Welcome to 2020!
Here are my notes in fairly raw format from a few weeks ago at the 2020 National Association of EMS Physicians Annual Meeting in San Diego. As always, I apologize now for any spelling or grammatical errors or if I heard anything incorrectly as this is always an exercise in speedy note taking which starts with a laptop computer, progresses to a Surface and ends with an Android tablet (with all three dead at the end of each day after multiple social media posts in real time).
This is simply a repeat of all of those posts in one place for a complete compilation.
Enjoy a massive dose of EBM!
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It wouldn't be NAEMSP in San Diego
without a Seagull trying to steal your
breakfast on Day 1. |
NAEMSP - David Tan - President's Address - 2019 Annual
Report is complete and out. Medical
www.naemsppac.com
Director's Courses and Quality Courses are
continuing with good attendance. Board Certification Review course is in high
demand (a third course was held this past year). State chapters of NAEMSP
continue to do work and there is a Federal and Military chapter now as well.
The new website does have a CME learning center up and running now. This is
under the Career Development tab on the NAEMSP website. The Women in EMS
Committee was formalized in 2019. There is a revision to the Clinical Practice
and System Oversight textbook underway. Membership is essential to support work
on availability of essential emergency medications, EMS physician reimbursement
and advancement of the physician sub-specialty. Automatic renewal is now
available for annual membership. The Advocacy and the Political Action
Committee need your voice and your financial backing. There is now a Government
Relations Academy to be held on March 24, 2020. This is the day before EMS on
the Hill Day. Be a member be a driver of progress. The Program Committee has
put together an excellent educational program and App for guiding everyone
through the meeting. Go to committee meetings. That is where the work is done.
NAEMSP - David Williams, Institute for Healthcare
Improvement - The Science of Quality and Driving Change in EMS - Do you
remember the movie "Bringing Out the Dead?" When he saw the movie, many
colleagues thought it was incorrect where he identified with it. One of the
scenes at the start of the movie is a cardiac arrest and there was a wall of
family/lifetime pictures. The main character starts his breakdown while doing
this resuscitation when realizing the importance of the opportunity to this
individual in that moment. How many times do we not appreciate the value of
what is done in those moments? Mentions Gunderson, Taigman, Dean and Stout as
those who showed him how things could be done to improve impact. System design
resonates with him. "Every system is perfectly designed to get the results
is gets." - Deming. Covers the IHI Triple Aim. Improving the health of
populations, improving the patient experience of care, and reducing the per capita
cost of health care. If you look up EMS Triple Aim there is not one. What does
good look like? There are a lot of beautiful trucks out there but not a lot
written on good outcomes. Covers funnel plots on STEMI and Stroke bundles of
care. There is wide variation in performance. Mentions cardiac arrest save
rates across communities from 2008 and the wide variance of results. They all
had ACLS. They all had defibrillators. They all trained, but all were
different. The process was what was different. Potential was not realized. Now
we know the process is important. Looked at patient satisfaction results.
Comment cards sent to patients. Instead of asking what we want to know we need
to find out what matters to them and their outcomes. GAO cost per transports continue
to go up. We need to improve reliability and decrease cost. Hard to find EMS
entities that are actively engaged in decreasing cost. It is easy to do
activity without changing results for patients. Ideas must be tested to see if
there is impact. Many get stuck on the plateau of just doing activity. They
need to move one step up to doing planning and applying small tests of change.
There is the majority and then there are there exemplars. Exemplars have a
non-stop madness for improving outcomes for the patients. We must understand
the science of improvement. This is why the NAEMSP Quality Improvement and
Safety Course is important. Discusses PDSA cycles with the addition of asking
questions. Brought three students of the Quality course to the stage. They
discussed their projects. One was reducing pain in patients. The second was
appropriate 12-lead acquisition and increasing the rate in atypical
presentations. The third was goal directed therapy in sepsis patients. They all
picked projects that were important to their organization and affected
patients. He quoted Covey on "working on the big rocks." Do not find
something abstract and insignificant to work on. EMS tends to work on high
acuity, low frequency patients. We need to work on the common things we see
every day as well. Each student discussed the methodology used to figure out
causes and drivers, and what was done to test improvements and improve
outcomes. Flaws and issues are found in the processes as you go. What are we
trying to accomplish? How do we know a change is an improvement? What change
can we make that will result in improvement? How do you charter a project? Aim:
What, by how much, by when? Measures: Outcome, process and balancing. Changes:
Ideas to test. Team is a loose term. If it is everyone's responsibility it is
really no one's responsibility. When you build an improvement team, select
those who bring something to the process. PDSA is perfect for small scale
testing of changes. Change at fixing things requires a strict application of
testing changes. Some things are simply system design flaws. Education usually
focuses on one correct answer where this is not necessarily true. The true care
that we desire to be performed may not be what a caregiver believes is right or
was trained to do initially. Small tests of change on one thing at a time are
usually low risk. Change is incremental. If you cannot make it work for five
patients, it will never work for four hundred. PDSA cycles allow us to do those
small tests under varying conditions. What happens when this is hard wired and
I am no longer paying attention to this? An easy thing to measure is response
times, but it is hard to prove any impact. Yelling and education make no
difference if the system remains flawed. Student important points - Nikki:
Examine everything you do. Brooke: Don't give up. You may not see giant
changes, but over time improvement accumulates. Ian: Do not focus on
investigation of incidents. That is important but it must lead to improvement.
Effect system change. This gives you the structure to do something with your
data. Closing: There is always a gap between where we are and where we can be
with improvement. Best practice improvers are relentlessly focused on making
things better. Use tools and methods to make an impact. Three things get in the
way are WILL, IDEAS and EXECUTION. Overcome all three and get unstuck. "The
people to do it are here at this conference."
www.dmwaustin.com
NAEMSP - Clemmancy/Gausche-Hill - ABEM Update to NAEMSP
(sub-specialty update) - There will be a new platform to assist with EM
Physicians to educate and renew their ABEM certification. It is called
MyEMCert. It takes a formative approach to the education. Designed in modules.
About 1,200 persons will test the system. Some in 2021 will be able to follow
this path rather than traditional pathway to re-certify. There is now an
Ultrasonography practice focus coming to allow for an additional designation.
Growth of the EMS sub-specialty has been fast and furious. There are now 69 EMS
fellowship programs. A large percentage of the applications for the
sub-specialty are approved. Pass rates on the certification test range from
45.9 to 75.4 depending on background and fellowship. 66.7 first time pass rate.
Fellowship trained are highest rates at 75.4. Covered changes to the ABEM
website. ABEM is very responsive to contact and questions. Pass rates are
holding steady and did not follow the predictive downward trend. Discussed
eligibility requirements and time frames of availability and cycles of testing.
Approximately one third of fellows are female and one third are of a minority.
Two new major review books. 265 candidates took the review course in 2019. Some
changes in content of the exam. New textbook (mentioned in earlier comment) is
expected to be released in 2022. Volume 23 of PEC was primarily clinical and
maybe there should be something to cover operational medicine science. There
may be 400 taking the exam in 2021 between initial and those re-certifying.
NAEMSP - Wang/Sayre/Collela - Supraglottic Airways or
Endotracheal Intubation in Out-of-Hospital Cardiac Arrest (OHCA) - ETI is one
of the most important interventions in EMS. Most common OOH airway intervention
in the United States. 1) Wang speaks first. Unrecognized esophageal intubation
remains an issue. Multiple attempts are sometimes required. SGAs have gained
traction for airway control in OHCA. They are easier. A study showed ETI may
have better outcomes. This caused several trials to be performed. One showed
better SGA survival at 72 hours (not discharge). This study only showed a 51%
success rate with ETI. Another study used SGA (Igel). This found no difference
in outcomes between the SGA and ETI. On further analysis it showed Igel had
better outcome than ETI. The third (CAAM) was BVM only versus ETI. The analysis
is flawed, but shows no difference in outcomes. The study did indicate that BVM
made airway management more difficult and regurgitation was a large problem. 2)
Collela takes the stage. If you want to become an unpopular medical director
support taking away ETI. There really is no consensus on a best adjunct. Maybe
it is not the airway at all. We look at some point on the survival arc to tell
us what works. Survival in OHCA is not great. They use the King SGA. Why SGA?
Number of paramedics doubled (meaning less skill exposure per paramedic). There
were political and labor union push for more paramedics even though science
suggests that less paramedics provide better skill exposure and outcomes. More
paramedics decreases skill performance success. Local OR opportunities for
continuing skill exposure was not available. The success were monitored concerning
ETI. One in five patients did not receive an ET attempt due to concerns of
difficult airway by the paramedic. This was 20%. Protocols used to allow the
paramedic to make the choice in airway control based on the presentation. This
further decreased ETI opportunity. Another issue was that ETI required further
funding of the paramedic training in the fire based paramedic system
(ambulances and engine companies). So the system moved to SGA as the primary
approach. 3) Sayre presents. Cites ED physician success in the emergency
department. Median is they get about 10 opportunities a year. The paramedics in
the system get median of 11 opportunities a year. Sol slightly more in EMS.
91.3% of OHCA events received an ETI attempt. Only 17.% of cases had a pause in
compressions for intubation. 65.7% were first pass success. 93.3% were
successful in getting the patient intubated over all attempts. Better view has
higher rate of success. Measure and improve. Seek factors to improve view.
Would video laryngoscopy improve success? In conclusion is that ETI works with
great training, measurement and feedback.
www.resuscitationacademy.org/blog
NAEMSP - Prehospital Emergency Care Journal Update -
Evidence based Guidelines for Naloxone Administration had over 7,100 downloads.
2019 had 607 submissions for publication which was the highest so far, tripling
in a decade. PECJ ranks 6th of all EM medical Journals. Article downloads have
skyrocketed. Spinal restriction statement was the number one downloaded article
in 2019 from the PECJ. They continue to need peer reviewers. Advertising
revenue tripled this past year. The level of quality of the journal continues
to improve.
https://www.tandfonline.com/loi/ipec20
NAEMSP - RESEARCH ORAL ABSTRACTS SESSION - 1) Wake County
EMS - Smart Phone Based Medication Administration Resource - Utilized the
Handtevy Application. Medication error is an issue in EMS and Medicine and no
one is immune. Tested, trained, implementation period and post-test was
methodology. Used simulation to train on the application. An error was defined
as a deviation of 10% or more for volume or intended dose. No significant
difference in error was noted between pre-testing and post-testing. There was
an upswing in Versed error. With Versed errors removed there was a significant
improvement in the remaining field. Amount of time to give the medication was
improved as well. Single system study and optimization occurred during the
study. Use of an app may improve error rates. Implementation requires time and
support. What caused the Versed upswing in errors? It was found that there was
an error in calculation in the App. 2) University of Arizona - Telemedicine
on-site EMT to reduce transports, hospitalizations and patient costs - SNF
residents tend to be older and more medically complex. After hours episodic
illness usually results in transports to an ED for care as the only option.
This utilizes an ET3 model. Used telemedicine contact between an EMT and an EM
physician. Evaluated and treated at bedside via telemedicine. This was a single
202 bed SNF in New York. Retrospective study. All residents were included in
the study. 11.7% reductions in transports to the ED. 15.4% reduction in
hospital admissions. 4.42% reduction in patient costs. Extensive quality review
was used on each case. The model was successful. Data only analyzed for
patients covered by Medicare. No emotional impact on residents and families was
measured. Future study needed. Noted to be an important abstract by the
moderator. There was some initial push-back on the change, but it went away
fairly early within the facility. The on-site Clinical specialist was either an
EMT or a paramedic. 3) ESO - Use of Shock Index in pre-hospital environment in
Sepsis - Early detection of sepsis is better for outcomes and EMS can be a part
of that. Shock index has not been studied well in this context in the EMS
realm. The hope was the shock index and the modified shock index would help in
early diagnosis in the EMS phase of contact. ICD codes used for ending
diagnosis. Modified shock index believed to give earlier indication of sepsis.
Median age: 60. 53% were female. Over 35,000 patients in the study. Both
indexes had better recognition with SBP alone being a lower indicator than both
shock indexes. Indexes were more of an indicator than SBP alone. Use indicated
strong association with Sepsis in medical patients. 4) University of Arizona -
EPIC Pediatric Traumatic Brain Injury Study - 133 EMS agencies involved.
Covered 93% of all TBI cases statewide in Arizona. Goal to aggressively treat
Hypoxia, Hypotension and Hyperventilation. 36,000 initial PCR field. 98.7% of
TBI cases linked to the PCR (astounding correlation). 4,000 cases. Median age
was 15. Severe TBI had improvement where moderate and critical showed no
difference. EPIC was not randomized. Cannot account for potential impact on
in-hospital patient care. More funding needed to see long term impact of care.
Was not designed to compare impact between children and adults. Findings appear
to be just as strong between children and adults. Conclusion: Severe TBI was
improved with aggressive treatment. Critical TBI is highly likely to die
regardless of treatment. Widespread implementation of pediatric TBI guidelines
is warranted and indicated. Findings may be understated if anything. 5)
University of Florida - Pediatric Analgesia - Peds injuries are frequently
managed first by EMS. Pain relief in peds is sub-optimal. 18 years of age or
younger. Long bone fracture or burns. Excluded if allergy to analgesia. Median
age of 14 and more males in data field. Only 17 patients received analgesia by
EMS.(20%). Why? It was not IV access as more than 60% received an IV. Length of
transport was an indicator in frequency of administration. Peds received
analgesia faster in the ED than adults. No relations exist to outcomes or
length of stay in this study or previous studies. Needs to remain a high
priority for research. This study did not include cold application or
non-opioid pain medications. 6) University of Toronto - FIRST Study (STEMI) -
Reperfusion injury occurs in STEMI in some cases. Remote ischemic conditioning
may reduce reperfusion injury in some studies but has not been measured for
outcomes. RIC by EMS. Four cycles. Stable straight to cath lab in study. Unstable
to ED first. Inclusion was STEMI by EMS and ED diagnosis and over 18 years old.
This study included post-cardiac arrest and cardiogenic shock which have been
excluded before. 99% patient study records were linked. Most were LAD and RCA
lesions. Less reperfusion injury in those receiving RIC therapy be EMS but only
in cardiac arrest and cardiogenic shock, not in other groups. Results similar
to other studies on RIC. Small STEMIs may not benefit, but large ones do.
NAEMSP - Smith - Jackson Hole, Wyoming - EMS Medical Errors:
Recognizing Bias and Improving Decision Making Strategies - Heuristics. Buzz
words: CRM, Resilience. Lots of things out there to think about. Metacognition,
thinking in an organized way. Errors can be... procedural: technical, skills. Affective:
Emotions, positive or negative. Cognitive: Process of thought. 30+ Cognitive
errors that every EMS provider makes. Will focus on five for this session. 1)
Anchoring: You can be anchored in thinking by frequent patients, addresses and
patient types. 2) Availability: Things you do not think about because they are
not common or too common. 3) Commission bias: Over eager caregiver, looks for
reasons to do things. 4) Omission bias: Apathy, not wanting to do what needs to
be done. 5) Search satisfying: As soon as you see/find one thing, you stop
looking, not completing assessments or not reassessing. Five simple strategies
to prevent error: 1) Incorporate simulation into training. 2) Force
consideration of alternative diagnosis. 3) Be wary of diagnostic labels,
especially when assuming patient care (transfer of care). 4) Ask for feedback
and modify care. 5) Use checklists and reference materials. Summary: To prevent
errors; Think. Be competent. Be caring.
NAEMSP - Hoyle - Western Michigan University - Pediatric
Prehospital Drug Dosing Errors: What We Need To Know and Where We Need To Go -
In one review they found that 66% of Epinephrine doses were incorrect.
Encouraged tape measurement and reference materials and it went down to 35%.
Still room for improvement. Another study found Epinephrine was incorrect 69%
to 75% of the time and tape was used incorrectly. Midazolam dosing was even
worse. One study showed that 43% of pediatric dosing was incorrect across all
drugs and tape use was at only 12%. Focus group showed calculations were error
prone and difficult, Broselow tape was helpful but confusing, and that new
tools were needed. Only 51% of paramedics thought they could report an error
without disciplinary action. 27% had not given a pediatric a medication in the
last 12 months. Three year study now in progress with a safety bundle. Bundle:
1) Dispatch obtains patient weight from family and relays to crew (tape is back
up then age). 2) Checklists. 3) Twice monthly online pediatric training. 4) Enforced
use of references (tools). 5) Every pediatric case gets QI review. Collecting
anonymous reporting of errors. Four scenarios are used for drug dosing training
in pediatrics. Compliance was 68.8% correct in simulation with scenarios. With
introduction of reference and process there was a significant improvement in
correct doses but not elimination. There were still cases of omission and
commission as well in the simulations. Air bubbles can cause under-dosing in
the syringe. Simulation has been helpful. PALS and PEPP needs to include
drawing up the dose and confirming it. Just now analyzing results of the
simulations. Dangers of D10 in pediatrics (hypotonic) discussed. The answer
would be D10/NS or D10/LR but neither is commercially available. Eliminate diluting
drugs in pediatrics to reduce errors.
NAEMSP - Redlener (Panel Discussion) - Innovations in
Quality Improvement - 1) Williams - Quality improvement assures that actions
are taken on all occurrences. Quality improvement measures the effects of
change on the actions taken. "Given two numbers one will be bigger or
smaller than the other." We cannot look at individual numbers and react. We
must look for special causes and not react to common cause variation (my note:
this is what we have been preaching for over a decade... look for LCL and UCL
data limit breaches and astronomical points of variance!). Control charts must
be utilized to determine Common Cause from Special Cause. It is the difference
between looking at a rhythm strip and looking at a 12-lead. We must look at
system stability to build stable processes and improve them as time goes on.
Mistake 1: React to an outcome as if it came from a special cause, when
actually it came from a common cause variation. Mistake 2: Treat an outcome as
if it came from a common cause, when it actually came from a special cause. 2)
Vithalani - Use monitor files for review. Case study given. Monitor files
actually give you the data to support or refute documentation. No ETCO2 = no
ventilation (this is NOT usually a detector fault or occlusion of the probe).
Use Just Culture to change system or correct human error. If it is the monitor
file it really happened (or really did not happen if absent). You can lose an
entirely different perspective if you cannot look at it. Some of the software
packages create a Cardiac arrest report card. 3) Counts - Change ideas in
action. Mantra for the Resuscitation Academy is "everyone in VF
survives" as the goal. Not attainable in the near future. VF without any
intervention over 10 minutes, dies. The slope of survival changes with each EBM
intervention. This changes potential for survival. It starts with the
dispatcher as the curve cannot happen without dispatcher recognition of arrest.
Seattle preparing to use an AI to recognize arrest through voice recognition of
key words during the call. Once implemented it will provide a time where
recognition of cardiac arrest occurred. Can the AI coexist with the dispatcher?
It has to be operationalized. A controlled trial is in use in Copenhagen. It is
a work in progress. 4) Stemerman - Data visualization - Data visualization is a
tool to make it easier to understand data. DV solves real data problems by
allowing you to digest data. Humans can only process so much data at a time.
You have to have quality data to analyze data. DV accelerates data utilization.
DV is a perfect quality improvement partner tool. Dashboards are an example of
DV. We need to use DV to support clinical decisions. DV can be used to produce
individual clinician score cards on performance so learning about strengths and
weakness can occur. No one thinks of themselves as being a low performer until
shown the data. Quality is kind of a big deal! Speaker is going to try and do
some data analysis around the Copenhagen Burnout Index and do it by shift to
see if there are differences between shifts. How do you evaluate yourself as a
clinician?
NAEMSP - University of Arizona - The EPIC TBI Study: Results
and Implications - The three H Bombs of TBI: Hypoxemia, Hypotension and
Hyperventilation. 22,000 TBI cases in the study with 4,000 intubated. 11,000
EMS providers involved. We need to wipe out the three H Bombs. Threshold 90%
oxygen saturation. All potential TBI immediately get continuous high flow
oxygen via NRB on everyone. No such thing as hyper-oxygenation in TBI. These
patients crash unexpectedly so pre-oxygenate for their next unexpected crash.
If you have a single reading less than 90% SPO2 in prehospital care, you triple
the chance of dying. Intubate only if you cannot oxygenate with a BVM. If there
is ANY sign of hypoxia, go straight to BVM. IV crystalloids if systolic BP
approaching 90 or dropping rapidly. If you get lower than 90 SBP, mortality
increases by 50%. Initial 1000ml bolus, repeat 500ml bolus and repeat to keep
SBP above 90. For peds 10 years and younger use 70 SBP as the limit.
Ventilation rates to be used: Adults, 10. Demonstrates two finger technique of
minimal ventilation volume. One finger technique in pediatrics. ETCO2 target is
40. Range of ETCO2 is to be 35-45. Need a designated watcher on the ETCO2. No
one can properly ventilate in the emergency setting without ventilation
adjuncts. IVI: Inadvertent Ventilation Inattentiveness. Distraction is
inevitable (Our Epi level is higher than the patient's). Training in this
methodology is only two hours. Implementation benefits: Higher SPO2 approaching
100%, lower rate of intubation, more BVM use, greater reversal of hypoxia by
trauma center arrival, a greater volume of fluid boluses, and lower rate of
hypocapnia. This resulted in a 70% increase of surviving to admission. EPIC did
in fact change the practice. The severe TBI group was 70% of the patients.
Survival tripled on intubated patients in the severe group, and doubled in the
non-intubated in the severe group. TBI has a therapeutic sweet spot. Dramatic
survival improvement in a major public health problem is rare in medicine. TBI
is managed by simple interventions. Do the three simple interventions and do
them right. Oxygen, fluid and ventilate (intubating when needed). This
management does not require expensive equipment or long training programs. Lack
of attentiveness to the guidelines is not just an EMS issue (the Ed or trauma
center can start mismanaging the minute the patient arrives if they do not
follow through on the care). Do not hand off the patient until they are ready
to adequately ventilate. Ventilation matters a lot. We still have no idea
whether basic or advanced airway matters. No study available today looks at
that part of the picture. If you ignore breathing, the airway measurement does
not matter. Distraction is an ever present risk. This treatment requires
refresher training and a continued focus during treatment. Do not just use
ETCO2 for airway patency confirmation. WATCH THE NUMBER and react to it. It
only takes 30 seconds of distraction to change the ventilatory rate and have a
negative impact on ETCO2. There is a high statistical impact of this training.
Must have intermittent organizational re-emphasis on the guidelines.
NAEMSP - Donofrio-Odmann - University of California -
Pediatric Intubation: 30 Years of Literature - This lecture focuses on ground
paramedic care. This will be a walk through three decades. 1) First paper was
in 1989. Success on pediatric intubation was low. 2) 1989 again. 64% successful.
Large number of complications. Dismal survival. 3) 1989. Trauma study. Less
than 20 year olds. Over 90% intubated for trauma had closed head injuries.
First pass success was low. Complications and mortality was high. A lot of
unneeded intubations were noted. 16 out of 63 had complications. 4) 1995. Seven
year retrospective review. 355 successfully intubated. 57.5% survival. 11.5%
were cardiac arrest. 40% had wrong tube size. Incorrect placement 11%. 5) 1999.
300 patients. 15% had rigor. 90% of non-rigor were successfully intubated.
Positive association between intubation and ROSC. 6) 2000. Three year study
under age 13. 830 patients. This is the LA study. 57.7% rate and matched the
complication rate. Unique in the fact it measured a lot of different complications.
8% had tube dislodgement. Wrong size 24%. Study favors BVM over intubation. 7)
2001. 31,464 patients, 578 with severe head injury. 83% ETI, 17% BVM only. ETI
offered no survival advantage. 8) 2002. 1158 patients with 324 intubation
attempts. Three misplaced tubes. 9) 2004. 10 year study with 109 rural peds
patients. Less than age 19. Higher rate of failed intubation and complications.
BVM would have been applicable. 10) 2005. 50,199 patients with over 5,400
intubated. Field intubation associated with higher mortality. Lower acuity that
is intubated has higher mortality than more severe injury. 11) 2008. Five month
study on all intubated patients. 23 pediatric intubations. 48% correct
placement in pediatrics. Failure was 39%. 12) 2008. 5.5 years. 300 patients all
peds. 155 receiving ETI. Netherlands study. BVM survival 63%. ETI survival
4.9%. 37% rate of airway correction at the scene. 13) 2015. ROC data. 2,244
OHCA 3 days to 19 year olds. Seven years. The younger you are the lower your
survival rate. Advanced airways not associated with improved survival. 14)
2016. Six year review under age 13. 299 ETI. 97% overall success in intubation.
66% first pass success (53% under 12 months). 25% complications. 15) 2017 CARES
database. 1724 under 18 age. BVM provided better survival than both SGA and
ETI. 16) 2016. 2,294 patients. 1,550 intubated. Survival lower in ETI group.
17) 2017. Japanese registry. Over 2000 patients. 17% advanced airway received.
Advanced airway was not associated with improved survival and favored BVM. 18)
2018. Japan and Korea. 974 children with OHCA. This study shows improved neuro
survival with an advanced airway. 19) 2019. First pass study. First pass
success is much lower in kids. SGA success same in adults as kids. 20) 2019 14 study
review by ILCOR. Sates "low to very low certainty of evidence" but
supports BVM over both ETI and SGA for peds OHAC. NOW LETS TAKE A SECOND LOOK:
It sounds like BVM is always preferable given this data. Trauma had the lowest
first pass success. Higher complication rate. Higher failure rates. Lower first
pass success. Peds ETI dislodges very easily. Interesting piece of information:
There seems to be a lot of intubations are for seizures. Extubations in the ER
were primarily seizures. Just use BVM until medications take effect. What
happens if we take out OHCA, trauma and seizures? This goes down to about 10
ETI in a year in a large urban system. LOW FREQUENCY. BVM has better outcomes.
Questionable need for ETI in pediatrics. How many tubes do you need to be
competent at pediatric airways? Ventilation is tough. Should we just focus on
ventilating properly?
NAEMSP - Shah - Baylor University - Pediatric Seizure
Management - What do you do to actually stop their seizure? Where can EMS
improve in pediatric seizures? What are the challenges? How do you update your
pediatric seizure protocols to current EBM? 12% of pediatric responses in EMS
are seizures. Case study presented of a febrile toddler. There is a lot of
variation in protocols across the country. In 2009, NHTSA and EMSC created a
pediatric seizure recommended process. It was published in 2014. Check glucose.
Correct glucose. Give IM/IN Benzos. IV/IO benzos if needed. Do not use rectal.
Do not place an IV/IO initially. Do not require Med Control for second doses of
Benzos. There have been several studies since. It is rare to see hypoglycemia
in pediatric seizures (less than 2%). In 2017, an alternate was proposed. Go to
Midazolam first then check glucose if actively seizing. Check glucose first if
not seizing currently. It just flips the order. Multiple studies show rectal
administration is inferior. RAMPART trial referenced. Referenced PEGASUS. Upon
measurement, many paramedics still gave meds via IV even after training. IM/IN
should be route used. Tend toward under dosing pediatric seizures. Used
reference cards. Figure out the proper dose and route. Dose and maximum varies
by route and age. Can create a lot of confusion. A point of care reference tool
is an enabler. Having a choice of routes was also identified as an enabler.
Lack of equipment noted (not having atomizer or smaller needles). Take out the
math. Simplify the approach and remove barriers to activating the protocol. Use
0.2mg/kg for pediatric dosing IM or IN. Use the 5mg/ml concentration. If the
seizure continues look at and correct blood glucose. Midazolam should be first
line therapy. Hypoglycemia is rare in this patient group. Treat seizures and
febrile seizures the same. Avoid calculations and use tools.
NAEMSP - Panchal - Ohio State University - 2019 Practice
Analysis: A Description of Current Practice to Shape the Future - Care is very
different between two different places due to geography and local healthcare
needs. Scope of Practice model defines a basis of what we do and how we can
credential caregivers. Are medical directors preparing these prehospital
caregivers for what is needed? A practice analysis can define clinical events to
allow for educators, regulators and medical directors to prepare the education.
When a change of information occurs, how is it spread through the system? How
fast does practice change? Fairly quickly. Change in practice can come through
position papers or other methods of EBM information distribution. Measure how
often skills and procedures are being done. We must assess the dissemination
and implementation of EBM frequently. The analysis of this data provides
required content validity for all levels of certification. It defines the work
performed in EMS. The 2019 Practice Analysis: Define frequency of
presentations. Define criticality of clinical presentations. Identify the tasks
and KSA associated with EMS care. Frequency: Used NEMSIS, 30 million records
from 10,000 EMS agencies. Psych is 11% of all calls. Trauma is 19%. Respiratory
is almost 11%. Cardiac arrest is only 1.46%. Criticality: What is the harm?
Weighted score. Identify tasks: What is the knowledge and abilities to perform
a 12-lead? Must identify specific knowledge, skills and abilities. Cognitive
assessment? Psycho-motor assessment? Used clinical impressions and derived the
tasks and skills for each from the data. Focus on KSAs. Many areas where tasks
are performed from pre-scene to special circumstances. 532 tasks identified.
This will help define quality care.
NAEMSP - Online Medical Control, Who Needs It? -
Gallagher/Lyng - EM physicians dislike giving
online medical control. It
violates normal practice behavior. Many EM docs do not know EMS protocols or
order meds that EMS does not have. Medics do not like OLMC either. It may be
needed when there is no protocol for the situation or a specific difficulty
needing consultation. There is a way to do it better... find it. Who picks up
on the other end? Some have a direct line to the actual medical director. Some
go through a senior medic or a supervisor. Others have an RN or NP picking up
and relaying information to an MD/DO. Others have the on-duty EM physician.
Sometimes medics are called into rural emergency departments to provide care
for some NPs, but then call NPs for orders in other cases. Creates a disparity.
Critical cognitive domains for OLMS: Care Environment, Operations and Clinical
Care. What are the local protocols? Meds? Scope of practice? Who do we want
them to call? It depends. OLMC goes wrong by washing hands by saying do
everything or do nothing. Collaborative consultation is the answer. Where the
answer is consistent to the condition/question, make it a standing order
protocol. EMS providers leave out critical elements 68% of the time for
Refusal
of Medical Aid (RMA). OLMC actually increased transport rate when there was
engagement of the EM Physician. EMS should give a succinct SITREP. Clear
description of what EMS needs from the OLMC contact. Read back all orders for
confirmation. Sometimes there are communication failures. There must be
redundancies for contingency plans. Is there a secondary medical control? What
do you do when there is total loss of communication? We need to move beyond the
radio? Cell phone allows for better communication in voice communications.
Internet based telephones are becoming common in OLMC applications. There is
generally liability even when there is not a direct physician-patient
relationship in some states. Other states have protections in this area. Job
just needs to be done well to protect from liability. "Liability reminds
caregivers that they have skin in the game." If OLMC can be classified as
telemedicine it may be reimbursable. CMS may require actual interaction with
the patient to be billable. We have audio down but video may need a change in
how it applied. Platform must be HIPAA compliant. If the platform does not
store the video file it is most likely HIPAA compliant. Limit use of restrictive
protocols. Make sure the SITREP is succinct and complete. Build in redundancy
pathways. Ideally it should be recorded.
NAEMSP - Oral Abstract Presentations - 1) An Analysis of
Walkability Among Pulsepoint CPR Alert Dispatches - Pulsepoint recruits bystanders
to provide CPR in emergency dispatches. Only 2% of the US population are
trained in CPR each year. Pulsepoint works with member 911 systems. Alerts
bystanders within 1/4 mile of the arrest event. Study identifies obstacles to
getting to the event. Used 1,100 alerts and overlaid the alert radii. Barriers
are terrain, water, railroads, etc. 743 events out of 1,100 had an obstruction.
22.5% of the alert area was obstructed. Routes can be excluded due to time and
distances. Geographical features inhibit bystander response to OHCA patients.
Expansion of alert radius did not not mitigate obstruction in this data set.
Used Alameda County 911 data. 2) Red Lights and Siren: How Often are
Life-Saving Interventions Performed? - Lights and siren is asociated with increased
collisions, injuries and only marginal time savings. What is the proportion of
RLS responses with potentially lifesaving Interventions (pLSI). Used 2018
annual data. pLSI is defined as an intervention to reverse a critical condition
or rapidly improve stability. 7.5 million calls. The majority had a paramedic
on the call. 86% responded to scene with RLS (considered high). The good news
is that only 10% went to the hospital with RLS. The two largest causes of RLS
in skills were Epi (21%) administration and airway control (20%). Glucose was
next at (12%). Of conditions, cardiac arrest was responded RLS 97% of the time.
RLS response is common, but pLSI is rare (5%). Assuring EMD is used accurately
is key to reduction. This must be individualized by system. 3) Head Up CPR in a
Swine Model - Chance of survival neuro intact is still dismal in the US.
Improved outcomes are needed. Head Up CPR is a promising concept. Head up with
ITD and ACD devices. VF induced in swine with pressure and perfusion monitoring.
Pigs randomized to flat with ITC and ACD and another group with sequential
elevation plus ITD and ACD. Slow elevation key to priming cerebral perfusion.
Elevation over two minutes to 9cm and then 22cm. A vet assessed CPC at 24 hours
post resuscitation. 16 pigs randomized to two groups of 8. Physiologic data
covered. Conclusion: Demonstrated neurological survival benefit associated with
ACD, ITD and controlled sequential elevation of the head in prolonged arrest in
a porcine model.4) Does Routine use of Bougie Improves First Pass Success in
ETI? - 39 month study in three phases with planned interruption as a phase.
Seattle Medic One. 7% improvement in first pass success with Bougie. Attempt
defined as any insertion of the laryngoscope into the mouth. Bougie associated
with higher first pass success and overall less attempts at ETI per patient. 5)
No increase in debilitating injuries between switch from Spinal Immobilization
to Spinal Motion Restriction. Statistically insignificant. 6) Implementation of
a Standardized Worksheet Tool for the Evaluation of Patients Calling 911 for
Lift Assist - Low priority calls where first respondents do the assist and no
EMS transport is dispatched. Call defined as having no medical treatment and
patient moved to a more mobile position. Implemented a red flag checklist for
assists. If red flag met, patient was recommended to be transported by EMS.
Using the worksheet increased those marked as medical significantly. Transports
increased with the use of the tool to identify appropriate transport. 51%
transported with worksheet versus 12% without the tool. Discharge diagnosis of
those transported contained significant medical conditions. Conclusion:
Detailed assessment should always be used on calls considered lift assists as a
high number have significant medical issues.
NAEMSP - Oral Abstract Presentations - 1) Prehospital and ED
Use of Chemical and Physical Restraint on Disposition - Physical and chemical
restraints are used for protection of patients and EMS personnel. Psych and Tox
are the two biggest indicators for restraint in EMS. No difference in length of
stay between chemical and physical restraint or where the sedation was
administered (EMS or ED). Ketamine was NOT associated with a higher risk of
respiratory failure. EMS or ED medication use does not significantly alter ED
disposition or length of stay. 2) Reasons for pediatric dosing errors - Which
medicine? Which dose? What weight? What volume? There are several variables in
each step in what can be a high stress, time compressed situation. What is
dosing accuracy? What are paramedic’s thoughts and preferences? Broselow vs.
Handtevy for dosing. Handtevy had training program associated where Broselow
did not. Dosing accuracy was around 70% with Handtevy being only slightly
higher. Interviews of paramedics on their perceptions showed that they
preferred the calculation free tool (Handtevy). Accuracy is not the only
factor. User perception of ease is important to foster use of the tool. 3) CAT
vs. SAM-XT Tourniquets - CAT was already in place in the system (Greenville,
NC). One handed application was used for the study. Blood flow cessation was
observed by no wave form on SPO2. Measured windlass turns to achieve no blood
flow. 63 responders in study. CAT out performed SAM-XT on cessation of blood
flow and the least number of windlass turns to cessation. As far as ease of
application goes, 83% preferred the CAT.
NAEMSP - Ehrenfeld/Counts - Creating an EMS Data Warehouse:
From Acquisition to Visualization - Key performance indicators are typically
expressed as just numbers in a report on a page. The users of reports want them
to be easy to produce and take less time to analyze so visualization is
important. Two buckets in a data warehouse, these are culture change and IT
expertise. Know the stakeholders. Do not reinvent the wheel. Find sources for
those who have done what you need. Dashboards are great examples of
visualization of data. Change management is like rolling a boulder uphill and
every three days it rolls backwards. Data visualization must be understandable,
interactive, validated and up to date. You have to have a conceptual model of
what you want. Most agencies have data coming from multiple platforms. What
permissions do you need to combine data and who is going to pay for it? Data
security and HIPAA compliance are very important. ETL (Extract, Transform and
Load) to the export server. This takes a lot of IT support. The payback is the
elimination of ongoing workload to get quality, validated data. Time spent in
automation dramatically decreases time getting information later. Identify
subject matter experts (SME) early. SME: Medical, operations, HR, dispatch,
legal, IT, database managers. Data is inherently data. Do not mistake data for
knowledge. You have to analyze it to turn it into knowledge. Follow rules of
data visualization. Set it up for long term management, without this it will
fall apart over time. www.data.gov contains a lot of community data for
baselines on population and demographics.
NAEMSP - Panel Presentation -
(Carhart/Brown/Redliner/Crow/Taigman ) - Blurred Lines Between Research and
Improvement Science - Consider bias and question how we know things. First
appearances can be deceiving. Distinctions between methods of inquiry. There
are key distinctions between research and quality improvement. One finds out
data while the other seeks to make a change. Research and quality improvement
can overlap. Research creates the knowledge while improvement science makes
sure patients get the benefit of the knowledge. Ethical implications: IRBs are
required in many cases for research. Improvement projects usually do not
require an IRB. Some organizations use IRB review for QI projects. Safest to
use an IRB for large improvement projects if hoping to publish findings (some
organizations require this). See "Squire Promoting Excellence in Health
Care Reporting" for guidelines. There are Squire friendly journals.
Projects overlap meaning IRB approval may be desirable. IRBs need to be made
more available and affordable to organizations who do not have an academic
affiliation.
NAEMSP - Redlener - The National EMS Quality Alliance Update
- Talked about the standard in some services where quality is measured around
incidents. What needed to be measured? What tools were needed? Speaker joined
the NAEMSP Quality Committee. Even in 2011 he did not feel there were good
answers. He cited the Meyers NAEMSP paper on evidence-based quality measures.
He wanted to find a guide as a newer medical director. NHTSA funded EMS Compass
to make meaningful measures. 2016, 14 measures released. It was produced by an
excellent team. There were challenges as to whether this was for improvement or
compliance. Intention was incredible, usage needed improvement. In 2017, ACEP
helped form the NEMSQA (National EMS Quality Alliance). Vision and mission
developed. Steering committee has many organizations including NAEMSP, AAA,
NREMT and many others. There is a measure development committee. Some EMS
Compass measures retired due to data feasibility and changes in EBM. There are
now 11 measures. Other measures have been updated to drive improvement with
current EBM. We need to be flexible on how this adapted but focused on the
goals. Need to be laser focused on assuring that measures are based on
evidence. Need to pay close attention to published guidelines rooted in
evidence. Measures cannot remain static. The measures need to be approached
with an improvement mindset. We need to look at the drivers and the ways that
we improve. NAEMSQA intends to continue measure development and expand
partnerships and work on improvement. They desire to make recommendations to
NEMSIS as well. Future benchmarking may be possible. Entities may join for
$2,500.
www.nemsqa.org
NAEMSP - Braude - University of New Mexico - PECMO in ABQ -
Lecture assumes a knowledge
of ECMO and eCPR, and that eCPR is good and
beneficial, and that earlier is better. Speaker does not consider this as
experimental but just moving a hospital therapy to the field. Things must be in
place to do prehospital ECMO. Inspired leadership helps. This is occurring in
the poorest of the 50 states. They came up with a streamlined method of doing
the skill. Started with a conventional ambulance with minimal modifications,
stationed near the hospital to pick up the cannulator (physicians are already
in the field). Patient loaded feet first. Cannulation is in the ambulance while
parked. The paramedics serve as surgical first assist. Unit is ECMO-1. Built on
a existing reserve unit. Training was done in the stations on duty. Ultrasound
is needed to do this. Dispatch trained to identify potential ECMO candidate
patients. Normal cardiac response and the ECMO team responds separately after
picking up cannulator. First unit can cancel ECMO team. Next step the
prehospital physician verifies or cancels need for ECMO. If ECMO is to proceed,
patient moved to curbside with good ACLS measures during movement. Cannulator
only focuses on the cannulation tasks and all other cognitive functions have
been offloaded to other crew members. ECMO efforts block the street. The crank
alone is $5,000. No pump is used in emergent ECMO but a pump is used for IFT.
Retrofit was $7,500. Circuits are $1,200. Uses on-duty personnel. ECMO can be
unavailable if personnel are on another call. All training was on-duty (no
additional cost). Circuits come with the cannulator. Currently no additional
compensation for anyone involved, but this is for proof of concept. So far
there have been two cases without good neuro outcome. Generally good outcomes for
regular ECMO is only 35% normally, so this is not yet outside of the norm. Low
volume is a mixed blessing. Oxygen utilization is high. PECMO is possible.
NAEMSP - Our EMS Workforce, Where is it Going? - Wages by
region covered from the JEMS survey. Statement made that EMS must change from a
vocation to a profession AND that reimbursement must be corrected to allow for
better EMS and better wages (my note: this is the first lecture I have heard on
the issue that recognizes reimbursement is a huge part of the issue. Willing
the change from vocation to profession alone will not fix the issue). Reasons
people stay and leave from a Michigan survey were covered. One study showed
over 26% intended to leave EMS within five years. Multiple jobs = job
dissatisfaction. Burnout caused by exposure to trauma, strains of shift work,
organizational culture and hazardous environments. Copenhagen Burnout scale can
be used to assess. Ten days of illness absence per year highly associated with
burnout. Decreased enrollment in EMT and paramedic programs is problematic.
Explorer Posts can help recruit for the future. Degree programs are desired but
can also add time-frames to the process and lend toward the shortage issues (my
note: can this be accelerated with any level of quality?). The agencies
retaining employees are ones where the employees feel taken care of and are
family. One comment maker stated that they are already seeing much
dissatisfaction in a post-degree situation because it has not increased the
wages. Actions and solutions are needed.
NAEMSP – EMS Medical Directors Liability Insurance – It is
very typical for medical directors to not be insured properly. Being a
volunteer medical director is no protection. Medical directors are almost
always liable for their actions as a medical director. If direct care is
provided on scene by a medical director it is most likely not covered by
standard malpractice insurance or your hospital coverage unless specifically
written into the policy. Even indirect care may perceived as direct care by
courts. Most common claims are EPLI, Discrimination, wrongful termination and
harassment. Buy an insurance policy or require the service to buy a policy for
you. Be sure it includes professional liability coverage. Questions can be
directed to
Tjames@NFP.com
NAEMSP 2020 Award Winners:
President’s Award – Alex Isakov
Ron D. Stewart Award (lasting, major contribution to the national
EMS community) – Lynn White
Keith Neely Outstanding Contribution to EMS Award – Sandy
Bogucki
Friends of EMS Award – Rick Murray
All in all the NAEMSP Annual Meeting did not disappoint. I usually come away each year learning quite a bit. Some years I would classify the science and data as "groundbreaking" while other years it would be more "confirming." This was a confirming year. A lot of things I had heard or read before were presented with even better confirming science.
These are just the notes from what I attended as some of the time spent at NAEMSP is utilized for much needed networking and learning from this great gathering of prehospital peers and experts. So until Eagle's in June (in it's new home at Hollywood, Florida), I will leave you with a picture of me trying to reach Dr. Ben Abo on his personal banana phone network...
