Timely Topics in EMS CQI: The ALS Downgrade Note

A 76-year-old male complaining of chest pain after a motor vehicle crash is assessed by the paramedic/basic crew on scene and the medic determines the patient is low likelihood for an ACS event and triages the call to the BLS partner for transport.

I am sure this happens countless times in every EMS system in the country. On CQI review, the BLS run report states the 76-year-old male continued to have chest pain throughout the transport. He is elderly, has a significant cardiac history, and just had a traumatic emotional event due to the MVC he was involved in.

The common question that comes up during a CQI review will almost always be, should this patient have had an ACS workup? A discussion with the medic usually reveals; (a) the medic cannot remember the specifics of the call, (b) the medic recalls that this patient’s pain was not likely to be cardiac because the pain was along the seatbelt track, was reproduceable, or some other unreliable assessment criteria or, (c) the medic does not recall the details but never would have triaged a cardiac type pain to the BLS provider.

Triage to BLS is a common phenomenon in EMS but can be fraught with medical and legal implications. More system medical directors and EMS regulatory agencies are beginning to see the risk involved in triages without proper supporting documentation to the patient, the provider, and the EMS agency. Unfortunately, many agencies still do not require ALS downgrade notes or rarely enforce them.

What is an ALS Downgrade Note?

In its most basic form, a downgrade note is simply a brief explanation by the advanced provider as to why this patient was safe to be transported BLS. The note can be relatively simple, and the essence of the note should be to explain the clinical findings that support the proper transport level. In the case above, the ALS provider should have performed an exam to show the patient was fully examined by an ALS practitioner and what the results of those findings were. The findings should be consistent with the clinical decision to downgrade the patient.

Like Farmer’s Insurance, we know a thing or two because we’ve seen a thing or two.  Having reviewed almost 400,000 ambulance trip sheets since 2005, our data shows that 55% of ALS downgrades appear to be inappropriate based on what the BLS provider documented on the ambulance trip sheet.  This is not to say that all of those calls should have received ALS. It is a statement that with only a BLS report with no supporting documentation by the ALS provider, the initial impression of the call is that it should have had ALS.

When the post auto-crash, seatbelt-attributed chest pain tells the BLS provider on the way to the hospital that the pain “feels like an elephant is sitting on my chest…,” without a thorough pre-downgrade ALS eval and appropriate documentation of the clinical decision-making process. It’s not difficult to see the significant risk to the patient, the provider, and the EMS agency, whether or not something really bad happens to the patient.

Additionally, the lost revenue associated with inappropriate ALS downgrades places increased burdens on the EMS agency and the taxpayers while limiting investments in human capital (pay raises, employee benefits, training), investment in equipment, and company investment in technology. At a minimum, the agency has just lost out on the associated revenue that could have been derived from an ALS transport. More importantly, the patient may not have received the proper care they needed to potentially avoid a less than desirable outcome. From a legal perspective, these calls may be very difficult to defend against many weeks or months later when the agency and the provider are called upon to defend their actions.

Agencies that attempt to develop downgrade policies are often left to their own devices in determining what constitutes a proper policy to document the downgrade of patients.

As mentioned already, a proper policy needs to explain the importance of the ALS provider performing a proper assessment and what the results of that assessment were. It can be written as a separate addendum to the primary report or, as some agencies have decided, it can be written at the end of the BLS narrative with a proper notation of which comments are the medics add on comments.

This policy seems to work well in that it allows the medic to read the BLS narrative to structure their comments to include any information that the BLS provider may not have made clear or was limited based on their assessment capabilities. This is also a good way to have the ALS provider help mentor the BLS provider in proper documentation techniques and correct any errors in the record that the BLS provider may have missed. This has major implications for the billing process, the QA/QI process, and having an accurate record for medical/legal purposes. Everyone wins!

For more information on downgrade note policies, listen to our podcast, The G&A Way – The Importance of ALS Downgrade Notes. Or contact paul.girard@girardassoc.com.