WHAT, HOW AND WHY

EMS Base Station MeetingsFall 2013

Objectives – What, How and Why

State EMS Authority Quality Core Measures Project Review – where do you fit in…

Review 2012-2013 STEMI Benchmarks

Review six months data from 2013 cardiac arrest study

Objectives – continued

Trauma system- the first 12 monthsDiscuss opportunities of improvement through case studies

Communication M- mechanism I - injuries V - vital signs T – treatment Documentation Destination

State Core Measures

State Quality Core Measures

Why…California first to establish statewide standard set of core measures

Purpose: increase accessibility and accuracy of prehospital data

Measures process data vs. outcome data

System Core Quality Measures include: Trauma Acute coronary syndrome Cardiac Arrest Stroke Respiratory Pediatric EMS Provider skill performance EMS response and transport Public education/by-stander CPR

State Quality Core Measures

STATE CORE MEASURES

ACS-1 “ASA Administration for Chest Pain” Year Percent

2010 72.2%

2011 70.9%

2012 71.9%

STATE 2010 66%

STATE 2011 43%

Core Measures

How can you help?Challenges

Consistent data reporting – check your charts Acquiring data from non-transporting agencies

including: First responders Dispatch agencies Hospitals

Understand we only ask for information that we need

STEMI

STEMI Benchmarks

(Time in Minutes by Quarter) Q1 Q2Number of STEMI Activations 13 12

Average time on scene (15 min)14 min 9 min

Time from 911 to Pt. Contact (10 Min) 8 min 8 minTime from Pt Contact to ECG (5min) 4 min 2 minTime from ECG to SRC Contact (10 min)

12 min 8 min

Time from Pt Contact to Arrival at SRC

27 min

25 min

False Positive % (<30%) 30% 50%Time EMS to Intervention (E2B) (90-120min)

78 min

77 min

Time from Door to Intervention (D2B) (<90 min)

56 min

41 min

(Time in Minutes by Quarter 2013) Q1 Q2

Number of STEMI Activations 13 12

Average time on scene (15 min) 14 min 9 min

Time from 911 to Pt. Contact (10 Min) 8 min 8 min

Time from Pt. Contact to ECG (5min) 4 min 2 min

Time from ECG to SRC Contact (10 min) 12 min 8 min

Time from Pt. Contact to Arrival at SRC 27 min 25 min

False Positive % (<30%) 30% 50%

Time EMS to Intervention (E2B) (90-120min) 78 min 77 minTime from Door to Intervention (D2B) (<90 min) 56 min 41 min

STEMI Feedback

Cardiac Arrest 6 Month Review

Cardiac Arrest Study

Four time sensitive links to survival:Early recognition of the emergency and activation of the local emergency response system

Early bystander CPR

Early delivery of a shock with a defibrillatorEarly, advanced life support followed by post resuscitation care

Data Overview

Arrests and Outcomes    

Total number of cardiac arrest transported to a hospital

52  

Number survived to hospital admission 21 40%

Number survived to discharge 8 15%

Number discharged with normal/functional neurologic status

7 13.5%

Number of organ donors 4 8%

CPR/AED

CPR/AED Summary

Number of witnessed arrests 37 71%

Number receiving CPR prior to EMS arrival 23 44%

Number of times AED was applied 16 31%

Number of patients where AED shocked was indicated

11 21%

Number of patients surviving to discharge with CPR prior to FR) 6/8)

6 75%

Number of patients surviving to discharged with AED use (4/8)

4 50%

Cardiac Arrest Rhythms

First Cardiac Rhythms Identified by ALS Providers

Sinus Tachycardia 2 4%

V-Fib 14 27%

Asystole 23 44%

PEA 12 23%

Sinus Arrhythmia 1 2%

ROSC at some point in resuscitation  26 50%

Survivor Rhythms

First ALS Rhythm of the (8) Patients that survived to discharge

Sinus Tachycardia 1 12.5%

V-Fib 6 75%

Asystole ( resulted in poor neurologic outcome)

1 12.5%

Times

Notification and EMS Times    

Times obtained from First Responders (40/52) 40 77%

Average time from notification to FR on scene 6 min (1-17 min)

Average time from notification to first responder CPR (30 /52 CPR times recorded)

7 min (2-13 min)

Average time from notification to ALS on scene 8 min (1-25 min)

Average time from notification to ROSC 24 min (7-50 min)

What Now? (Goals)

Data collection – request PCR from all providers (BLS and ALS) for cardiac arrest that are transported

Obtain dispatch information – pre-arrival instructions etc.

Improve by-stander CPR from 44% - classes and public education

AED access – identify locations and add to CADImprove out of hospital survival – “Pit-crew

CPR”

Trauma 2012-13

Trauma Call Volume

Consults - MOI and GLF

2013 – Quarter 2 Consults

MOI – Step 3 Criteria

Falls Adults: >20 feet (one story is equal to 10 feet) - Children:

>10 feet or two or three times the height of the child High-risk auto crash

Intrusion of passenger compartment >12 inches occupant site or >18 inches any site including roof/floor

Ejection (partial or complete) from automobile Death in same passenger compartment ·

Auto vs. pedestrian/bicyclist thrown, run over, or with significant (>20 mph) impact

Motorcycle or unenclosed transport vehicle crash >20 mph

Special Considerations - Step 4

EMS provider judgment –Anything not listedAge >65 or <14 yrs. Two or more proximal long bone fracturesAnticoagulation therapy (excluding aspirin) or

other bleeding disorder with head injury (excluding minor injuries)

Pregnancy >20 weeks Burns with trauma mechanism (*) Trauma Consultation is not required for ground

level/low impact falls with GCS ≥ 14 (or when GCS is normal for patient) – follow SLO County patient destination policy

PCR Missing After 24 HoursSVRMC Fax line for all PCRs - 805-596-7509

Prehospital Performance

Transports > 30 minResponses > 20 minScene time > 10 without extrication

MCI/Multiple Patients Law Enforcement Questioning

Total call times

Fall outs are reviewed with the providers to determine if there is a system issue that needs further attention.

EMS Helicopter Resource

High Risk SituationsConsider EMS Air Resources

High risk motor vehicle accidents Major damage to vehicle e.g. head-on/entrapment Patients ejection (partial or complete) from an automobile Multiple injured patients/reported death

Auto vs. pedestrian/bicyclist – thrown or run over with significant injuries

Motorcycle (or like vehicle) crash > 20 mph with significant injuries

Falls – adults greater than 20 feet or children greater than 10 feet or 2-3 times their height with injuries

Unconscious person(s) Penetrating (stabbing or gunshot) injuries to head, neck or torso Paralysis Amputations and/or mangled limbs Burns to face or major portion of the body Multi Other situations not covered but dispatcher/FR believes

condition of patient is critical

Scene considerations

Questions to ask yourself Do you think this patient requires specialty care? Is this a time sensitive injury or illness? Does the county have this capability, i.e. intubated

pediatric patient Is the patient inaccessible by ground? Are ground resources maxed out? Is this a MPI? Should these patients be dispersed over

a larger area?

Time Considerations

Trauma Center

SVRMC Trauma Registry Data

SVRMC Trauma Registry Volume by Age

SVRMC Trauma Registry Volume by MOI

Trauma Center Quality and Performance

Quality Indicators ED through hospital discharge GCS < 14, no head CT GCS >8, no definitive airway Under and Over Triage rates Surgeon response times to activation ED/Resuscitation: ED throughput, CT tech + tat,

ATLS/TNCC standards, time on the backboard, IR, transfer OR- room- team- anesthesia ICU: transfer to, readmission to, reintubation, monitoring Blood Bank: MTP, blood availability All transfers, All mortalities

Trauma Center Quality and Performance

Transfers IN Trauma Transfer Line- 1-877-903-0003 One central point of contact for all transfer decisions,

recorded and reviewed

Transfers OUT All recorded and reviewed by the TPM/TMD/TOPPIC Relationships with tertiary centers Reasons for transfer:

Complex pelvic fractures, acetabular fractures, reimplantation, aortic injuries, pediatric patients needing PICU level of care

Communication

Points to remember TC prefers Med Channel 3 - overhead PA TC point of medical control - even if with change in

destination iPhone app – its free

Tools include: GCS calculator Time and distance to TC and other hospitals Trauma Guidelines Drug formulary Other protocols

Case #1- Friday night @ 1915-”The Good”

Medic 52 “ SV Base this is Medic 52 calling in with a Trauma Alert”

“Medic 52 this is SV Base MICN 844 go ahead” “SV Base this is Paramedic 007, we have a 17 yo male patient

meeting Step 1 trauma criteria” M:”Pt is a football player from a local HS was tackled by another

player, taking a hard hit to his head” I: “pt. walked off the field c/o severe headache and then

collapsed” V: 97/50- 52- 10- GCS- 4 –decer posturing, R pupil is 5mm nr, L is

2 mm and sluggish T: Pt is in full C-spine precautions, 1 IV right AC, our ETA to you

is 8 minutes” Medic 52 this is SV Base, we copy that report, we’ll see you

in 8 minutes, proceed to room 8A on arrival”

“The Bad & Ugly”

What if you don’t have the information….

What is

the …?

Really…..

Trauma Radio Report

Include the trauma step criteria at the beginning of the call

“Trauma Alert- patient meeting… Step 1 – MVC- Driver with GCS 8” Step 2 – Stabbing to upper chest with SOB

“Trauma Consult- patient meeting…. Step 3 - Auto vs. tree with >18” intrusion (meets

MOI) Step 4 – Auto vs. tree with major front end

damage, no PSI (paramedic judgment, + seat belt sign)

Communication

Paint the picture

Case #2 “Non-Stat Trauma”

0118: 911 TC car into telephone pole at 50 mph- 2 pts0123: PM arrival to 25 yo female passenger, + restrained, sitting up in seat with SLOFD holding C-Spine. Vehicle had front end damage, no PSI. Pt admitted to ETOH. Denies any c/o. 0125: 90/P-110-22-GCS 14. PE- bleeding form nose, L eye hematoma, L shoulder hematoma from seatbelt, stable chest wall, no pain on palpation, RUQ/RLQ painful on palpation, hematoma RUQ, pelvis stable, no neuro deficit0146: Report to the TC 8 minute ETA- BP 110/46- 108-14- GCS- 14

Case # 2 Outcome

Tier 2 activation- no documentation of criteria metStable in ED, FAST neg, CT, admitted to trauma

service/surgeon on SDUDX- Basilar skull fracture, orbital fx, L ptx- small,

small liver laceration, fx sacrum, coccyx, metatarsal fx

TX: NPO, serial hgb, serial examW/in 24 hours developed increasing abdominal pain

and distentionTo OR next am- laceration + repair to sigmoid

colon, adm to ICU

SB PositionSB Position Driver or Passenger?Driver or Passenger?

Paramedic Evaluation + Assessment

Penetrating Mechanisms

Stabbings and GSW – Step 2 Not always what you see High risk - “killer zone” head, neck, torso, proximal

extremities Patterns – female vs male Caliber and distance

MOI Predictors

Motorcycle crashes> 20 mph ATV – dunes vs ranchFalls from > 20ft adults or > 10 feet or 2-3

times the height in childrenConsiderationsLower speed with sudden deceleration ( MC vs

wall)Landing surface impactedProtective gearAge

MOI Predictors

Bicycle Crashes Bike Crash Auto vs bike

??

Yes!

Injuries

Expose the injuries – clothes off!Signs + symptoms suggestive of injury

Seat belt marks Steering wheel or other impression on the chest or abdomen Pain in any of the abdominal quadrants Chest pain with air bag deployment or steering wheel

damage Pelvic deformity, instability, pain

Special considerations Pediatric patients Older adults AMS

I-Injuries

Isolated Orthopedic Injury?

Pelvic fractures

Injuries- Pelvic

o Challenging to assesso Index of Suspicion

o Patient w/o distracting injuries that c/o of pain in pelvis, back or groin

o History – a marker for considerable transfer of energyFront seat head-onVehicle impact on their side with intrusionPedestrian accidentsMotorcycleFall from great heights

• Uneven landing

I - Injuries

Pelvic Injuries – s/s of significant injury

Deformity, bruising, swelling over bony prominences, pubis, perineum or scrotum

Leg - shortening or rotation w/o fractureWounds/bruising over pelvisBleeding from rectum, vagina or urethraNeurologic abnormalities distally (rare)

Case # 3

0947- 911 call for an 80 year old female involved in an MVC. Pt states she lost control of her vehicle on a curve and hit a tree head on

1000-Pt contact- awake, alert, c/o headache, neck pain, back pain, chest pain, abdominal pain, R ankle pain. Single occupant, no PSI. 186/108-80-18-GCS-15

1038- arrival at TCIs this a trauma patient? What step criteria is

met, if any?

V- Vital Signs

Important to share with TCBP < 90 at anytime - First Responders need to communicate with transporting providers

V- Vital Signs- Geriatric

VS in the elderly More often under triaged Elderly = > 65 locally but really > 55 Significant increase in mortality after 55 with

greatest > 70 Confounders in the elderly Pre-existing conditions and medications BP< 110 should be considered equal to <90 GLF with head injury or change of GSC on

thinners

V- Vital Signs- Pediatric

Pediatric Physiologic Criteria for children < 14 years or < 34 kg GCS ≤ 13 Evidence of poor perfusion- color, temperature, etc. Respiratory Rate

• > 60/min or respiratory distress or apnea• <20/min in infants < 1 year

Heart Rate• ≤ 5 years (<22kg) - < 80/min or > 180/min• ≥ 6yrs (22-34KG) - < 60/min or > 160/min

Blood Pressure• Newborn (<1mo) SBP < 60• Infant (1mo-1yr) SBP < 70• Child (1yr-10 yrs) SBP < 70 +(2x age in years)• Child (11-14 yrs) SBP < 90

Pediatric GCS

Pediatric Glasgow Coma Score  Infant < 1 yr Child 1-4 yrs Age 4-Adult

EYES4 Open Open Open3 To voice To voice To voice2 To pain To pain To pain1 No response No response No response

VERBAL5 Coos, babbles Oriented, speaks, interacts, 

socialOriented and alert

4 Irritable, cry, consolable Confused speech, disoriented, consolable 

Disoriented

3 Cries persistently to pain Inappropriate words, inconsolable

Nonsensical speech

2 Moans to pain Incomprehensible , agitated Moans, unintelligible 1 No Response No Response No Response

Motor6 Normal, spontaneous 

movementNormal, spontaneous movement

Follows commands

5 Withdraws to touch Localizes pain Localizes pain4 Withdraws to pain Withdraws to pain Withdraws to pain3 Decorticate flexion  Decorticate flexion Decorticate flexion2 Decerebrate extension Decerebrate extension Decerebrate extension1 No response No response No response

Treatment Plan

1. ALL trauma patients need O2 until proven otherwise

2. ALL trauma patients are bleeding until proven otherwise

3. ALL trauma patients have cervical spine injury until proven otherwise

4. ALL unconscious trauma patients have a brain unjury until proven otherwise

Treatment Priorities

A- airwayB- breathing

High flow O2 for all

C- circulation Control bleeding if possible- direct pressure/pressure

dsg Take a note of EBL Tourniquets if needed Bind the pelvis if hypotensive

D- Get a baseline neuro + communicate early Avoid hypotension + hypoxia

E- strip, flip, keep warm!

Treatment

Fluid resuscitation Single IV – leave an arm for the hospital Add extensions when possible – helpful for TC to add

blood warmers Fluid – none or controlled – boluses (250-500cc)

Rapid infusion may increase bleeding/dilutional Maintain BP of 90mmHg or radial pulse (elderly >110

mmHg) Patient needs: transport and blood/TXA

T-Treatment- Suspected Pelvic Fractures

Signs/symptomsPhysical exam often unreliableDo not rock or aggressively palpateAvoid excessive log rolling Consider splinting if obviousBind the pelvis if hypotensive

T-Treatment- Splint Fractures

Transfer of Care

Team ReadyTransfer the patient to the stretcher firstParamedic bedside report- to the team

“Moment of Silence” Additional details to the trauma scribe

More details of the MOI Restraints? Field photos?

PCR at time of drop off it all possible

Documentation

Real examples….Patient became alert to person, place and presidentDefibrinatedLou Garritt's DiseaseDrug Attichimlich maneuverpatient trapped under steeringlingUpper rear biceps femoris areaFound actively sieving

Documentation

More…..orbital region of the headlight headlessnessanginal respirationshead contraindicate to mechanical fall100 y/o -- ATV roll-over Pt does have a gauge reflexPt. experienced year lasting just less than 5 min.

Documentation

What, how and why

Review the for accuracy Fax all SVRMC PCRs to 805-596-7509

Destination

Considerations with in destination decisions

Unmanageable airway CPR with trauma

Blunt vs penetrating

Notifying SVRMCStabilization with rapid re-triage

Transfer process and Phone # 805-596-7509

Destination

Multi-PatientMulti-IncidentMass-Casualty

Destination

MMC – status No Change – Step 1 and 2 to SVRMC Remote areas consider EMS Air early Step 3 and 4 consult SVRMC for destination

Summary

Communication Add the Triage Step to the radio report Information to make a destination decision or

treatmentMOI

Paint the picture Predictors

Injury Expose – clothes off Injury patterns Paramedic judgment Not included in guidelines

Summary

VS BP< 90 at any time (<110 elderly) Pediatric and Geriatric considerations Communicate why essential VS cannot be obtained

Treatment - Field considerations Single IV with extension Small fluid volumes unless hypotensive O2 Warm Pelvic binder - consider with pelvic pain and low BP

Summary

Transfer of care to TC Move to bed Lead RN to ask for silence and filed report Fax chart to 805-596-7509

Documentation Narrative should match check boxes Accuracy PCR addition coming

Summary

Destination Early medical air resource No change to current policy Contact SVRMC for destination on Step 3 and 4 Inform SVRMC with any change in destination

Multi-patient Incident 3 or more critical Polling of hospitals for status by MedCom SVRMC still point of contact for trauma patients

Questions