The clinical approach represents the minimum standard of assessment that paramedics should provide for a patient.  Patients in BCEHS care require ongoing assessments of vital signs every 15 minutes to monitor trends.  If this standard cannot be met, or is considered clinically unnecessary, the rationale should be documented.  Patients who are unwell or predicted to deteriorate should have their vital signs monitored more frequently. 

For the majority of patients, it will be appropriate to establish a personnel rapport and to collect a verbal history prior to beginning any physical assessments.  This process should not lead to excessive delays in obtaining vital signs.  Critically ill or otherwise unwell patients will require a more formalized primary survey and systematic approach to information gathering.

BCEHS provides patient centred care.  This means that paramedics will provide safe, effective and compassionate patient-centred care in all interactions, by

• Treating patients, carers and families with dignity and respect
• Encouraging and supporting shared decision making by patients, their families and carers
• Communicating and sharing information with patients, their families and carers, and other members of their healthcare team
• Obtaining consent and considering patient wishes and values in all decisions

• First, do no harm.  Paramedics must act, at all times, with due consideration for the safety of patients.
  • Always assess the risk versus the benefit of any treatment or procedure
  • Advocate for the health and safety of all patients
  • Demonstrate person-centred care by acting in a manner that ensures the patient’s dignity, safety, privacy, confidentiality, and decision-making are maintained
• Professionalism, accountability, and responsibility.  Each paramedic’s professional and legal responsibilities are prescribed by
  • The Emergency Medical Assistants Regulation and the Code of Ethics
  • BCEHS Clinical Practice Guidelines, Pharmacology, Skills and Procedures
  • Compliance with BCEHS Policies and Procedures, Practice Updates, and Safety Alerts
• Scope of Practice.  Paramedics must treat within their own scope of practice as defined by BCEHS and the EMALB.  Paramedics cannot exceed the scope of practice for which they hold an EMA license (including Schedule 1 and 2); however, their scope of practice can be limited or restricted by BCEHS (→ A04: Duty of Care).
• Scene assessment.  Safety of the paramedic, patient, and bystanders is of the utmost priority.
  • Scene assessment commences as soon as visual contact is made with the scene (CPG A02: Primary and Secondary Survey)
  • The dynamic risk assessment must be part of every clinical event.  BCEHS does not expect paramedics to place themselves at risk of injury during any patient encounter.
• Infection Prevention and Control (IP&C).  The main goal of infection prevention and control is to prevent the transmission of health-care-associated infections to patients and paramedic practitioners.  The modern application of infection control is described as “routine practices and additional precautions” which must be applied to every patient on every event.
  • Routine practice does not include the use of personal protective equipment (PPE).  Paramedics should apply a point of care risk assessment (PCRA) and, if a hazard exists, then apply appropriate precautions (i.e., one of the three isolation procedures).
  • The single most effective IP&C procedure to control infections in the workplace and reduce the spread of infections is hand hygiene.
  • Gloves are task specific and meant for single use, change between procedures and patients.  Their use does not replace the need for hand hygiene after their removal.
• Communication.  Early activation of additional resources is essential.
  • Clear, confident verbal and nonverbal communication is central to a patient’s perception of professional care.  Communication must take into account the psychosocial needs of patients, family, and carers.
• Treatment and Referral Decisions.  It is the responsibility of paramedics to
  • Perform comprehensive patient assessment (→ A02: Patient Assessment)
  • Discuss and explain the patient’s presenting clinical condition, including any related comorbidities, with them or their carer and determine the appropriate treatment and referral decisions
  • Manage the patient as required through the application of the BCEHS Clinical Practice Guidelines
  • If in doubt about the diagnosis and the specific treatment required, give basic supportive measures, minimize time on scene, and consult with CliniCall if possible
• Transportation Decisions.  Time on scene must be kept to a minimum with only time critical and/or meaningful interventions performed on scene with additional treatment provided enroute.
  • If the arrival time of clinical back-up is expected to exceed the time required to load and transport the patient to a hospital, paramedics should transport the patient.  In the event that higher levels of care or additional resources are required for safe patient care, enroute intercepts can be considered.
• Choice of Destination Facility.  The destination facility is influenced by the patient’s presenting condition and the relative proximity to a designated specialized care facility.  Follow BCEHS Destination Guidelines when determining hospital destinations.
  • Stroke patients may bypass the local facility and proceed directly to a primary or comprehensive stroke centre as directed by the FAST-VAN Stroke Tool
  • STEMI patients may bypass the local hospital and proceed directly to a facility with specialty expertise in reperfusion strategies
  • Trauma patients may bypass local facilities and be transported directly to a Trauma Center.  Follow guidelines in the local clinical pathways.
  • Certain patients may meet criteria to be transported to Alternate Destinations.  Local clinical pathways are available.
• Alternative referral decisions.  When patients are not transported by ambulance, paramedics must
  • Provide the patient with information on how to manage their condition, what to do if their condition does not improve, including when to see their general practitioner.
  • Confirm the patient is able to mobilize and alternate transport is available to enable the patient to access alternative care facilities.
• Ambulance off-load.  Prepare patient and equipment for off loading.
  • Remove PPE prior to leaving the vehicle and perform hand hygiene.  If the patient’s condition does not allow the removal of PPE, remove and replace gloves prior to departing the ambulance.
  • On-going patient assessment and treatment continues at the receiving facility until the formal clinical handover takes place.  This includes repeating vital signs, continuation of various monitoring devices, and rechecking of the effectiveness of interventions.
• Clinical handover.  It is the responsibility of paramedics to ensure they provide and receive a comprehensive clinical handover using the mnemonic ISBAR or IMIST-AMBO (→ A03: Clinical Handover) whenever patient care responsibility changes from one clinician to another and to ensure they understand all care requirements for the patient.
  • Whenever possible, and when it is in the best interest of the patient, practitioners should provide the handover report with the patient in view of the accepting healthcare provider to facilitate patient recognition and encourage assessment as required.  It is recognized that extenuating circumstances may make it unacceptable to complete clinical handover in the presence of the patient.
• Documentation.  Documentation is important and a clinical record is required for all patient contact (→ A06: Documentation Standards).  Patient care documentation must
  • Be accurate and as factual as possible and provide a clear, concise, complete account of the event
  • Be completed at the time of, or as close as practicable to, the event Include all treatment/interventions provided, including patient vital signs and assessment findings prior to and post treatment and recording of ECGs where appropriate. 
    • Note: In cases where a minimum of two sets of vital signs are not taken or recorded, paramedics must document, the reasons as part of the free text in the clinical record
  • Record the paramedics’ recommendations and reasons, including a summary of any communication made between paramedics and patients and/or carers
  • Record a copy of any first responder documentation
  • Record any advice provided by a paramedic specialist or the emergency medical services physician online support doctor
  • Record the at least the minimum dataset required per CPG A06 documentation standards
  • Practitioners shall leave copies of the patient care record and any associated documentation with the receiving the receiving facility prior to leaving the facility; this may include uploading a digital version of the PCR without printing a hardcopy.  In particular, ECG’s must include the patient name and copies of the pre/post treatment (e.g. SVT treatment with adenosine).
  • Document and co-sign all controlled substance usage and wastage in the patient care record per BCEHS MP 210
  • Ensure verbal orders from a physician or employer direction from a paramedic specialist in CliniCall are documented in the PCR.  Transcribed orders must fall within the scope of practice of the paramedic.