should patients be transported to the facility more capable of

> addressing their illness \ injury even though there is a much closer

> facility that will only begin treatment, many times available on the

> ambulance, then transfer out to the other facility hours later? If so

> what criteria should they meet to justify the bypass? I have my own

> opinion but have not seen any studies, thanks in advance.

>

> Drew Bohn NREMT-P

> Operations Training Officer

> Orange County Ambulance Service inc.

> Orange, Texas

> drewbohn@...

> dbohn@...

>

April 28, 2005

Have your checked your regional RAC trauma plan? TSA-A addresses this issue

in the plan. Kay , RAC A Program Manager

Closest vs. Most Appropriate Facility

>

> Does any one have any research on Closest vs. Most appropriate facility?

> Should patients be transported to the facility more capable of

> addressing their illness \ injury even though there is a much closer

> facility that will only begin treatment, many times available on the

> ambulance, then transfer out to the other facility hours later? If so

> what criteria should they meet to justify the bypass? I have my own

> opinion but have not seen any studies, thanks in advance.

>

> Drew Bohn NREMT-P

> Operations Training Officer

> Orange County Ambulance Service inc.

> Orange, Texas

> drewbohn@...

> dbohn@...

>

April 28, 2005

Have your checked your regional RAC trauma plan? TSA-A addresses this issue

in the plan. Kay , RAC A Program Manager

Closest vs. Most Appropriate Facility

>

> Does any one have any research on Closest vs. Most appropriate facility?

> Should patients be transported to the facility more capable of

> addressing their illness \ injury even though there is a much closer

> facility that will only begin treatment, many times available on the

> ambulance, then transfer out to the other facility hours later? If so

> what criteria should they meet to justify the bypass? I have my own

> opinion but have not seen any studies, thanks in advance.

>

> Drew Bohn NREMT-P

> Operations Training Officer

> Orange County Ambulance Service inc.

> Orange, Texas

> drewbohn@...

> dbohn@...

>

April 28, 2005

<<Have your checked your regional RAC trauma plan? TSA-A addresses this issue

in the plan. Kay , RAC A Program Manager>>

Unfortunately, usually just for trauma. It leaves the other 80% of EMS calls

unanswered in most RAC's.

, BS, LP

Director, & White Pre-Hospital Services

www.swphs.org

Member, Air Medical Committee, Govenor's EMS & Trauma Council

Adjunct Faculty, TAMU Health Science Center (Medical School)

Adjunct Faculty, Temple College EMS Program

Re: Closest vs. Most Appropriate Facility

Have your checked your regional RAC trauma plan? TSA-A addresses this issue

in the plan. Kay , RAC A Program Manager

Closest vs. Most Appropriate Facility

>

> Does any one have any research on Closest vs. Most appropriate facility?

> Should patients be transported to the facility more capable of

> addressing their illness \ injury even though there is a much closer

> facility that will only begin treatment, many times available on the

> ambulance, then transfer out to the other facility hours later? If so

> what criteria should they meet to justify the bypass? I have my own

> opinion but have not seen any studies, thanks in advance.

>

> Drew Bohn NREMT-P

> Operations Training Officer

> Orange County Ambulance Service inc.

> Orange, Texas

> drewbohn@...

> dbohn@...

>

April 28, 2005

<<Have your checked your regional RAC trauma plan? TSA-A addresses this issue

in the plan. Kay , RAC A Program Manager>>

Unfortunately, usually just for trauma. It leaves the other 80% of EMS calls

unanswered in most RAC's.

, BS, LP

Director, & White Pre-Hospital Services

www.swphs.org

Member, Air Medical Committee, Govenor's EMS & Trauma Council

Adjunct Faculty, TAMU Health Science Center (Medical School)

Adjunct Faculty, Temple College EMS Program

Re: Closest vs. Most Appropriate Facility

Have your checked your regional RAC trauma plan? TSA-A addresses this issue

in the plan. Kay , RAC A Program Manager

Closest vs. Most Appropriate Facility

>

> Does any one have any research on Closest vs. Most appropriate facility?

> Should patients be transported to the facility more capable of

> addressing their illness \ injury even though there is a much closer

> facility that will only begin treatment, many times available on the

> ambulance, then transfer out to the other facility hours later? If so

> what criteria should they meet to justify the bypass? I have my own

> opinion but have not seen any studies, thanks in advance.

>

> Drew Bohn NREMT-P

> Operations Training Officer

> Orange County Ambulance Service inc.

> Orange, Texas

> drewbohn@...

> dbohn@...

>

April 28, 2005

<<Have your checked your regional RAC trauma plan? TSA-A addresses this issue

in the plan. Kay , RAC A Program Manager>>

Unfortunately, usually just for trauma. It leaves the other 80% of EMS calls

unanswered in most RAC's.

, BS, LP

Director, & White Pre-Hospital Services

www.swphs.org

Member, Air Medical Committee, Govenor's EMS & Trauma Council

Adjunct Faculty, TAMU Health Science Center (Medical School)

Adjunct Faculty, Temple College EMS Program

Re: Closest vs. Most Appropriate Facility

Have your checked your regional RAC trauma plan? TSA-A addresses this issue

in the plan. Kay , RAC A Program Manager

Closest vs. Most Appropriate Facility

>

> Does any one have any research on Closest vs. Most appropriate facility?

> Should patients be transported to the facility more capable of

> addressing their illness \ injury even though there is a much closer

> facility that will only begin treatment, many times available on the

> ambulance, then transfer out to the other facility hours later? If so

> what criteria should they meet to justify the bypass? I have my own

> opinion but have not seen any studies, thanks in advance.

>

> Drew Bohn NREMT-P

> Operations Training Officer

> Orange County Ambulance Service inc.

> Orange, Texas

> drewbohn@...

> dbohn@...

>

April 28, 2005

This is a subject addressed by your protocols. You always want to have medical

direction in to make a decission not in your protocols.

DPEMS500@... wrote:

<<Have your checked your regional RAC trauma plan? TSA-A addresses this issue

in the plan. Kay , RAC A Program Manager>>

Unfortunately, usually just for trauma. It leaves the other 80% of EMS calls

unanswered in most RAC's.

, BS, LP

Director, & White Pre-Hospital Services

www.swphs.org

Member, Air Medical Committee, Govenor's EMS & Trauma Council

Adjunct Faculty, TAMU Health Science Center (Medical School)

Adjunct Faculty, Temple College EMS Program

Re: Closest vs. Most Appropriate Facility

Have your checked your regional RAC trauma plan? TSA-A addresses this issue

in the plan. Kay , RAC A Program Manager

Closest vs. Most Appropriate Facility

>

> Does any one have any research on Closest vs. Most appropriate facility?

> Should patients be transported to the facility more capable of

> addressing their illness \ injury even though there is a much closer

> facility that will only begin treatment, many times available on the

> ambulance, then transfer out to the other facility hours later? If so

> what criteria should they meet to justify the bypass? I have my own

> opinion but have not seen any studies, thanks in advance.

>

> Drew Bohn NREMT-P

> Operations Training Officer

> Orange County Ambulance Service inc.

> Orange, Texas

> drewbohn@...

> dbohn@...

>

April 28, 2005

This is a subject addressed by your protocols. You always want to have medical

direction in to make a decission not in your protocols.

DPEMS500@... wrote:

<<Have your checked your regional RAC trauma plan? TSA-A addresses this issue

in the plan. Kay , RAC A Program Manager>>

Unfortunately, usually just for trauma. It leaves the other 80% of EMS calls

unanswered in most RAC's.

, BS, LP

Director, & White Pre-Hospital Services

www.swphs.org

Member, Air Medical Committee, Govenor's EMS & Trauma Council

Adjunct Faculty, TAMU Health Science Center (Medical School)

Adjunct Faculty, Temple College EMS Program

Re: Closest vs. Most Appropriate Facility

Have your checked your regional RAC trauma plan? TSA-A addresses this issue

in the plan. Kay , RAC A Program Manager

Closest vs. Most Appropriate Facility

>

> Does any one have any research on Closest vs. Most appropriate facility?

> Should patients be transported to the facility more capable of

> addressing their illness \ injury even though there is a much closer

> facility that will only begin treatment, many times available on the

> ambulance, then transfer out to the other facility hours later? If so

> what criteria should they meet to justify the bypass? I have my own

> opinion but have not seen any studies, thanks in advance.

>

> Drew Bohn NREMT-P

> Operations Training Officer

> Orange County Ambulance Service inc.

> Orange, Texas

> drewbohn@...

> dbohn@...

>

April 29, 2005

We have three patient categories that are transported to special facilities

(frequently bypassing smaller/closer facilities):

1. Critical Trauma patients go to Level I trauma center

2. STEMI patients go to designated cardiac center (cath lab with

interventional cardiologist)

3. CVA patients go to designated cardiac center

Other patients can go to the closest or patient requested hospital.

_____

From: dbohn

Sent: Wednesday, April 27, 2005 12:19 AM

To:

Subject: Closest vs. Most Appropriate Facility

Does any one have any research on Closest vs. Most appropriate facility?

Should patients be transported to the facility more capable of

addressing their illness \ injury even though there is a much closer

facility that will only begin treatment, many times available on the

ambulance, then transfer out to the other facility hours later? If so

what criteria should they meet to justify the bypass? I have my own

opinion but have not seen any studies, thanks in advance.

Drew Bohn NREMT-P

Operations Training Officer

Orange County Ambulance Service inc.

Orange, Texas

drewbohn@...

dbohn@...

April 29, 2005

We have three patient categories that are transported to special facilities

(frequently bypassing smaller/closer facilities):

1. Critical Trauma patients go to Level I trauma center

2. STEMI patients go to designated cardiac center (cath lab with

interventional cardiologist)

3. CVA patients go to designated cardiac center

Other patients can go to the closest or patient requested hospital.

_____

From: dbohn

Sent: Wednesday, April 27, 2005 12:19 AM

To:

Subject: Closest vs. Most Appropriate Facility

Does any one have any research on Closest vs. Most appropriate facility?

Should patients be transported to the facility more capable of

addressing their illness \ injury even though there is a much closer

facility that will only begin treatment, many times available on the

ambulance, then transfer out to the other facility hours later? If so

what criteria should they meet to justify the bypass? I have my own

opinion but have not seen any studies, thanks in advance.

Drew Bohn NREMT-P

Operations Training Officer

Orange County Ambulance Service inc.

Orange, Texas

drewbohn@...

dbohn@...

April 29, 2005

Why would a CVA patient go to a cardiac center? Might as well take them to a

day care center.

E. Bledsoe, DO, FACEP

Midlothian, TX

Don't miss EMStock 2005 (http://www.EMStock.com)

Closest vs. Most Appropriate Facility

Does any one have any research on Closest vs. Most appropriate facility?

Should patients be transported to the facility more capable of addressing

their illness \ injury even though there is a much closer facility that will

only begin treatment, many times available on the ambulance, then transfer

out to the other facility hours later? If so what criteria should they meet

to justify the bypass? I have my own opinion but have not seen any studies,

thanks in advance.

Drew Bohn NREMT-P

Operations Training Officer

Orange County Ambulance Service inc.

Orange, Texas

drewbohn@...

dbohn@...

April 29, 2005

Why would a CVA patient go to a cardiac center? Might as well take them to a

day care center.

E. Bledsoe, DO, FACEP

Midlothian, TX

Don't miss EMStock 2005 (http://www.EMStock.com)

Closest vs. Most Appropriate Facility

Does any one have any research on Closest vs. Most appropriate facility?

Should patients be transported to the facility more capable of addressing

their illness \ injury even though there is a much closer facility that will

only begin treatment, many times available on the ambulance, then transfer

out to the other facility hours later? If so what criteria should they meet

to justify the bypass? I have my own opinion but have not seen any studies,

thanks in advance.

Drew Bohn NREMT-P

Operations Training Officer

Orange County Ambulance Service inc.

Orange, Texas

drewbohn@...

dbohn@...

April 29, 2005

Why would a CVA patient go to a cardiac center? Might as well take them to a

day care center.

E. Bledsoe, DO, FACEP

Midlothian, TX

Don't miss EMStock 2005 (http://www.EMStock.com)

Closest vs. Most Appropriate Facility

Does any one have any research on Closest vs. Most appropriate facility?

Should patients be transported to the facility more capable of addressing

their illness \ injury even though there is a much closer facility that will

only begin treatment, many times available on the ambulance, then transfer

out to the other facility hours later? If so what criteria should they meet

to justify the bypass? I have my own opinion but have not seen any studies,

thanks in advance.

Drew Bohn NREMT-P

Operations Training Officer

Orange County Ambulance Service inc.

Orange, Texas

drewbohn@...

dbohn@...

April 29, 2005

Only because that's what we call them; these hospitals are capable of

providing fibrinolytic therapy for strokes, others are not.

john

_____

From: Bledsoe

Sent: Friday, April 29, 2005 3:07 PM

To:

Subject: RE: Closest vs. Most Appropriate Facility

Why would a CVA patient go to a cardiac center? Might as well take them to a

day care center.

E. Bledsoe, DO, FACEP

Midlothian, TX

Don't miss EMStock 2005 (http://www.EMStock.com) <http://www.EMStock.com)>

Closest vs. Most Appropriate Facility

Does any one have any research on Closest vs. Most appropriate facility?

Should patients be transported to the facility more capable of addressing

their illness \ injury even though there is a much closer facility that will

only begin treatment, many times available on the ambulance, then transfer

out to the other facility hours later? If so what criteria should they meet

to justify the bypass? I have my own opinion but have not seen any studies,

thanks in advance.

Drew Bohn NREMT-P

Operations Training Officer

Orange County Ambulance Service inc.

Orange, Texas

drewbohn@...

dbohn@...

April 29, 2005

Only because that's what we call them; these hospitals are capable of

providing fibrinolytic therapy for strokes, others are not.

john

_____

From: Bledsoe

Sent: Friday, April 29, 2005 3:07 PM

To:

Subject: RE: Closest vs. Most Appropriate Facility

Why would a CVA patient go to a cardiac center? Might as well take them to a

day care center.

E. Bledsoe, DO, FACEP

Midlothian, TX

Don't miss EMStock 2005 (http://www.EMStock.com) <http://www.EMStock.com)>

Closest vs. Most Appropriate Facility

Does any one have any research on Closest vs. Most appropriate facility?

Should patients be transported to the facility more capable of addressing

their illness \ injury even though there is a much closer facility that will

only begin treatment, many times available on the ambulance, then transfer

out to the other facility hours later? If so what criteria should they meet

to justify the bypass? I have my own opinion but have not seen any studies,

thanks in advance.

Drew Bohn NREMT-P

Operations Training Officer

Orange County Ambulance Service inc.

Orange, Texas

drewbohn@...

dbohn@...

April 30, 2005

What does the law say about this? I got into an argument with my LP partner

about this subject.He said he would take an adult code to children's medical

center if it was the closest facility. (in the scenario, I said that children's

and parkland weren't next door, that children's was the closest facility but a

regular adult ER was another 5mins down the road).

He also said that if we had a burn pt, I said if they had second degree burns to

36% (both legs) if he would go to medical center at Lancaster (our closest

facility), or Parkland. I said that the weather was bad or something, no bird

available so we would trans. by ground, and he said that he would go to MCAL.

We run an MICU, I am a basic and my partner is an LP.

I think he is in the wrong, but what does the LAW say?

Red

Closest vs. Most Appropriate Facility

Does any one have any research on Closest vs. Most appropriate facility?

Should patients be transported to the facility more capable of

addressing their illness \ injury even though there is a much closer

facility that will only begin treatment, many times available on the

ambulance, then transfer out to the other facility hours later? If so

what criteria should they meet to justify the bypass? I have my own

opinion but have not seen any studies, thanks in advance.

Drew Bohn NREMT-P

Operations Training Officer

Orange County Ambulance Service inc.

Orange, Texas

drewbohn@...

dbohn@...

April 30, 2005

Where should stable cardiac patients be taken?

It is amazing how often this question comes up for debate. The answer is

simple What is in the best interest of the patient? There is no law. Only

the moral law of doing what is right.

To answer that question we only need to be the patient. Four years ago I

was being transported to San with chest pain by Bulverde/ Spring

Branch EMS. They asked me if I wanted to go to North Central ER because it

was closer. I emphatically said, ³NO². I wanted to go to a hospital with

cardiac cath and open-heart capabilities. So would you and so would any

knowledgeable patient. The additional time for me to ³divert² to a cardiac

capable hospital was only 9 minutes. That decision probably saved my life.

We emergency physicians have all lived through the nightmare of transferring

cardiac patients from a hospital with no cath lab to one of the cardiac

hospitals. It delays definitive care by at least an hour or more, which

places these patients in grave jeopardy (time is muscle) and unduly stresses

them with another ambulance ride. Because of the delay these patients

often die in our facility or arrest in route. One slightly longer ambulance

ride is always better than two separate transports. Even if the patient goes

into V-tach in route, paramedics can shock the patient just as well as we

can. That is why I have mandated paramedics under my medical control to take

all suspect cardiac patients to the closest hospital that has cardiac cath

lab facilities. They should only stop at the closest (non-cardiac) hospital

if the patient is crashing (malignant arrhythmia, hypotension, airway

problems etc).

This policy should be obvious to anyone analyzing the situation. Many

recent trials have driven this point home. This is the standard of care.

This is in the best interest of the patient. This is in the best interest of

the ED physicians. And this is certainly in the best interest of EMS to

provide patients with their best chance of survival. The only feeble

complaint I have ever heard is from one of the non-cardiac hospitals,

because they were loosing revenue. That argument should never enter into our

decision to do what is right.

Larry MD

> What does the law say about this? I got into an argument with my LP partner

> about this subject.He said he would take an adult code to children's medical

> center if it was the closest facility. (in the scenario, I said that

> children's and parkland weren't next door, that children's was the closest

> facility but a regular adult ER was another 5mins down the road).

>

> He also said that if we had a burn pt, I said if they had second degree burns

> to 36% (both legs) if he would go to medical center at Lancaster (our closest

> facility), or Parkland. I said that the weather was bad or something, no bird

> available so we would trans. by ground, and he said that he would go to MCAL.

>

> We run an MICU, I am a basic and my partner is an LP.

>

> I think he is in the wrong, but what does the LAW say?

>

> Red

> Closest vs. Most Appropriate Facility

>

> Does any one have any research on Closest vs. Most appropriate facility?

> Should patients be transported to the facility more capable of

> addressing their illness \ injury even though there is a much closer

> facility that will only begin treatment, many times available on the

> ambulance, then transfer out to the other facility hours later? If so

> what criteria should they meet to justify the bypass? I have my own

> opinion but have not seen any studies, thanks in advance.

>

> Drew Bohn NREMT-P

> Operations Training Officer

> Orange County Ambulance Service inc.

> Orange, Texas

> drewbohn@...

> dbohn@...

>

April 30, 2005