Most of us are familiar with the 999 call to a patient who fits into the category of ‘generally unwell’, but what can we do for these patients? NHS drivers and policies (Department of Health (DH), 2005; 2011; Health and Care Professions Council (HCPE), 2012) are rightfully directing ambulance clinicians away from taking every patient to the local emergency department and more towards treating patients at home or utilising alternative pathway referrals. The Department of Health state:
‘[the ambulance service] is recognised as having a wider role, as a conduit to other NHS services and in ensuring patients can access the facilities they need, close to their home (DH, 2011:7).’
To do this safely, ambulance clinicians require a recognised method of assessment that leaves nothing to chance, and ensures the most appropriate care for the patient.
This article describes the system of patient assessment, including the review of systems (RoS) that is useful for a non time-critical patient. This is for the patient whose primary survey has not shown any life-threatening illness or injury, and no immediate critical intervention is necessary. Time can be taken to obtain a more holistic view of the patient, the presenting complaint, past medical history and other factors, which may then influence the clinician's treatment or alternative pathway referral. The skills involved in history taking and physical examination are as important now as ever, despite advances in technology, which has improved diagnostic and therapeutic treatment (Douglas et al, 2005). ‘The ability to take an accurate medical history from a patient is one of the core clinical skills and an essential component of clinical competence’ and together with the fact that up to 80% of diagnosis comes from the medical history we can see how important this skill is (Watt, 2008: 1).
Many widely read and cited authors (Douglas et al, 2005; Jarvis, 2008; Bickley 2009; Gregory and Mursell, 2010; Gregory and Ward, 2010; Blaber and Harris, 2011) use the same format for patient assessment and history taking in the pre-hospital environment, and it is this format that we will discuss here. The patient report form (PRF) does follow the same format, but in an abbreviated form, and the newly introduced electronic PRF (ePRF) system is structured in the same logical way. One of the reasons for adopting this system is that other healthcare professionals use this method in their practice. Doctors, nurses, emergency care/nurse practitioners and medics will use the same method of history taking, and, although their clinical level of physical assessment will differ from the paramedic, the basis is the same as the one discussed here. The obvious advantage to paramedics is that if all healthcare professionals adopt the same system, and perform the assessment effectively, we will gain more professional credibility. The author has found that in referring a patient via telephone to various other healthcare professionals, this method gives other clinicians confidence and reassurance that the patient has already had a thorough and appropriate assessment, and is safe to be referred, without actually seeing the patient themselves. An example is shown in the later scenario to illustrate this point.
Discussion
The introduction, gaining informed consent and primary survey always occurs first (Mental Capacity Act 2005 (c.9)). Gaining consent and evaluating a patient's mental capacity to consent or withhold consent is compulsory, in both a legal and ethical sense (Mental Capacity Act 2005 (c.9); Joint Royal Colleges Ambulance Liaison Committee (JRCALC), 2013). The Mental Capacity Act 2005 (c.9) also describes how to assess paediatric, young adults and elderly patients for mental capacity. Patients with dementia, mental health problems or learning difficulties can still have mental capacity and can still make their own decisions, and the Mental Capacity Act 2005 (c.9) advises on these specific issues. If it is deemed that the patient does not have the mental capacity to make their own health care decisions, and they have no legal advocate to make these decisions on their behalf, then the paramedic should act in the patient's ‘best interest’ (Mental Capacity Act 2005 (c.9); JRCALC, 2013).
The primary survey should highlight a ‘big sick’ or ‘time critical’ patient, who should be treated expediently and appropriately in accordance with relevant local policies and guidelines, and will not be discussed in this article (Blaber and Harris, 2011).
In-depth assessment
If the primary survey does not suggest any time-critical conditions, it is then safe to proceed with the in-depth assessment, bearing in mind the privacy of the patient; for example, if they are in a public place. It is important to recognise whether it is appropriate to ask questions there, or if it would be more appropriate to move somewhere else or to the ambulance for privacy. The next stage is to observe the patient, noting any obvious problems. Factors to look out for include whether the patient is clean or unkempt, appropriately dressed, overweight or malnourished, confused or alert, and coherent. This list is not exhaustive but illustrates some of the basic things to look out for. Most experienced clinicians will pick up subtle clues in the appearance of the patient. This may be described as ‘down to experience’, ‘gut feeling’ or ‘clinical intuition’ (Gardner, 1983; Benner et al, 1996). Although it can be argued that these skills are difficult to teach to new or inexperienced staff, Benner et al (1996) claim that these skills can only be gained by experience. What is needed is a structured approach to assessment and history taking to ensure that we as clinicians do not omit any vital clue to the patient's condition.
Presenting complaint
Next, the presenting complaint (PC) should be ascertained. Ideally this should be kept to one sentence, e.g. ‘I have a headache and my throat hurts.’ The PC should be the reason why you were called to the patient. Document the patient's own words verbatum if it is appropriate. If the patient has more than one PC, prioritise and assess all of them and document accordingly. For example, if the patient complained of nausea and chest pain, then the chest pain would be assessed first. At this point, it should be made clear to the patient that you need to document your assessment, and ask them if they consent to you sharing that information with other healthcare professionals that may be involved in their care. Reassure them that all of your records, whether it is a paper PRF or electronic PRF, are treated with confidentiality, in accordance with Caldicott guidelines (Caldicott Committee, 1997) and the Data Protection Act 1998 (c.29).
History of the presenting complaint
The next logical stage is to elicit the history of the presenting complaint (HPC). There are several ways of describing the component parts of the HPC. Bickley (2009) describes the HPC as the ‘present illness’, whereas Gregory and Mursell (2010) use the term HPC and split the components up into:
Another method is to use the PQRSTU acronym (Jarvis, 2008), where:
Although the PQRSTU acronym is usually applied to assessment of pain, it can also be used to assess other symptoms (Jarvis, 2008). Young adults and children may have a different perception of pain or illness, especially if it something they have never encountered before (Rudolf et al, 2011). They may respond better to a different mode of communication (Jarvis, 2008), allowing you to gain relevant information, or you may need to direct your questions to the parents (Rudolf et al, 2011). Children's pain score can be assessed by using Wong and Baker's (1988) FACES pain rating scale (Figure 1).
Past medical history
After this information is gained, it is time to move on to the patient's past medical history (PMH). The PMH may have an impact on the patient's current medical status, or it may give pertinent clues to the PC and how to treat it (Jarvis 2008; Gregory and Mursell, 2010). As far as is reasonable, it is vital that all medical history is elicited, as a patient may not remember to tell you that they have a condition. For example, you would need to know if a patient had asthma if you were advising them to take a non-steroidal anti-inflammatory drug (NSAID) for minor injuries or pain. Ask specific closed questions such as ‘Do you have asthma? Diabetes? Heart problems, including a heart attack or irregular heartbeat? Have you ever had a stroke?’ This method requires closed ‘yes’ or ‘no’ answers, and can simplify and direct the collection of the PMH data (Jarvis, 2008; Blaber, 2011).
Do not use jargon or medical terms like cerebrovascular accident (CVA) or myocardial infarction (MI), as a patient may not know what it means, or even worse, they may confuse it with something else and unwittingly give you unreliable information. Ask about any operations, previous and/or chronic illness, recent foreign travel and any immunisations and note the dates.
Drugs/medication History
The patient's drugs/medication history (DMH) is important to consider, as it may provide clues for the PC, or may affect any advice you give them (Blaber, 2011). For example, a patient taking warfarin sodium may not be safe to treat at home for a minor laceration or epistaxis. It is important to ask about all DMH, not just prescribed medications. Over-the-counter drugs (OTC) can have an effect on prescribed medication (Rx). For example, St John's Wort can have a significant negative impact on some Rx (Joint Formulary Committee, 2012). Ask specifically about drugs such as oral contraception for women of child-bearing age. These drugs can interact with others, and some oral contraceptives carry a risk of venous thromboembolism (Joint Formulary Committee, 2012). Recreational drug history should be asked about, although this information is not always readily volunteered.
Allergies are important to consider and document, especially before administering any drugs. Specifically, ask the patient what sort of reaction they had to a drug. Was it a mildly upset stomach, or airway problems, swelling and urticaria? If you refer a patient to an alternative care pathway it will be vital to inform them of any patient's allergies in case they want to prescribe any drugs. If the reaction was severe, note that on your documentation.
Family history
Family history (Fam hx) is the next component, and this is relevant in many ways as various medical problems have shown to be inherited genetically. Bickley (2009) outlines a list of these (see Table 1). For example, if you are assessing a 35-year-old man with chest pain, it would be relevant to know that his father died at 37 years of a heart attack. For general minor illnesses such as flu, chest infections, stomach upsets, it is useful to ask if other members of the family have had symptoms recently. It may also be pertinent to ask if any family members are pregnant or seriously ill, and to advise an infectious patient to avoid contact with them until recovered. If relevant, enquire about recent travel or holidays and contact with any contagious diseases.
| Condition | Present/absent |
|---|---|
| Hypertension | |
| Coronary artery disease | |
| Elevated cholestrol | |
| Stroke/TIA | |
| Diabetes | |
| Thyroid/renal disease | |
| Cancer | |
| Arthritis | |
| Tuberculosis/asthma/lung disease | |
| Seizures | |
| Mental health problems | |
| Suicide | |
| Alcohol/drug addiction |
Social history
Social history (Soc hx) may be more important for some patients than for others. For example, a normally fit and well 23-year-old living alone may cope adequately at home if they have a chest infection. The patient may be able to look after themselves, cook, clean, bathe and keep warm. An elderly, infirm 80-year-old patient with no family support or carers may have immense difficulties with even minor illnesses affecting their ability to cope. If there are carers in place, what do they do? Are they a home help, or do they assist with personal care and medications too? Do community nursing teams visit the patient? If not, would it be an idea to contact the patient's GP or the out of hours GP service in your area to arrange this?
Sexual health
One area of assessment that is not usually considered pre-hospitally is sexual health. Although it is not an area that ambulance clinicians enquire about, if the patient has a clinical presentation and symptoms that suggest genitourinary (GU) involvement, it may be prudent to make sensitive and relevant enquiries on the subject. For example, asking when the patient's last menstrual period (LMP) was, whether the patient's usual method of contraception or sexual partner recently changed, whether there have been any episodes of unprotected sexual contact, and if there is any chance of pregnancy? (Jarvis, 2008; Bickley, 2009)?
Mental health and risk of suicide is another common aspect that clinicians have to assess, albeit as a very brief and basic overview. A SADPERSONS risk assessment chart (see Table 2) should be completed where relevant, to determine whether the patient is a high, medium or low risk (Gregory and Mursell, 2010; JRCALC, 2013). It is advisable that this group of patients are referred on to either the local community mental health team or to a GP if they refuse to attend hospital.
| Item | Value | Patient score |
|---|---|---|
| Sex: Female | 0 | |
| Sex: Male | 1 | |
| Age: less than 19 years | 1 | |
| Age: greater than 19 years | 1 | |
| Depression/hopelessness | 1 | |
| Previous attempts at self-harm | 1 | |
| Evidence of excess alcohol/illicit drug use | 1 | |
| Rational thinking absent | 1 | |
| Separated/divorced/widowed | 1 | |
| Organised or serious self-harm | 1 | |
| No close/reliable family, job or active religious affiliation | 1 | |
| Determined to repeat or ambivalent | 1 | |
| Total score of patient |
<3 = Low risk; 3–6 = Medium risk; >6 = high risk
Review of systems
Does the patient smoke? How many? Drink alcohol? How much? Is the patient's diet adequate and healthy? Is the patient employed and will this injury/illness have an impact on this?
Once all the above questions have been asked and the responses considered, it is time for the review of systems (RoS) (see Table 3). The RoS provides a safety net of questions that uncover symptoms that the patient may have not described, or may not think them important enough to mention. For example, if a patient has recently started to sleep sitting up, or uses two more pillows than normal to prevent becoming breathless at night, they may not think it relevant; however, if linked to other associated symptoms, it may be an early indication of a serious medical condition.
| General health | How do you feel compared to normal? How is your appetite? Have you lost/gained weight? Do you feel more tired than normal? |
| Respiratory (Resp) | Any breathlessness? Colds, coughs, wheezing? Sputum? Colour? |
| Cardiovascular (CVS) | Any chest pain or breathlessness? Palpitations or dizziness? Any oedema? |
| Nervous system (CNS) | Any headaches or visual disturbance? Numbness or tingling? Any fits? Balance problems? Tremors? Any (new) speech or hearing problems? |
| Gastrointestinal (GI) | Any episodes of D&V? Any abdominal pain? Any change in bowel habit, or blood in stool? |
| Genitourinary (GU) | Any change in frequency of urination? Burning or stinging sensation? Blood in urine? Discharge? Last menstrual period? Any risk of pregnancy? Any unprotected sexual contact? (If appropriate to ask) |
| Bones/muscles/joints (BMJ) | Any new joint pain? Any stiffness or aching? Decreased mobility? |
| Other | Endocrine problems —excessive thirst, sweating? Intolerance to heat or cold? Bleeding or bruising? Rashes? Any swollen lymph nodes? |
| This is not an exhaustive list of questions, but should serve to show the level of questioning that is appropriate. | |
After the RoS, it would be time to carry out the physical examination, which would parallel the questions asked. Firstly would be the respiratory (RESP) exam, then the cardiovascular (CVS), then central nervous system (CNS), gastrointestinal (GI), genitourinary (GU), and bones/muscles/joints (BMJ). All of the answers supplied during the RoS should prompt the clinician to which part of the assessment requires more in-depth focus. For example, a patient complaining of symptoms suggestive of a chest infection may not necessarily need a GI or GU examination, unless the answers supplied indicate so. All of the questions and the information supplied might be viewed as tools in a toolkit. You would not need every tool for every job, rather you would be selective about which tools you choose to do the task. It is expected that the paramedic reader will already have the requisite skills to carry out a physical examination, and this article merely reviews a recognised format of how to carry out those skills. It is not always appropriate to carry out the whole RoS; for example, if a physical observation or an answer to a question highlights a time-critical problem, such as an abnormal electrocardiogram (ECG), or the patient tells you that they have chest pain that you think might be cardiac in origin. In this case, the RoS would be abbreviated and carried out while en route to an appropriate receiving hospital.
After completing all of the above, which with practice and familiarity should take no longer than 30 minutes, the clinician should have gained an overall impression, or provisional diagnosis. It is difficult to diagnose pre-hospitally, and this is why the term ‘impression’ is more appropriate to use here. For example, if you are referring a patient via the telephone to their GP, would it be more appropriate to say ‘I have diagnosed a simple throat infection?’ or ‘My impression of the patient is that they may have a simple throat infection?’
After the impression is gained, the next logical step is to formulate a treatment plan. This will vary depending upon the geographical area, the alternative pathways and resources available in that area, and of course, the patient's wishes. At this point it is good clinical practice to review your assessment and documentation, and check that the patient agrees with your findings (Jarvis, 2008; Bickley, 2009).
Documenting all of the above may be difficult on some paper PRFs, as there is limited space for clinical examination text; however, most ambulance services advocate the use of follow-on PRFs, annotated to show that it is a follow-on sheet. The ePRF has large amounts of free text space available, so this is not an issue.
Example scenario
While waiting for the GP to call back, you complete your documentation (see Table 4). It is important to include documentation of the pertinent negatives as well as your positive findings, to record that these areas have been checked, i.e. °SOB oCP (no shortness of breath or chest pain.) You advise Bill to take 1 g paracetamol every 4–6 hours, up to a maximum of 4 doses in 24 hours (Joint Formulary Committee, 2012).
| PC: sore throat and headache |
The GP calls back, you hand over your assessment and findings, and the GP is comfortable that the patient can safely await a visit.
Conclusion
The ultimate aim of a more thorough patient assessment method is to improve standards of patient care. An advantage of this method of dealing with the minor illness patient is that the patient does not travel unnecessarily to hospital to be seen in the emergency department. Instead, the patient remains in comfort at home, the spread of infection is reduced, the workload of the hospital is reduced, and the ambulance crew are able to be released from scene to be available for the next potential emergency.
Arguably, the ambulance clinician spends longer on scene initially, but the overall benefit to the NHS as a whole, and also the benefit to the appropriate care plan for the patient undeniably outweigh this. Depending on the various levels of alternative care pathways available regionally and the levels of demand, this will usually result in a faster turnaround for the ambulance crew. All of the above mentioned advantages are seen as desirable in the various recent NHS political drivers such as the NHS Plan (DH, 2000), Transforming NHS Ambulance Services (DH, 2011), and Taking Healthcare to the Patient (DH, 2005).
Aside from the political agendas, an advantage for paramedics and other ambulance clinicians is improved job satisfaction. At a time when the ambulance service is undergoing immense changes (South West Ambulance Service NHS Foundation Trust, 2008) we can all integrate ourselves into the multi-disciplinary approach to patient care. With the launch of the new NHS 111 system in the UK, it is uncertain whether the amount of patients dealt with by UK ambulance services with minor injuries and illnesses will increase or decrease. Paramedics are required by the Health and Care Professions Council (2012) to be able to assess and refer patients to appropriate alternative care pathways and to work alongside other healthcare professionals. Standardising paramedics' methods of history taking, assessment and documentation will improve patient care and increase our professional standing in the healthcare community.