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The Latest Column
Questions are from the latest Standards Q&A column, posted in June 2017.
Can a Paramedic Do the Physical Exam?
Is it within the scope of a paramedic to perform the physical examinations / hands-on portion of the health assessments?
Standard E-04 Initial Health Assessment requires that inmates receive an initial health assessment as soon as possible and provides two options for completing this task: the full population assessment and individual assessment when clinically indicated.
The initial health assessment requires many components, some of which involve having a qualified health care professional collect additional data to complete the medical, dental and mental health histories including any follow-up from positive findings obtained during receiving screening and subsequent encounters as well as recording vital signs. A qualified health care professional is defined as anyone who by virtue of education, credentials and experience is permitted by law to evaluate and care for patients.
Your question relates to the physical examination component of the initial health assessment. The standard specifies who is permitted to complete this portion on both options. For the full population assessment, the physical exam may be completed by a physician, a midlevel provider or an RN who has completed the appropriate training. For the individual assessment when clinically indicated, the exam may be performed only by a physician or midlevel provider. The standard does not permit a physical exam to be conducted by a paramedic in either option.
15-Minute Suicide Checks
We perform 15-minute checks on our potentially suicidal inmates. Is this practice in compliance with the G-05 Suicide Prevention Program standard?
Nonacutely suicidal (potentially or inactive) inmates are those who express current suicidal ideation and/or have a recent prior history of self-destructive behavior. These inmates should be monitored on an unpredictable schedule with no more than 15 minutes between checks (e.g., 5, 10, 7 minutes).
To answer your question, we would need clarification on a couple of points: what you mean by “15-minute checks” and who completes the checks. If the observation is occurring regularly every 15 minutes, this is not in compliance with the standard. The idea is to check on the nonacutely suicidal inmate at irregular, unpredictable intervals, with no more than 15 minutes in between each check (see compliance indicator #1d). If the nonacutely suicidal inmate is placed in isolation, then constant observation is required. In addition, the monitoring must be done by staff.
Other supervision aids (e.g., closed circuit television, inmate companions or watchers) can be used to supplement but never substitute for staff monitoring.
Process and Outcome CQI Studies
Our question relates to A-06 Continuous Quality Improvement Program, compliance indicator #4. We understand that we need to conduct process or outcome studies. Can you explain the difference in the two types of studies and what evidence is required to meet this indicator.
A study is a process of reviewing an identified problem to assess potential causes. A CQI study is one in which a facility problem is identified, a baseline study is completed, a corrective action plan is developed and implemented, and the problem is restudied to assess the effectiveness of the corrective action plan. Subsequent corrective action is documented and evaluated to see if the intervention was effective in addressing the problem.
Process studies normally answer the question “Is what we are doing effective and efficient?” They focus on implementation of policies and procedures (usually involving more than one category of staff) and the effectiveness of those processes. For example, examining your chronic care procedure might involve looking at how you identify chronic care patients, how you schedule them for clinics, whether security escort problems cause delays, how documentation is kept and so forth. Process studies often focus on timeliness and efficiency.
Outcome studies answer the question “Are our patients getting better?” or determine whether the expected outcomes of patient care were achieved (degree of control is a helpful consideration). Looking again at chronic care, an outcome study might focus on whether the chronic care patients’ symptoms are actually decreasing or at least are not worsening as a result of the care.
Documentation for these studies must address all components listed under compliance indicator #2, including the established thresholds, and all components outlined in the definitions of process and outcome studies.