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Introduction

Advanced Life Support (ALS) is an essential level of out-of-hospital medical care. Various predictors indicate that under ordinary situations 5 to 25 percent of all calls in a system will be for patients in need of ALS care. It is important that every prehospital patient needing ALS care receive it without delay and that all are transported to definitive care at a hospital in a timely fashion.

The policy serves to:

Define ALS intercepts.
Define parameters for the utilization of ALS as well as to provide objectives every intercept should meet
Minimize delay in transporting patients to definitive care at a hospital.
Enhance the provision of patient care by maximizing the availability of ALS for those patients identified as being in need of ALS care.
Provide guidelines to assist in identifying and accessing the most appropriate ALS service at the time of request.
Encourage REMACs to develop regional specific guidelines and protocols that enhance the availability of ALS and the appropriate use of ALS intercepts in the region.
New York State Statewide BLS Protocol

In 1996, the NYS BLS protocols were changed to introduce the concept of ALS intercepts and their use as the principal method of providing ALS care to patients needing this level of care when the initial EMS system contact is a BLS ambulance.

The provision of ALS by intercept permits the appropriate utilization of ALS resources by identifying a hospital or ALS service as the nearest ALS provider at the time of need. Call location, staffed ALS unit availability and/or direction of travel will effect the decision.

Excerpt from NYS BLS Protocol:

The goal of prehospital emergency medical care is DEFINITIVE CARE for the patient as rapidly and safely as the situation indicates with no deterioration of his/her condition and, when possible, in an improved condition. BLS units shall deliver their patients who will benefit from ALS care to this higher level of care as soon as possible. This may be accomplished either by intercepting with an ALS unit or by transport to an appropriate hospital, which ever can be effected more quickly.

A system of ALS intercept (when available within a given area) shall be pre-arranged. Formal written agreements for the request of ALS shall be developed in advance by those agencies not able to provide ALS.

A request for ALS intercept shall occur as noted in specific treatment protocols.

Initiation of patient transport shall not be delayed to await the arrival of an ALS unit, unless an on-line medical control physician otherwise directs.

Immediate Transport Decision:


Determine patient status (CUPS):
Critical or Unstable --- Immediate transport
Potentially Unstable -- Secondary survey and transport
If the patient's condition dictates immediate transport, the vital signs, secondary assessment, and treatment should be completed en route to the nearest appropriate hospital (as defined below in Section VII, Transport).

Intercept with an ALS unit (if available) en route to the nearest appropriate hospital as noted in specific treatment protocols.

Note: Do Not delay patient transport to await the arrival of an ALS unit.

ALS Intercepts

An intercept is an authorized and staffed ALS unit, dispatched by request or protocol, meeting a BLS unit while it is en route to the nearest appropriate hospital.
A BLS unit assesses the patient, determines the need for and requests ALS, packages and begins patient transport. The BLS unit shall not wait on the scene for the ALS unit's arrival. The request for ALS should be made as soon as the the patient's condition is recognized as needing ALS.
A hospital emergency department (ED) is the highest level of ALS medical care. Patients should be transported without delay to the nearest appropriate ED by the BLS unit. Definitive medical care can only be provided at a hospital ED.
ALS mutual aid is a misnomer and does not exist. The statutory definition of mutual aid(1) as well as the need for priority transport makes the use of the term "mutual aid" inappropriate in these circumstances.
BLS services should identify ALS services in advance which are staffed and readily available to provide ALS intercept. More than one service may need to be identified if the BLS service regularly transports to more than one hospital. All formal response agreement needs to be established in advance. Dispatch entities should monitor actual staffing and operational status of ALS resources to insure their availability at the time of the call and minimize any potential delay. The use of the "closest unit" concept is appropriate to dispatch ALS units.
All ALS patients should be transported to the hospital without delay by a BLS ambulance, particularly when the arrival of the ALS unit to the scene is estimated to be longer than the transport time to the hospital.
In developing ALS intercept relationships, REMACs must consider the patient's and ALS unit's proximity to the hospital. Patient transport to an emergency department should not be delayed. BLS/ALS care should ideally be administered en route.
Simultaneous dispatch of BLS and ALS resources should only be provided under the direction of dispatchers trained in the principals of emergency medical dispatch for those calls identified by a recognized dispatch algorithm.
REMACs should develop protocols that permit a certified provider who arrives on the scene after the time of dispatch, to cancel initially dispatched ALS resources when, after assessment, it is determined that ALS care is not needed.

Quoted Text

Is the line between BLS and ALS getting fuzzy?
Doing the best for the patient may mean changing the EMT's role


inShare
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By Mike Ward

In 1990 my fire department was looking to place defibrillators on engine companies. Firefighters were EMT certified and the pumpers carried oxygen and an ambulance-sized jump kit. Only paramedics or EMT-Cardiac providers could operate a defibrillator in the Commonwealth, following the Emergency Medical Technician – Ambulance curriculum.

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Staffing increased to four in 1994 when five engines upgraded to paramedic. The fourth position was for an ALS credentialed firefighter. That was the same year major revisions were made to the National Standard Curriculum (NCS).1

Under the 1994 NSC revision:

EMT-Ambulance providers became EMT-Basic with a less intense curriculum
EMT-Basics could operate defibrillators.
Physician medical direction expanded from ALS providers to EMT and First Responders.
Under administrative regulations, the bright line between ALS and BLS was the ability to start an IV, administer drugs, decompress a chest, run a three-lead EKG and intubate.


Bright Line gets fuzzy
This spring I have had the opportunity to conduct EMT refreshers at a handful of agencies that are teaching to their local medical protocols. It has been exciting to see the expansion of care that EMTs are expected to provide.

In one system, EMTs are providing continuous positive airway pressure (CPAP) without direct paramedic direction.2 Looking at the 2013 review of CPAP peer-reviewed literature shows the first mention of EMT-provided CPAP in 2007.3

EMT-level medical assessment includes obtaining a blood glucose level (BGL) and documenting a pulse oximetry reading. (I feel compelled to call the 900 year old EMT instructor that scolded me for stating BGL was not an EMT level assessment tool a few semesters ago. "EMTs never perform an invasive therapy!")


Shared Tasks in a 1-and-1 transport unit
There appears to be no difference in tasks delivered in a simulated cardiac arrest with a one paramedic and one EMT crew.4 Using the "pit crew" approach to cardiac arrest means that EMTs are applying 12-lead patient cables, spiking IV bags and participating in the medication administration cross check (MACC).6

Shared tasks also mean shared patient responsibilities along with an expanded use of specialized equipment and procedures by EMTs. They are expected to immediately master new patient care tools and procedures.

Outcome-based EMS care requires close monitoring and implies intensive continuing training, as providers focus on tasks and procedures that improve patient disposition.


Finding a sweet spot using a mix of techniques
At the 2013 EMS State of the Science conference, Dr. Paul Pepe shared the results of paying attention to cardiac compressions as part of the Resuscitation Outcomes Coalition research in the Dallas-Fort Worth region. Using monitoring equipment that showed detailed feedback on chest compressions, training was provided in 2006 and 2009 to improve provider delivery of fast-and-deep chest compressions.

The sweet spot is 120 compressions per minute. Using a metronome that provided both a light and sound significantly improved the consistency of the compressions. Comparing the "Survival to Hospital Discharge" results from 2006 to 2011 showed dramatic improvement:6

City      Improvement
Dallas      157%
Irving      57%
Mesquite      100%
Carrolton      376%
Research is showing the importance of uninterrupted chest compressions to maintain adequate cardiac flow. Trials are underway to determine the safety and efficacy of external defibrillation WITHOUT stopping cardiac compressions.8

In addition, there is an indication that using an Impedance Threshold Device (IPD) with an Active Compression-Decompression (ACD) during CPR improves long term survival with favorable neurologic outcome.9


Looking at a military example
Soldiers who take the 40 hour Combat Lifesaver (CLS) Course are taught to handle massive hemorrhage, lung collapse and airway blockage that cover 90% of the battleground fatalities.10 CLS trained warriors use oral airways, decompress chests, start IVs, splint fractures and administer a pill-pack.

They are not combat medics but are trained beyond the level of self-aid or buddy aid. The CLS is not intended to take the place of medical personnel, but to slow deterioration of a wounded soldier's condition until medical personnel arrive or the wounded can be transported to a medical facility.

EMS first responders function in a similar role, providing rapid response to deliver immediate life-preserving skills until arrival of a paramedic or transport vehicle.

EMTs are in the middle of the breadth and depth spectrum of the 2009 EMS Educational Standards.11 Paramedics are expected to integrate pathophysiology, physiology, anatomy and patient assessment into a patient care plan. Emergency Medical Responders are expected to use tools and procedures, remembering "sticky side down." It is time to reconsider the expectations of EMTs as the National EMS Advisory Council looks at the next version of the Educational Standards.

Quoted from bumblethru