AIV Responsibility of Care

Question#: 696

Question:

 Quick inquiry – is it expected practice that an AIV certified would assume pt care if there was potential or required need for a pt to have IV access initiated? The same way an ACP assumes pt care, would the same apply to the AIV partnered with a PCP not certified in AIV?

I would like to promote this thought process here in Leeds and would like your thoughts/support.

Answer:

 The ALS PCS 5.1 speaks to responsibility for care (page 10).

It establishes that:

The highest level available is ultimately responsible for patient care,
The highest level available should discuss and decide which level of care is appropriate to attend during transport, and
When an intervention is performed, the paramedic most appropriate for that intervention will remain with the patient.
RPPEO believes that PCP-AIV is a higher level than a PCP non-AIV, therefore, the preamble standard applies.

Responsibility for Care

While on scene, the highest-level paramedic shall assess the patient and make a decision on the level of care required, and on the level of paramedic required for the care of the patient. The highest-level paramedic is the ultimate patient care authority on the scene. If there is any disagreement between paramedics, the Base Hospital physician may be contacted. It is expected that when an intervention has been performed, the paramedic most appropriate for that intervention will remain responsible for the patient.

In all patient care, the highest level of paramedic is responsible for the care of the patient, including decisions on the level of care required during transport. A paramedic may choose to assign aspects of care and procedures to an alternate level paramedic, as long as the care and procedures are within that paramedic’s scope of practice. Paramedics must alert the highest-level paramedic of any change of patient status.

When it comes to the AIV scope of practice, it can be interpreted the same as the ACP/PCP handover. Generally speaking, the RPPEO encourages that the ACP remain with the patient for CTAS 1 patients due to the higher possibility of rapid deterioration. Although it is possible to pull over and switch positions, this may be unsafe (depending on roadway conditions etc.) and ultimately delay transport to definitive care.

For all other patient care requirements, the RPPEO trusts paramedic clinical judgment and discuss the clinical risks of the patient and the patient management strategy on a case-by-case basis regarding what level of care during transport is best for each individual patient.

While we can’t envision every scenario, I can offer you the following as examples. In the setting of a PCP AIV administering a dose of Gravol or Ketrolac, can they hand over care to a PCP? In this context, given these medications are within the PCP scope, and there is no repeat dose, it would be reasonable for the PCP to maintain care of this patient.

The PCP AIV administered a bolus due to hypotension, but the patient’s BP has now returned to normotension. Should they maintain patient care? It's important to consider the future state of the patient. Given the possibility of the pt becoming hypotensive again, it’s reasonable that that PCP AIV maintain continuity of care, as they may need to intervene again. Similarly, there are certain patient presentations that may need AIV intervention based on a reasonably expected clinical course (i.e. cardiac ischemia, anaphylaxis).

Generally speaking, there is an emphasis on open crew communication and sound clinical judgement, taking into account variables such as transport time, presenting complaint(s), potential for ongoing treatment (e.g. fluids) and paramedic comfort level. Incorporating these aspects and maintaining open dialogue in transit plays a considerable role in patient safety, and we trust that the paramedics will make the right decision on a case-by-case basis.

Patient Care Standards:

ALS PCS 5.1 - Responsibility for Care (page 10)