So... with that being said, here comes my usual disclaimer. Even though there are fewer lectures at NAEMSP than at Eagles and the sessions are a bit longer, these are still just
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| My sister by another mother... Shannon Marshall, AMR West Region Clinical Director |
The roller coaster ride begins here... Share the link to this blog as much as you want. The messages here are good ones:
NAEMSP18 – Brent Myers – NAEMSP President – Status of the
NAEMSP. More outreach through social media. Patient access to medications act
has passed. NAEMSP has released a challenge coin from the office of the
president for those who donate to the formation of a PAC to lobby for NAEMSP
concerns regarding EMS at the federal level. Next year’s meeting is in Austin,
Texas. www.naemsppac.com to donate. Work
being done on the EMS Agenda 2050 for guiding EMS. All present are encouraged
to attend committee meetings. World class EMS research being presented this
year.
NAEMSP18 – Astronaut Dr. Story Musgrave – The patient as a
mission with a very critical outcome, how to get it right the first time every
time. “When I am dim nothing works.” It’s all about finding methods of personal
growth. You learn things and you take it with you. “I’m not here to fix you.
You do not need fixing. I am here to raise the bar.” You need the best
formation possible with your team, your company. Life… give it your all, figure
it out, get up to speed, get it done, learn from it, take it with you and climb
the next challenge. Always take it with you. Every day you climb the next
mountain. You have to have fun. Fun guarantees you will do it well. Fun is
better for your family too. Exploration and curiosity… what is next? Are you in
the game? Are you excited about everything you see? Tells the story of how he
ran a tractor in the river.
His concern was not regarding drowning but more the
reaction of his dad regarding of putting the tractor in the river. “I’ve been
trying to survive my entire life.” He states he was a product of child labor
and he got hurt but it made him who he is today. By age 9 he was driving every
tractor and truck on the farm without instruction. Got pulled over by state
police in a farm truck at age 12. He solo flew at age 13 in a private plane.
Went into highway construction equipment maintenance. Never finished high
school. No one ever asked him if he had a high school diploma but now has 20
honorary doctorate degrees. Great with repairing engines in the Marines. Moved
quickly up the ladder. He made airplanes ready to go to war. Signing off for
airworthiness at age 18 on aircraft. When your airplane leaves and does not come
home you take it personal. Always raise the bar for others and yourself. He had
no high school so he could not go up in the Marines. Syracuse turned him down
for entry so he chose to go there anyway. He showed up and they let him start
anyway. Don’t take no for an answer. Pursue, identify, comprehend and control
every factor that will affect your desired outcome. Logic and reason will not
find them all… Curiosity and imaging will. Joined active reserve in the
Marines. Got on the varsity team and got his college pretty much paid for. GI
Bill covered it too so there was twice the needed money to go to college.
Drives a 94 Corvette today. There isn’t a space program yet but he took up
flying. “I like airplanes.” How good can I be needs to be your question. Successful
endeavors have a system… they have a process. Healthcare needs that too. Went
to UCLA for deeper mathematics. He was in the forerunner to system design. The
power of curiosity… don’t leave it alone. Keep playing with it. Did not have any pre-med. Went to Marietta
College and asked for pre-med. Did pre-med there. He got accepted to every
medical school he applied to and went to Columbia Presbyterian for Medical
School. He offered to work for nothing to get into the neurosurgery lab in
1960. He was on salary in a month. Lab
could not make a 1 micron electrode. He took the machine apart and put it under
a microscope, watched the process and then built the electrodes by hand. “I am
pragmatic and I am practical.” He ended up in every article the lab published
for the next four years. He published
nearly 20 papers as a medical student. He had low grades but great successes.
Engage humble interaction. Engagement is so important for perfection. He had a
kid every year of medical school. He has seven kids. He is 80+ and has an 11
year old. Did general surgery internship at the University of Kentucky.
National Academy of Sciences and NASA looking for a science astronaut concept.
After UK he got into aerospace medicine with a minor in aeronautical engineering.
He studied effects of free fall on the human body. E flew aerobatic air shows
during this time as well (hardest job he ever had). Every maneuver is an Earth
avoidance maneuver. Got into NASA. Out of 6,000 applicants, seven got to space.
While at NASA, he worked several shifts a month in Trauma at Denver General.
NASA sent the Marine to the Air Force to learn jets. They taught him jets. He
taught commercial rating on weekends so the pilots could get commercial airline
jobs post military. He kept working on airplanes. Vigilance and awareness is
your intensity in looking at how things are going. We bury people due to
accidents. He ended up being the lead NASA space-walker for 25 years. He has
more vacuum testing than any other human on earth. He became the primary
physician for the Hubble Telescope. The ability to see the current and future
nuanced intricacies of failure is important to success and predicting what can
happen. Operate systems within parameters the way they are supposed to operate.
He was lead communicator for 25 NASA missions. Google “Hubble Mirror Accident
Report” if you want to know what failure is. Everyone in this room has the
spirit to do great good. When things fail early it is a design problem. We need
to see intense faces. Empower people. Start the conversation by asking everyone
in the room if they are uncomfortable about what we are doing. Do not be afraid
to say you are uncomfortable with a track your team is on. Do not turn alarms
off. Be empowered within the process and do not deviate. He went up in the
shuttle and did the mechanical fixes to Hubble while in orbit. Last month he
was climbing poles with Duke Energy repairing electric lines to stay sharp. He
brings his skills, they teach him theirs. The sirens are ringing, somebody else
is coming. The sense of humility lets you get the job done. He is now a design
professor. He is also a painter. The world is ever increasing complexity. As an
80 year old he also runs a palm farm. What are you good at? Do not worry about
what you are not good at. Do what you are good at. The future is in engagement
and curiosity. There are grade school kids today building planes. Who are we?
He states he has been incredibly privileged. Continue the quest. Feet above the
earth, head and hearts in the heavens.
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| Dr. Story Musgrave |
NAEMSP18 – David Williams, PhD – Institute for Healthcare
Improvement – Improvement Science and Safety in EMS – Speaker has a long
history of Quality Improvement functions in EMS. Talked about spinal rule out
protocols and paramedics still getting blamed for doing the wrong thing and
deviated from the protocol. They had 21 deviations so it was obviously a
system/process issue not a people issue. In order for us to get outcomes we
need to have the processes and systems in place that get the outcomes. IHI uses
Deming’s definition of the science of improvement. Four parts – System,
Phycology, Learning and Variation. Patient safety in EMS is a primary role of
quality improvement. England – NHS developed clinical performance indicators
for English ambulance services. Hey had started with Response Times much like
the US and moved on to other more important issues. They worked on reliability
to the process of treating certain conditions. Variation is reduced by getting
the caregiver to do the things we know that positively affect outcome. Look at
the data and identify the variation then work to reduce by bundling care
components. This was a national improvement collaborative for ambulance
services. Qatar – Measuring Adverse Events – Used IHI Global Trigger Tool.
Pulled 20 runs every two weeks. Collected adverse events, triggers and data.
They looked for EMS Trigger Tool items. In process of being submitted for
publication. United States – Organization as a system. Mecklenburg EMS. Used
Deming’s “Organization as a System” design. Design the organization where
quality is a business strategy. This drives strategic priorities. How do we
describe what we do? If you cannot describe it, you cannot improve it. Scotland
– A leader in patient safety issues worldwide. NHS Scotland EMS has a chief
quality officer. Focusing on quality as a business strategy. They have ability
to look at patient records as every patient has a unique patient identifier.
Google “Towards 2020: Taking Care to the Patient” document online by the
Scottish Ambulance Service. Look at the SAS Clinical Model.
NAEMSP18 - Oral Abstracts – 1) “Timing of Airway placement in
Cardiac Arrest: Earlier is better” – Optimal timing is unknown and unspecified
in ACLS. Secondary analysis is from ROC Prime Study (ROC sites only). Focused
on witnessed arrest to draw time frame. Measured to ROSC only. Used Cox
proportional hazards model. 7,547 patients in study. ROSC decreases as time to
advanced airway increases. This is for both shockable and non-shockable
rhythms. Probability of ROSC and timeliness of ROSC both improve the shorter
the time from EMS arrival to advanced airway placement. Attempts were not
measured, just time to successful airway placement. ET and SGA were treated the
same. Airway to ROSC probability is time dependent. Study could be further
improved by looking at survival and neurological status post discharge. Keep in mind
that if ROSC is not obtained prehospital, survival is less than 1%. 2) “EMS
Agencies with High Rates of termination of cardiac arrest also have high rates
of survival” – Transport of CA patients without ROSC impacts EMS and ED
utilization with low chance of survival (less than 1%). Used CARES database.
Four year period analyzed (my note: Evansville data is included in this!). Looked
at ROSC and survival to discharge along with neurological status. 122,834 patients
included. High termination group had higher scene times also. High termination
group also had more medications given (my note: stay on scene!). 8.5% in the
lower field termination group and 12.5% discharge rate for in the high field
termination group. Higher rate of neurological intact discharge notes as well. Longer
on scene times are beneficial in cardiac arrest. 3) “Prehospital Death
Notification associated with higher burnout among EMS Professionals” – Training
related to how to deliver death notifications reduces stress. Stress causes
burnout and leads to lack of commitment to EMS work and negative mental health
issues. Causes increased turnover. 19,330 EMTs and Paramedics surveyed.
Measured in April 2017. Used 19 item validated instrument, Copenhagen Burnout
Inventory. Surveyed perceived training in the delivery of death notification
training. Call volume is a confounding variable. Measured self-reported number
of death notifications delivered. Delivering one or more death notifications
increases burnout rate by 47%. Response bias make response numbers conservative
as well. Training was associated with lower rates of burnout, but delivering
death notifications in general has an impact on burnout. 4) “Incivility in EMS
that violates social norms and the negative effects” – Does this reduce
workforce retention? Effect on workplace absence? Sample of 38,000 EMS workers
sent a survey. Used a Workplace Incivility Scale adapted for EMS. Stress
measured by the Depression/Anxiety Stress Scale (DASS). What is the association
between incivility and workforce reducing factors? Includes practicing EMTs and higher that are
non-military. 2,815 responses completed were used for analysis. 47% reported an
at least once a week incivility incidence at work. High association with
dissatisfaction with job in the presence of incivility. Fivefold increase in
stress. Fourfold increase in intent to leave job. Exposure includes the overall
EMS environment (co-workers, supervisors, other healthcare interactions). 5)
“Statewide trends in OHCA related to OD.” OD is a major heath issue in Arizona.
Huge variation in overdose related to OHCA. OD related OHCA are younger and
less likely to receive bystander CPR. Study looks only at Arizona data.
Observational study. Uses Utstein model for measurement. Uses OHCA reports
where Naloxone was given. Multivariate logistic regression was used for the
study. 987 OD related OHCA cases were studied. Accounted for 5.1% of arrests.
OD OHCA had a higher incidence of survival (18%) versus Cardiac etiology (11%).
Bystander CPR appeared to have an impact on both groups. Limited by inability
to know exact drug of use at time of OD. Proportional increase occurring in OD
related OHCA. Arizona is a model state in measuring EMS data. 6) “Death by
Suicide: The EMS Profession compared to the general public” – 40,000 suicides
in 2012. Number 10 cause of death. Between ages 15 and 35 it is number two.
From 2000 to 2012 suicide increased 21.1% in the United States. Rate affected
by occupation. Seventeen states reported highest rates in female public safety
workers. EMS is related regularly in critical events. Mortality Odds Ratio
indicates whether an occupation has a higher rate of dying. EMS suicide MOR has
not been published. Law enforcement has been measured and it is high. Arizona
used a death registry. Manual review of each case was performed. Firefighter,
EMT and Paramedic used to indicate EMS. Logistic regression used. 63 EMS
suicides occurred during 2009-2015 in Arizona. 2.2% suicide percentage in
general population. 5.2% of suicide deaths were EMS. No significant differences
in method of suicide. EMS 39% more likely to doe of suicide than the general
public and on the increase. Co-morbidities not analyzed. Some may have also
been veterans. Increased awareness is urgently needed. Programs and strategies
are available today.
NAEMSP18 – The Refractory VF Arrest Patient – Marc Conterato
– What is refractory VF? What is Electrical Storm? ECMO? Scenario given where
ECMO was used. Does anyone feel good about terminating arrest efforts on the VF
patient in the field? Is the VF recurrent or refractory? Refractory VF is shock
resistant and continues. This is the concept of electrical storm. What happens
when you hit the end of the algorithm? Mentions Bicarb as an option. Epi may
make VF harder to break. Epi may produce negative outcomes. Lower doses do not
help in preliminary studies. Supports not using Epi. Have defined roles in
arrest management. When you reach the hospital if transported, what happens
next? Do your refractory VF go to the cath lab? What about an ECMO team to
prolong resuscitation? Esmolol shown to increase survival to discharge with
good neurological outcomes. Intra-Lipid Emulsion Therapy opens a different
calcium channel. Automated CPR devices – much debate. Automated CPR may be a
good gap bridge to get a refractory VF patient to the cath lab. Dual/Double
Sequence Defibrillation (DSD) – has been around over 30 years. DSD relies on more energy
and multiple vector pathways for effectiveness. Cleaning skin prior to defibrillation
electrode placement and placing more pressure on the defibrillation electrodes
will help with impedance. Success of DSD mirrors Amiodarone success. Is it the
DSD or Amiodarone before DSD? Several trials in progress. Proper placement of
electrodes is key. What if we take conversion of VF out of the picture and
concentrate on oxygenation and perfusion till intervention can occur? ECMO!
ECMO provides cardia and oxygenation support. Paris has a prehospital ECMO
team. Patients in RVF have a high rate of cardiac disease (65%). Survival rates
with ECMO may be much higher with preserved LV function. Survival may be as
high as 45% with CPC1-2 neuro status.
Simple Inclusion Criteria: 18-75 of age, no DNR, Standard ACLS has
failed. Uses a treatment window of 60 minutes from 911 call to arrival at the
designated resuscitation center. 132 patients with 45% survival rate and 42% at
CPC1-2. Case study with ECMO had a 12 day stay and discharged home CPC1. Limit
Epi to a total of 3mg or eliminate use in VF. Consider Esmolol. Esmolol and
Lipid Emulsion cannot be used together. Improve impedance. Get the patient to
ECMO. Using Bicarb routinely (interesting note!).
NAEMSP18 – NSTEMI: The Neglected Epidemic of Our Time –
Nania, MD – Relayed personal story of a friend who died from non-recognized MI.
Heart disease is the leading cause of premature death with the average age of a
heart attack around age 60. There are many statewide STEMI systems. This covers
about 30% of AMI. NSTEMI is every bit as lethal. Time criticality is a big
component. In the first four hours of a heart attack, every 15 minute delay
shows an increase in mortality and morbidity. The best tests we have delay care
in NSTEMI. The ECG is not very reliable in all MIs. Common high yield symptoms:
Neck, shoulder and chest pain, nausea, fatigue, radiation to an upper extremity
and diaphoresis. Generally not sharp or positional pain. Symptoms lasting
longer than 20 minutes. Presence of Levine’s sign (My note: to my past medic
students… What have I always said about Levine’s? We cover it for a reason.
Highly indicative of MI). Risk factor measurement has to get to the field (my
note: what has Tim Phalen said for years?). TIMI Risk Score can be used. MACE:
Major Adverse Cardiac Event (heart attack, PCA, bypass or death was a component
in TIMI score development. We need scores to indicate need for intervention,
not just STEMI on an ECG. People that suffer from depression are more likely to
have a heart attack as well. www.timi.org The initial ECG is often not diagnostic in
patients with ACS. Assure that you run
serial ECGs. Use broad spectrum use of 12-lead ECG. Giant T-wave inversion is
another indicator. New LBBB is yet another indicator. Use posterior and right
sided leads as well. In general, ECG software is as good as the doctors in
determining STEMI. We should not stand down over a negative ECG. Cardiac
markers and assessment are key and time is of the essence. In 991 Patients with
positive Troponin, 83% had a MI. Risk profiling is key. Get the patient to an
interventional center. We need better means of determining who is having a
heart attack. Currently we are only measuring the trunk of the elephant. 25% of
MI patients walk in the ER door and do not come by ambulance. Risk profiling
only has a cost of training. Let’s always talk ACS and not just STEMI.
NAEMSP18 – Pediatric non-Traumatic OHCA: Should we hit the
brakes? – What if we could save 1000 more children in non-traumatic OHCA each
year than we do now? Relays a case scenario of scoop and run in OHCA. This is
unacceptably common. Read Thinking Fast and Slow by Daniel Kahneman (my note:
Peter Antevy teaches this as well). A lot of this centers on system 1 and
system 2 thinking. We have to improve our ability to perform system 2 thinking.
Survival of pediatric OHCA remains around 5-10%. 70-80% are secondary to
respiratory failure. We have drastically improved adult OHCA management and
outcome. Children are being left behind. CPR during transport is bad and
dangerous. We have TOR standards for adults. What about kids. It is commonly
taught that kids are not little adults. THIS IS NOT TRUE! Many of the
principles of dealing with kids are the same as adults. Why would we stay on
scene with adult OHCA and maximize care and then scoop and run with a child? We
are making an emotional decision instead of a scientific decision. In hospital
pediatric OHCA has a good success rate (43%). Why? Rapid response teams, early
interventions and high quality CPR. Message? Do not move toward transport when
there are interventions to be done. Improve system 2 thinking by practicing
worst case scenarios with tools available (my note: train as you fight). Early
Epi (<5 minutes) associated with better outcomes. Longer Epi intervals may
also be better. Intubation does not equate to an improved outcome. If
transported without ROSC, survival in pediatric arrest is less than 1%. Longer
scene time associated with better survival (5.3% versus 10.2% when scene time
is 10-35 minutes). Stay on scene and do the interventions. Quality pediatric
CPR cannot be performed in transport. When do we stop? No national guidelines…
yet. After 42 minutes of CPR, survival decrease to below 1%. 56% of medics are
uncomfortable with pediatric TOR, however 81% believe that children have the
same or better chance of survival. Speaker believes there is more liability in
scoop and run than in working on scene. Speaker relays a new case scenario with
appropriate arrest management on scene. (my note: mirrors Antevy philosophy).
EMS needs training in communicating with the family.
NAEMSP18 – Promoting Patient and Family-centered Care in the
Prehospital Setting: A Tool Kit for Medical Directors – Srinivasan, MD –
Houston – Sometimes it is the smallest gestures that people remember. Relayed
the story of a sock returned to a mother on scene where the child died three
days later and the mom still regards that as an act of
kindness. Family
centered care acknowledges that family is a constant in the life of a child.
It’s not just being nice. It’s not about giving up all clinical decision making
to the family. It doesn’t mean there are no boundaries (disruptive family
members must be removed). Families do not typically interfere with care. Most
families feel it is a right to be present during resuscitation. Studies show
that family presence does not negatively impact care or performance of care.
Families need to be updated. 66% report that being present and touching their
child helped with grieving later. If segregated, the feeling is that their
child died alone. This is a well-studied topic. It improves family and provider
perception of the event. Be at eye level when communicating with kids. Smile! Start
at limbs with assessment, not core. Try “You’re job is to hold still,” instead
of “Don’t move.” Verbalize what you are doing and be totally honest. Do not say
it will not hurt when you know it will. Give options that offer small choices
in care like “Which arm would you like me to use for the BP?” Do not use false
choices like “Can I listen to your heart?” because we are going to do it
anyway. Difficult questions should be answered with descriptions about what may
be happening and assure them your job is to try and provide the best outcome
possible. Keep parents present whenever possible. Allow parents to maintain
line of sight and touch the child. Ask parents how the child is acting compared
to their normal self. Talk to parents. Thank them for calling 911 as it
validates the right decision. Parents need to be validated in their healthcare
decisions. Statements like “a high temperature
can be very scary” are
appropriate and validating. Pedi-STEPPS is a pediatric simulation course for
EMS. It increases comfort with pediatric assessment and family centered care.
It is a one day course. Morning is lecture. Afternoon is four high fidelity
simulation with well trained, consistent actors. https://emscimprovement.center/resources/toolboxes/patient-and-family-centered-care-toolbox/
Take home points: Easy and cost effective. It can be simple to implement or as
detailed as you wish to get. PFCC can be implemented everywhere.
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| Pediatric Simulation Set-up |
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| Pediatric Simulation Set-up |
NAEMSP18 – EMS Physician Board Certification – 2017 added
189 new diplomates with a current pass rate of 63%. Fellowship trained
physicians have a higher pass rate. There are now 655 EMS Board Certified
Physicians. 57 current fellowships.
NAEMSP18 -NAEMSP
Advocacy Update: PAC-man? - What is a PAC? The DEA bill is a primary reason to
have a Political Action Committee. Public Law 115-83 was done in light speed
compared to many bills. Standing order are now legal for controlled substances.
Prior to November 17, 2017 it was not legal. This bill also allows for the
provider to be the DEA license holder as opposed to the medical director. The
law requires there to be an EMS medical director to hold a DEA license. NAEMSP
partnered with ACEP and NAEMT to accomplish this feat. There was wide support
from EMS and the healthcare community. So what's next? Rules for the DEA law
need to be promulgated. There is a hope to work on EMS Quality Legislation. The
Pandemic and All Hazards Act is up for reauthorization as well. So where does
the PAC come in? It is a separate organization linked to NAEMSP. Money donated
is kept separate. NAEMSP can only solicit funds from members. The NAEMSP may
fund the cost of operating and raise money for the PAC. The PAC can spend money
to support candidates. Without a PAC the NAEMSP can lobby but cannot donate to
a candidate. There are contribution limits. We need to support candidates who
listen to NAEMSP and take our perspective. It is the best way to do it in an
ethical and transparent manner.
www.naemsppac.com
www.naemsppac.com
NAEMSP18 - Oral
Abstracts - 7) Assessment of the RACE scale in Real World Practice for
Prediction of Large Vessel Occlusion and Reducing Time to Thrombectomy - Peter
Antevy - Prehospital identification of LVO patients may lead to faster triage
and treatment. Is this reliable and can it be implemented in real world
practice? EMS agencies were trained. For a score of 5 or higher the
endovascular team was alerted prior to EMS arrival at the ED. 797 of 1498
stroke patients had a RACE score. Identified 64% of LVO patients. 499 patients
with a score less than 5, 8% had LVO. 68 versus 91 minutes if a RACE score
alert occurred. Further refinement of a prehospital stroke scale is needed. 8)
Effecting Neuro Intact Survival for Children with OHCA - Paul Pepe - POHCA
coined. Grim survival chances. Scoop and run practices have evolved. With scoop
and run there is a delay in first dose of Epi. Some studies indicate better
outcomes with longer on scene care. Concentrate on deferring transport and
prioritizing on scene care? Used Utstein for data collection. 2012-2017. In
2014 incorporated delayed transport and expedited drug delivery. Included
psychological training. Crews prepared Epi prior to arrival based on relayed
age of patient from dispatch. Results: 143 cases. Epi admin decreased from 1.5
minutes to 5 minutes. IGel utilized as well. 2012-2013 no survivors. 2014-2015
23% survived. 2016-2017 even better. Historically controlled study that was very
rewarding. Physiologically sound ventilatory support was also utilized. 9)
Motivations for Exiting the EMS
Profession Differ between EMTs and Paramedics -
Rivard, NREMT - Limited data. Research can lead to positive changes. NREMT did
a survey on the topic via email and online response to non-practicing still
certified persons. 2703 non-working responded. Retirement cited as 7% for EMT
and 30% for paramedic. Most important factors varied. See picture. 32% of EMTs
intended to return to EMS where only 17% of medics indicated intent to return.
Only assessed nationally registered EMTs and paramedics. 10) Properly Triaging
Out-Of-Hospital Pediatric Trauma - Pediatrics have a 35% under triage rate. Vital sign cut
points may not be accurate. Is the guideline accurate? Three year observational
study, multi-site. 9483 children in study. 231 met outcome data for study. Age
adjusted criteria improved over and under triage rates. Missing vital sign data
might be suspect in triage failure. BP was the least commonly measure vital
sign in triage situations. Missing criteria however had no effect on findings.
Not obtaining vital signs was common. 11) Antiarrythmics for OHCA - Is
treatment A better than treatment B? Eight randomized trials reviewed. Very
detailed meta-analysis. Consensus is drugs are given too late in the arrest.
ROSC is a very good measurement for EMS practice as it is within the control of
the paramedic and first responders. Hospital Discharge neuro intact is a good
measurement of EMS and the hospital response. No antiarrythmic was better than
placebo. 12) EMS Provider Perspective on Pediatric Calls - Helping professions
are particularly vulnerable to PTSD. Surveyed Allina Health EMS with over 600
employees. Line EMTs and paramedics surveyed. Mainly urban. What makes it
different? Social value of children, clinical difficulties (infrequent and
special dosing and equipment), nature and type of call. Parent are a big
stressor. Review was the most common answer on how you prepare. Also described
using calming techniques prior to arrival. Coping mechanisms: talking to
others, sarcasm and dark humor. Some discussed work/life balance. Relational
support was common. CISM was noted but many felt it was not helpful and more
stressful. Many wanted more training and Pediatric specific equipment. Providers
note management/command lack of compassion in these cases. Use the “Power of
the ask”... this is a tangible demonstration of your investment in crews
(supervisors and managers). Difficulty in getting rural clinicians to get
involved in this survey.
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| Motivators for leaving EMS (EMT vs. Medic) |
NAEMSP18 - The Canadian Prehospital Evidence-Based Practice Project - Does the evidence support certain interventions? EMS has borrowed evidence from other medical specialties and we need to start relying on measurement and information from the EMS environment. Do what works for patients and allocate limited financial resources. We must serve the healthcare needs of diverse populations and geography. Evidence matters. https://emspep.cdha.nshealth.ca PEP was designed as a resource database and it also was placed to show gaps in data where EMS research is needed. Monthly literature
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| PEP |
NAEMSP18 – National Model EMS Clinical Guidelines: A Resource to Help You Improve Patient Care – Cunningham, MD – NASEMSO based project. NHTSA created the acorn alongside professional organizations. EBG = Evidence Based Guidelines. Most practice is at the core similar. These are non-mandatory and non-obligatory. It is a patient-centric resource. Evidence-based when evidence is available, consensus-based otherwise. There is inclusion of public comment from the EMS community. There have been 15,435 downloads from the NASEMSO website so far since release of the first three EBGs in September 2014. There has been an update to reflect 2015 AHA updated material. Version 2 released in 2017. Fifteen additional guidelines in version 2. EMS Compass measures included. There is also a universal documentation guide. NEMSIS V3 codes included in guidelines. Seeking to find solutions to address EMS challenges. Many organizational partners in this including NAEMSP, ACEP and ACS-COT to name a few. https://www.ems.gov/pdf/advancing-ems-systems/Provider-Resources/National-Model-EMS-Clinical-Guidelines-September-2017.pdf
NAEMSP18 – Ethical Challenges in EMS – Wesley, MD – Speaker wants the audience to join him on a journey of discovery into ethical issues in EMS. He finds many of his discussions with EMS crews involving more time challenging their own beliefs of whether they did the right thing. He sees a lot of not knowing and self-doubt that occurs after the call. His goal for his paramedics is for them to come home renewed, not filled with self-doubt. This is not an evidence-based presentation, it is human-based presentation. Your people expect answers when you have MD behind your name. He joined the hospital ethics committee and his eyes were opened wide. He worked with hospice and home care to find tools that would help in EMS. Gave case studies from his service. Ethical question: Should the medic tell the LEO that the patient has been drinking and smoking pot when he was driving a semi and killed a family of five? The patient with no DNR has a family that attests that he does not wish to be worked. What do you do? Patient goes into cardiac arrest enroute to hospice with a DNR and hospice will not take the patient now. What do you do? A valid DNR attached to a suicide note… what do you do? Medical Ethics defined: Principles of proper professional conduct concerning the rights and duties of the provider to their patient. Ethics is sometimes about picking the least wrong answer. ECMO for example… a huge, expensive, manpower intensive issue in EMS for a very small impact. Pillars of ethics: Autonomy (directing one’s own care), Beneficence (the act of everything we do being for the benefit of the patient and it must be defined within the context of THAT patient), Justice/Fairness (the right to be treated fairly… distribution of healthcare resources for example, triage, without prejudice), and non-malfeasance. Ethical dilemma occurs where there are value conflicts and no clear consensus as to what to do. Do you violate a protocol to do what you should do? Must choose the least bad option. As educators, we struggle with teaching therapeutic communication. We, as a culture, have changed from primarily auditory learners to visual learners and few know how to truly communicate with patients. There is a Rapid Approach to Emergency Ethical Problems algorithm. There are many ethical, recurrent issues in EMS. He has made a two-hour training program on making ethical decisions. The intention and the outcome are two different things. Do you give the morphine to the DNR patient to ease the pain, knowing that it may cause respirations to cease? Your intent is to ease the pain, not stop the breathing. We cannot place EMS in these positions to make these decisions without resources. See Walker “Deceit and I.” https://www.youtube.com/watch?v=PgmRUJ3rofM
NAEMSP18 – The Judgement of Solomon, EMS Style: Hospital Sues to Establish EMS Protocol – Which of two mothers gets the baby? This story is true, names have been changed. STEMI patient destination determination law suit. It started 12 years ago. A system has been developed for STEMI. Those patients need to get to definitive care. Two hospitals, three miles apart. One was a STEMI center. Ambulance A does 80% of transports, two other small volume services. 6 years pass, personnel changes occur. The “other” hospital now wants to be a STEMI center. How do we divide the patients? State law did not address the issue unless trauma. He is asked as the medical director for all three services to define a protocol. Closest? Track record of the STEMI centers? Success rates? Number of PCI cardiologists? Number of cardiac surgeons? National recommendations on PCI per physician? Number of procedures per cath lab? Who decides? Needs to be between the two hospitals and they do not get along. Outside party? Mediator? Lawyers… The medical director is NOT paid by the hospitals or local government. Paid by the EMS agencies. Free enterprise? Best patient care? Resources available? Legal liability in the decision making? Made it so that all STEMI patients would go to the oldest center unless specific requesting of the patient to go to the new center. Re-evaluate at one year. New hospital mad. Medical director refuses to change protocol until the two hospitals talk. Four years later the sheriff arrives at the door with the subpoena with a trial 14 months later. Writ says patients will go to the closest STEMI center. Summons, complaints, precedents, discovery and depositions, etc. Apparently there was no precedents of lawsuits identified. Writ dropped as he was not a public official and time frame of delivery of writ. New hospital still demanding transport to that facility when closest. Judge did a summary dismissal as EMS protocols are at the physician discretion. Within the law so there is no need for a trial. Future? Not the end. New hospital appealed. Four months later appeal abandoned but threat of another suit. Make patients first and do your homework, Remember that email is there forever.
NAEMSP18 – Small
Victims and Serious Play: Simulations and Video Games for Pediatric Disaster
Education – Simulations and video games for training. Disasters are unexpected,
all victims are somewhat simultaneous and can be tornadoes, shootings,
accidents or terrorism. Is there an incubation period for a bioterrorism attack
involved? Resources are different everywhere. What do you do when resources are
overwhelmed? Children cannot flee as easily. Lower circulating volume of blood.
Children are more emotionally harmed. Poverty is a predictor of decreased
recovery as well. What is the balance of needs versus resources? Personnel?
EMS? Equipment and meds? ORs, ICU beds? Pediatric Disaster Education looks at
Scene safety, mutual aid, triage, treatment and much more. Kids may shut down
and not talk to responders about past medical issues if overwhelmed by a
disaster. What about timeframe from training until actual use? EMS information
and standards continue to change. How often do you recover the topic in CEU?
Use Kern Method of curricula
development. Do a needs assessment and define an ideal
approach. Do a needs assessment of targeted learners. Define goals and
objectives to drive the curricula content. Keep the goal the goal. Vary the
content. Sometimes it is a game, sometimes didactic. Implement and then
evaluate the effectiveness. Look at Modified Kirkpatrick Hierarchy for program
evaluation. Live simulations: Many great advantages but are costly and have
scheduling constraints. Pick subjects that happen but are not frequent to your
locality
(school shootings, bus accidents). Live simulations improve triage
accuracy. Greatest improvements were in red and yellow categories of triage.
Retention was sustained. Developed a video game called 60 seconds to survival.
This is just in time type training and it is fun. Incorporate the triage system
you use. It needs to be relevant and engaging so that when a caregiver has
downtime they choose to spend time on the continuing education. On screen
feedback. Simulation incorporation is an adjunct along with other types of
education. Pick the right educational intervention. You still need disaster
exercises. Speaker strongly advocate for periodic “triage days” where every
patient gets tagged for 24 hours. http://Disastertriagegame.org
NAEMSP18 –
Credentialing Pearls: Tales of Bumps, Bruises and Success – Gallagher – NAEMSP
now has a position paper out on Credentialing (my note: more ammunition in the
fight!). Credentialing is a worthiness assessment. There must be local
oversight in the EMS arena by the medical director. We must advance EBM
standards and assure that our caregivers can apply and perform these things. No
one wants to be accused of inadequate supervision. https://www.nremt.org/rwd/public/document/credentialing-ems Anyone that clinically provides patient
care should be credentialed. Verify licensure every time. FTOs need to be a
component but it must be fair and consistent. It needs to
allow for practice
variation but some things should not vary. Base new hire field experience on
number of patient contacts instead of time. They use four high acuity contacts
and 200 overall patient contacts. It has virtually eliminated new hire clinical
errors. No one is falling hard out of the nest. Remember FTOs sometimes need a
break. We burn out trainers. Credential to the scope of practice (vents? IV
pumps? Wound packing? All critical equipment? 12-lead? Etc…). Credentialing
defends the minimum standard. There is not a different standard of care between
a 10 year medic and a day one medic straight out of orientation. Be the
advocate. No one is guaranteed the right to work in medicine. Choose the hills
to die on… what are the most important things that must be checked. The FDM
(final decision maker) is the medical director. (my note: this is a topic that
must be expanded and adopted).
 |
| A point that all of us in performance improvement should remember |
NAEMSP18 – Mobile
Stroke Units Debate – Price/Louisville CON – Let’s lift the fog. Reasons for
being CON? No significant evidence to analyze. ELVO management is here to stay
and stroke units could be helpful. Noted to be true. However is it feasible? It
is possible to treat in a good time frame in a stroke unit but we need to see
if they can decrease time to ELVO management as well. This was looked at. Times
using MSTUs are not stellar. They can direct to appropriate care. What if we
just deploy telemedicine instead of CT scanners? Bypassing to the right place
is easier in urban areas anyway so do these unit solve this issue? Associated
operational costs are very high. Low patient numbers in studies. One study
noted only one patient meeting criteria every 33 days! ELVO patients need to go
to comprehensive stroke centers. When compared to “good old fashioned EMS” data
shows that mobile stroke unit decreases time to treatment. When you change the
intake process then numbers become close to the same (15 minute difference). Is
it worth it given infrequency? The needed step to implement are astronomical in
cost. 5 year cost is $1,465,000 for approximately one patient meeting criteria
a month. Money better used to benefit more patients. Persse/Houston PRO – Created
MSU in Houston. Not a simple undertaking. Needs a full time medical director.
Needs to be a multi-hospital collaborative to avoid conflict. No sponsors from
big pharma or a CT company. Needs third party evaluation of financial impact.
Hospital sharing data needed to use MSU as a solution. Are there better
clinical outcomes when using an MSU? That is currently blinded in the study. It
is the real answer everyone is waiting for. Recommends everyone thinking about
this wait till the study is over. Stroke unit does cost the number used
earlier. If it effects care of seven patients in five years it becomes cost
neutral when compare to long term care. Houston is seeing one criteria patient
every two weeks. You cannot talk about times till you actually do it. It can
identify patients and it can decrease time to care. When in a MSU that patient
gets focused care… one patient is the focus.
NAEMSP18 – Oral
Abstracts – 1) Effects of prehospital hypertonic saline for hypotensive
patients – Optimal fluid choice is unknown. Hypertonic fluids may increase
volume. Does hypertonic versus isotonic affect outcome to discharge? Article
review. Five studies in final analysis. All used 7.5% Sodium Chloride. Even
though the Hypertonic group had slightly better number but no statistically
significant difference. Many complicating factors reported. Hypertonic Saline
cannot be recommended for this use. 2) EMS Provider characteristics in response
to violence – Wake County – Violence against EMS is increasing. Trained
evaluators looked at 51 data elements during simulations regarding violent
scenes. Scripted simulations. Primary outcome was whether or not the provider
escaped and if they made a de-escalation attempt. 272 providers were evaluated
as 2-person crews. 55% escaped. 55% attempted de-escalation. Experience, CIT
and military training were associated with LOWER chance of escape. Providers
obviously knew they were being evaluated. Need to improve recognition of failed
de-escalation attempts. 3) Performance Characteristics of the Modified RACE
(mRACE) to evaluate large vessel occlusion – 800,000 ischemic strokes every
year. RACE was specifically designed for EMS. Modified version created and measured
by this study. Modified measured Aphasia and Agnosia regardless of laterality.
724 in study. Performs similarly to RACE. mRACE is easier to teach. Limited
access to hospital data in this study. 4) Effects of Failed Defibrillation on
Waveform Characteristics of VF – 350,000 out of hospital arrests each year. VF
typically degrades from Coarse to Fine in nature. Used ROC data. ECGs extracted
from the ROC database. 5195 total shocks, 681 patients. 1399 shocks in final
analysis after exclusion for quality. Failed defibrillation did not degrade VF,
possibly slight improvement. 5) Mortality
in Patients Transported by EMS – EMS is link between the community and the
healthcare system. Little is known about mortality in those transported by EMS.
Looked at mortality at hospital discharge. 127,867 final sample. Overall mortality
3.3%. Risk increases with age. Males higher mortality. 27% of all EMD Echo
Determinants died, and 37% of all EMD Delta Determinants died. 19% of all that
died were Condition 26 (Sick person) (my note: in Evansville, the “sickest”
patients using Rapid Acute Physiology Scoring is also Condition 26.
Interesting). For every 30 transports there is one death. For every ED death
there are five in patient deaths. 6) Suspicion of Infection and sepsis in the
prehospital setting – Almost 50% of sepsis patients come to ER by EMS. 9.7 % of
patients had infections. Sepsis present in 2.1%. Paramedic recognition at 11%
in infections. 9% recognition in Sepsis. Majority of Infection was EMD card 26
(Sick Person). Cards 6 (Respiratory) and 33 (interfacility) were next. Most
common symptom was dyspnea. Temperature was the best measure collected by
paramedics for recognizing sepsis.
NAEMSP18 –
Mission Quality: Can Mission Lifeline Help Your Performance Improvement
Program? – Mission Lifeline focuses on a system of care. It is a tool that can
be applied to your community. We all need information that describes practice.
Maybe not data, but information. It needs to be generalized and actionable. It
must be used to facilitate a culture of improvement. Chart review is reviewer
dependent and may lack consistency. May lack a defined focus. Data mining is
dependent on data entry and quality. Evaluation Rubric: Specific criteria for
scoring. Aimed at accurate, fair and consistent assessment. To have a rubric
you must have an area of focus. Clinical presentations? Skills? Medications?
Define performance criteria you wish to evaluate. Identify records; create and
distribute rubric to auditors. Evaluate the results and make changes where
indicated. What things were being done that delayed 12-lead? Identify, educate
and eradicate. Mission Lifeline participation by EMS requires engagement of
hospitals in Performance Improvement and data sharing. Take opportunities like
Mission Lifeline to give you defined metrics for improvement.
Sidebar comment by a speaker: Another name for
CT in the context of stroke… The Donut of Truth.
NAEMSP18 – Developing
Ambulance Quality and Performance Measures that Make a Difference in Patients –
“We wish we could be measured on something other than response times!” was the
cry when they started looking at real quality measures over 10 years ago.
Develop other measures/metrics. Heck whether theory of improvement is logical.
Compare competing theories, Compare with similar theories. You want a theory
that you can run with. Four theories of improvement: Just set targets, Create
better markets, add resources to the system or redesign the system. Focus on
improvement. Established indicators. Pilot indicators. Benchmark. Create care
bundles. You must measure indicators over time against interventions in the
system to see if improvement is occurring. Measure whether care bundles are
completed or not. Phoebe (Prehospital Outcomes for Evidence based
Evaluation). To better measure the
performance, quality and impact of ambulance service care. Outcome measurement
is always full of barriers. What patients think about their care is important.
Patients wanted to see confidence and professionalism, communication, not
waiting too long, reassurance and assurance of continuity of care. Consensus of
stakeholders is important in developing performance improvement functions. Survival,
pain management, re-contact with EMS and patient experience are considered
important topics for measurement. Whole service measures: Time to definitive
care, mean response times, under triage, compliance with care standards and
documentation. Measurement alone is not enough. You must have clinical,
operational and patient outcome results. https://www.youtube.com/watch?v=g2saLhBv9-U&feature=youtu.be
NAEMSP18 – Fire
Ground EMS – Roles of EMS and the EMS Physician on the fire scene. Roles: Fire
ground health and safety, integration with fire ICS/medical operations,
Emergency Incident Rehab. 90-120 Line of Duty firefighter deaths each year.
Sudden Cardiac Death is 51% of LOD deaths. Caught or trapped 25%. Struck by
object (usually a vehicle) 13%. Falls 8%. Burns rarely account for LOD deaths
in firefighters (when this occurs it is usually wildland firefighting). Tanker
rollovers are the second highest line of duty death due to MVC (responding in
private vehicle is number one). EMS physicians need to have the basic safety
and hazmat training as well as PPE to not get killed on the scene. DHS Wide BLS
and ALS Protocol book references rehab on page 18. https://www.amr.net/solutions/federal-disaster-response-team/references-and-resources/dhs-fema-als-bls-protocols.pdf
NAESMP18 –
Federal Disaster Response System – National Response Framework is basically an
outline of how Federal Government is involved in disaster management. There are
15 Emergency Support Functions (ESF). Seven types of incidents are identified
by type. Listed the ESF functions. ESF-8 is public health and Medical services.
The Stafford Act authorizes the Federal government to respond to disasters.
Governor must request assistance. FEMA evaluates the situation and the request.
Recommendation forwarded from FEMA to the DHS Secretary to the President and
the President decides. President declares an emergency. This can be money,
equipment, people, facilities or grants and loans. EMAC – Emergency Management
Assistance Compact: Legal system of mutual aid between states. It streamlines
process for requesting aid. Affected state declares an emergency. Affected
state requests resources. Other state sends resources. Allows for recognition
of certifications and licensure. Costs are reimbursed by requesting state.
Liability and Tort protection by requesting state. Workman’s comp by sending
state. Main agencies are DHS, HHS and FEMA. FEMA is part of DHS. FEMA
coordinates federal resources in a disaster. USAR – Urban Search and Rescue
Task Forces. USAR is for confined space collapsed structure incidents. Locate
and extricate. Type I USAR TF: 70 person search and heavy rescue team. Type III
USAR TF: Smaller team for shorter/lighter search and rescue. Localized
sponsored assets that are federally activated. ESF-8 controlled by HHS. HHS has
the OEM. OEM – Office of Emergency Management. They oversee the NDMS. NDMS –
National Disaster Medical System. If local medical system is overwhelmed, NDMS
teams come in to deliver care and evacuation. NDMS team members are
intermittent federal employees. DMAT – Disaster Medical Assistance Teams. NVRT
– National Veterinary Response Teams. DMORT – Disaster Mortuary Response Teams.
NDMS has a network of hospitals as well. NDMS is in partnership between HHS and
the Department of Defense. NDMS has 80,000 hospital beds available across the
country. MRC – Medical Reserve Corps. MRC is local volunteer healthcare workers
who bolster the local response. MRC units vary highly. The CDC is under HHS as
well. The CDC manages and maintains the National Strategic Stockpile as well.
Covered presidential directives as well. My note: This was a great primer for
those not familiar with the system.
NAEMSP18 – Top
Poster Presentations – 1) Impact of Critically Ill Patient Bundles in
Respiratory Distress patients in the Field – Bundles of care is a process based
system to improve care and reduce mortality. Referenced OPALS Trial. When
Respiratory patients actually arrest during care there is a mean time of 16
minutes from paramedic contact to arrest. Implemented a “crashing patient” care
bundle for respiratory patients. Urban system with 3,600 respiratory patients a
year. Bundle: EKG, ETCO2, BLS Airway, early CPAP, IV and Medications per
protocol. Did agency wide training on the bundle. CPAP usage increased.
Frequency of post EMS contact cardiac arrest was reduced. Small sample size so
it may not be statistically significant. Care bundle item usage all increased.
NNT to prevent one death = 18. Bundle may have utility to improve patient care
and safety. 2) Syringe
Administration of Epi by EMTs for Anaphylaxis – IM Epi
is the cornerstone of treatment in anaphylaxis. State required Epi be in
auto-injectors for EMTs. By switching to drawn up syringe Epi, over a million
dollars has been saved. 2.1 million Persons in King County Washington. EMT
response first with ALS following. Kit was designed with Epi, syringes and
checklist. Every record of administration was reviewed. 411 cases in the study.
Most were female. 16% of the patients were pediatric. Food, nuts and bee stings
were the most common (in that order). 76.6% had at least two symptoms of
anaphylaxis. Two cases of cardiac arrest cases due to anaphylaxis noted. 89%
followed protocol and 95% of the calls were deemed to have needed Epi even
though the protocol was not met. A limitation was inability to get outcome data
due to 20 hospitals involved. Conclusion: EMTs can safely draw up and use Epi.
3) Benchmarking Pediatrics Using EMS Compass Performance Measures - http://www.nasemso.org/Projects/EMSCompass/documents/10252016_Website_EMS_Compass_Measure_v10.3.pdf Data source was ESO for this project.
Looked at 941 agencies. They agreed to blinded use of their data. Looked at
only ALS agencies. Only used documented fields. Narrative data was not used.
95% confidence interval. Looked at differences between agencies. Over 200,000
patients in the study. 54.8% of pediatrics had a weight documented. Use of SPO2
and Respiratory rate documented in 87.5% of cases of pediatric respiratory.
Beta agonist use was at 69.9%. 84% got a beta agonist if SPO2 was under 90%.
Wide variance in performance between agencies. 4) Retrospective Study of Hypoglycemia
Transports as a predictor of Treat and Release Safety – Hypoglycemia is common.
A tool was designed with a sensitivity of over 90%. Predictors of admission of
within three days after event were defined. Reviewed six months of patients
with serum glucose less than 72mg/dl. Looked at some variables such as
homelessness. 392 patients in HYPO2 Study. Adults only. 9.4% had repeat access
to care with only 3.3% returning for hypoglycemia. Homelessness had increased
odds of return .Study shows that only 15% would have met criteria for treat and
release from hypoglycemia field care. If tool was implemented it would have
INCREASED transports and would not have lended toward treat and release. The
tool is potentially safe for a small number of patients to not be transported. 5)
Assessment of Ventilation and Perfusion Markers in Mechanical CPR with
endotracheal intubation and supraglottic airways – Theoretical advantages to
mechanical CPR, but no proof of improvement in outcome and possible safety
concerns with patient harm. Which is better in MCPR – ET or SGA? Retrospective
review over two years. Looked at intra-arrest ETCO2. Also looked at 24 hour
survival as well. 84 had ET, 42 had SGA. No difference in perfusion between
both groups. Sample size was a limitation. Use of SGA acceptable with MCPR. 6)
Effectiveness of Manual Ventilation in Intubated Helicopter EMS Transported
Trauma Patients – Helicopter use is frequent in trauma patients. No guidance on
type of ventilation used in helicopter transport. Assessed BVM adequacy during
helicopter transport of trauma. Observational, proof of concept study. 20
patients enrolled. 16 were male. All were blunt trauma. 17 were head injuries.
With BVM 83.6% adequately ventilated. 48.7% maintained a physiologic ETCO2.
Adequate oxygenation occurred the majority of the time, but hypocapnea was
twice as common as adequate ventilation was not maintained. Small sample size.
No penetrating injuries assessed in this study. Individual variance in applying
BVM ventilation? Must consider other causes of ETCO2 change as well.
Conclusion: Manual ventilation does not provide adequate ventilatory support.
NAEMSP18 – Prehospital
Emergency Care Update – Editor’s report. Completed volume 21 in 2017. 465
submissions. 790 pages of content. 28% acceptance rate. Four position papers
published. Free and open access to articles – PLEASE SHARE! Released a 15
article supplement on fatigue in EMS. http://www.tandfonline.com/loi/ipec20
NAEMSP18 – Pediatric
Emergency Care Applied Research Network (PECARN) Update – PECARN has added EMS
affiliates. Engaging field provider advisory groups. Concentrating on
developing relevant pediatric research. Seven node research centers, one is EMS
only and not hospital related. EMS node is Houston Fire EMS, Milwaukee EMS and
Mecklenburg EMS. Data covering about 200,000 pediatric responses geographically
within all nodes. NEMSIS compliant database. http://www.pecarn.org/currentresearch/index.html Anyone can join the EMSA Consortium. Need
to have an interest in EMS study with PECARN. First Project was to create a
response database. But why create a new database with NEMSIS in existence?
PECARN partnered with NEMSIS. This became the NEMSIS/PECARN Project. DUAs are
done with four states to get NEMSIS data. Path to research has been established
within PECARN. Working on pain management, developing triage tools, seizure
management, c-spine, etc…
NAEMSP18 –
Multi-disciplinary Approach to MIH/CP Medical Direction – A framework for
Medical Direction in a Mobile Integrated Health Program. A Medical Director can
be like a coach. There will not be a lot of money in medical direction for
these programs. Traditional model? Online? Offline? Non-Traditional models
where paramedics are joined by RNs, pharmacists who report to a MD. Yet another
model is using paramedics as you would a NP or PA. There is a lot of discussion
around using medics as with the independent nature or the PA/NP. Many are using
traditional medical control. Novel model of the inter-professional team. EMS
has not really be trained to operate with other healthcare providers so the
integration has to be very intentional. Very simple MIH/CP interventions seem
to work to reduce ER
visits and readmissions. Patients are usually VERY
satisfied with MIH/CP interactions especially in the combined personnel model.
Novel model of EMS personnel combined with the primary care practitioner is yet
another model. Case study covered looking at a system that triages assisted
living patients who fall as to whether they should have transport to ER. Three
groups: Obvious need for transport, Patient at risk with fall and patient not
at risk with simple fall. Number of transports were reduced by more than 50%
with no untoward outcomes. Then there is the NP/PA model. This may be a
discussion for another day as it is complex. The most common model is
traditional EMS medical direction. Other models however are emerging.
NAEMSP18 – Financial
Sustainability of MIH/CP – Getting paid for MIH/CP programs with anything other
than grant money is uncommon. EMS 911 calls could even fall under MIH/CP in the
future. Highest number of MIH/CP programs are in the admission/readmission
reduction arena. 40% of MIH/CP programs are generating $0. Grant funding is the
number one source of operational funds. MIH/CP have to demonstrate value. Some
hospitals pay for MIH/CP to work on readmission reduction, super utilizer
reduction and BPCI programs. Home health agencies are using MIH/CP for
afterhours support. Hospice agencies are paying for after-hours support also.
Post-Acute care Agencies are paying MIH to help navigate patients. Third party
payers and Medicaid are looking into funding some programs as they only
financially incentivize transport in most cases. Medicaid is somewhat
innovative as they can make changes at the state level. Managed care can pay
for MIH/CP but they pay it out of their margin. ACOs are also paying for and
partnering with MIH/CP to help meet their goals. Stop thinking about EMS as a
transport entity and start looking at them as the trusted resource that arrives
at your door. Anthem is starting to pay for non-transport. Anthem is willing to
pay $600 for treat and no transport. Capitation is coming as fee for service
dwindles. Shared savings models are also possible. Quality is a key word in
these programs.
NAEMSP18 – MIH
and Palliative Care – 70% of cancer patients wish to die at home, but 70% are
dying in the hospital. It is needed to meet patient wishes which will also
reduce costs. Families call 911 when their home based palliative care is late
or fails. Protocols for palliative care were different. Using controlled
substances and leaving patients at home was unheard of. There are times when
there are escalation of symptom crisis’s occurring and immediate response is
needed. Palliative Clinical practice Guidelines were developed and education
was provided. A database of patient wishes was established (patient specific
protocols). Guideline addresses pain, delirium, pulmonary congestion. Funeral
home directors and death investigators were involved in producing the
guideline. Expanded controlled substance formulary utilized including
hydromorphone. Patients are marked as special patients in all of the electronic
record databases. Goals of care are included in the special patient status.
Paramedic confidence and comfort assessed. Attitude of paramedics showed that
they felt strongly in support of palliative care. Much more confident after
launch or program. Many positive comments from paramedics. Patient and family
satisfaction measured as well. Patient and family satisfaction was very high
with many positive comments. Compassion of paramedics was noted. There was a
public plea to continue the program as it was being funded by grants. Time on
task greatly reduced in those not transported (mainly long transport times if
transported). Treat and release rate of 47.6%. https://novascotia.ca/dhw/ehs/palliative-care.asp Fit of palliative care into paramedic
identity was a perceived challenge. Appropriate training and guidelines are
essential.
NAEMSP18 –
Selective Psychiatric Clearance by Paramedics: The First 1,000 Patients – How
effectively and safely can a paramedic clear a psych patient and transport
directly to a psychiatric facility and bypass the ER. Specifically AMR
paramedics involved in this project in Stanislaus County, California. Very
simple process: sick, not sick? Safe for direct Psych, Psych accept/Reject.
Uses a MIH Paramedic. They are dispatched to where needed and do an assessment.
Well person algorithm. Are vitals normal? No medical or trauma complaints? Not
overtly hypo or hyperglycemic? Safe for Psych disposition – Reconfirm WPA and
assess for safety (alcohol/drugs). If they fall out of algorithm they go to ER.
If not accepted at psych they go to ER. Program is for those who are Medicaid
or non-payer based on what facility accepts. 412 fell out based on sick-not
sick. 336 fell out due to no beds or did not qualify on insurance, consent or
psych facility refusal (biggest number was no beds). 285 cleared and went
directly to psych. Only 12 of those went to ER in the next six hours. Three
were outside of BP parameters that went back. One needed CPAP. None of the 12
were admitted to the hospital and some were discharges home! Data acquisition
is a paramount challenge. Even with direct results, hospital systems still want
to see direct financial income more than they want to see savings. What was
learned? This is a multi-tool MIH medic as they also serve in a rapid response
capacity on 911 calls. Program greatly assists law enforcement. This program is
safe. Publication coming.
NAEMSP18 –
Continuing Education for Community Paramedics: Developing skills, mastery and
methods – Time is valuable. What skills do they need? What level of mastery?
What methods do we need to teach and assess? Speaker sees CP as a sub-specialty
of EMS. Remember Bloom’s Taxonomy. Cognitive, Affective and Psychomotor. What
do they need to know, do and value? Cognitive: They need specialized assessment
and triage. They need to understand systems of care to best help patients.
CPMERIT Assessment: Clinical, Psychological, Meals, Environment, Records, Income,
Transportation and Social Support. Triage needs to take into account if they
need immediate care. Abuse? Shelter? Environment? Ideal, sustainable,
unsustainable or immediate need. System of care: Structure, Culture and Craft.
What is the structure of the system (open times for resources? Access
process?). Culture differences; inside the house of medicine we all talk
differently and hold different definitions. And they need to know the craft; how do we
navigate the system to get the results for the patient they need. Psychomotor: Obtaining lab samples? New
devices? Affective: Rapport, Professional boundaries and compassion fatigue.
Need to establish trust and understand they have to help them within the guidelines
of the program. Compassion fatigue happens and there has to be protective
mechanisms. CP is the special forces of the healthcare system as these patients
are lost, distant from or have been kicked out of mainstream healthcare. http://connectmedics.com/ Methods
of Con Ed? QI Data, Case Reviews,
Observation, Standardized Patients, Role Play, Demonstration and Didactic
components. The standardized patients are the highest rated Con Ed they provide
for their CPs. They also share reviews of problematic patients with the entire
group. Where do you start? If you had to fire half your CPs, who would you
fire? Why them? What is the weakness that made them pop into your head? Educate
on those weaknesses! Is the Con Ed worth your time to do and their time to sit
through?
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| Pick the number on the left closest to your age. The number on the right is the number of Saturdays you have left to live. Put that many marbles in a jar and take one out each Saturday. Makes you take that Saturday seriously for what you accomplish that day. If you make people do Con Ed on a Saturday you had better make it worth it |
Those are the whole of my notes for the 2018 NAEMSP Meeting held in San Diego last week. I hope you find the commentary valuable to your practice whether you are a paramedic or a medical director. Everyone who would identify their career as EMS should consider joining the NAEMSP. The information gleaned at this meeting and the Prehospital Emergency Care publication are worth the price of membership and attendance.
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| Our plane at Chicago O'Hare on the way back home. |
NAEMSP is great for networking, meeting experts and seeing friends in EMS that you do not get to see very often. Beware of medical directors learning your real first name though... Name tag accuracy has become my nemesis. I heard "Gordo!" quite a few times from the most excellent Dr. Stephanie Gardner from Indy.
I will close out this entry with some pictures of the beautiful San Diego area.
Enjoy!
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| The wife and I |
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