INTEGRATING NEONATAL RETRIEVAL INTO THE STATE

AMBULANCE SERVICE

Dr. Amy Keir Neonatologist and Retrieval Consultant South Australian Ambulance Service

Chief Medical Officer South Australian Ambulance Service

Dr. Cathrin Parsch

The South Australian Ambulance Service and MedSTAR kids

FIRST THINGS FIRST

FIRST THINGS FIRST

BACKGROUND

BACKGROUND

South Australia Population 1 710 800 (2016) 1 262 940 (>70%) – metropolitan area

BACKGROUND Women’s and Children’s Hospital Flinders Medical Centre Lyell McEwin Hospital Mt Gambier Hospital Port Augusta Hospital Private metropolitan hospitals

BACKGROUND

Previous model (pre-2009/10) Hospital-based retrieval services

•Adult (RAH and FMC) •Paediatric (WCH) •Neonatal (WCH and FMC)

Review focused on adult services

BACKGROUND

Formation of MedSTAR (2009) Acknowledgement of highly functioning neonatal and paediatric retrieval services (unit-based) MedSTAR kids (2010) Combined adult, paediatric and neonatal retrieval service

BACKGROUND

Development of SAAS MedSTAR allowed for: • Retrieval coordination policies, procedures or

guidelines • Interagency coordination governance activities or

peer reviewed audit processes • Key performance measures

BACKGROUND

Development of: • Central coordination and communication with a

single point of contact • Statewide retrieval asset tracking and tasking • Integration between retrieval service coordinators,

SAAS and RFDS

BACKGROUND

Development of SAAS MedSTAR allowed for: •Standardisation of team appearance and uniform, retrieval equipment and operational policies, procedures, guidelines and funding models

BACKGROUND

Allowed for: •Operational base co-located with aviation assets (RFDS and Babcock)

•Rapid response for primary trauma care

•Dedicated response vehicles for road retrieval operations (priority 2 “lights and sirens”)

WHAT DOES SAAS MEDSTAR KIDS DO?

SAAS MEDSTAR

• MedSTAR kids service

• 0.5 FTE Clinical Director • 1.0 FTE Retrieval Consultant • 5.0 FTE Registrar/Fellow

• 15 nursing staff

SAAS MEDSTAR

• Standardised training – Orientation (10 days) – Safety briefs – HUET – Simulation – Equipment – Audit

SAAS MEDSTAR

2011-12 2012-13 2013-14 2014-15 2015-16

Adult 1577 1407 1430 1635 1895

Paediatric 331 317 302 318 388

Neonatal 628 585 522 416 557

Total 2536 2309 2254 2369 2840

SAAS MEDSTAR

2011-12 2012-13 2013-14 2014-15 2015-16

Neonates 28 weeks and under +/- 1kg and under

25 49 43 28 27

SAAS MEDSTAR

• Neonatal retrieval co-ordination

• Nurse retrieval co-ordinators (NRCs) • Medical retrieval co-ordinators (MRCs)

• Retrieval Consultants – Neonatal (RCNs)

– based at tertiary neonatal units (WCH and FMC) – clinical co-ordinators for all children <28 days of age – may accompany retrieval team for select cases

SAAS MEDSTAR - CHALLENGES

• Movement away from a unit-based model

• Communication, logistics/co-ordination, equipment and nursing staff highly regarded

• Medical staff: high-level neonatal and paediatric experience required (trainees)

AMBULANCE SERVICE AND NEONATES

SAAS

SAAS

January 2016 to March 2017 Total number of deliveries by SAAS = 31 Out of 31 delivery cases: 25 cases were delivered at home and 6 were at different locations

HOWEVER, NOT EVERYTHING ALWAYS GOES SO

WELL…

CASE STUDY

SAAS

000 call Birth: high risk, concurrent P2 tasking of paramedic and intensive care paramedic teams “head on its way out” 18 year old, 6th pregnancy

SAAS Multiple crews tasked Mother in pain, agitated, uncooperative ICP noticed legs and one arm out, second arm shortly after, head not delivered. Called for support, called MRC while holding baby and asked for kids team and obstetric consultant input

SAAS All manoeuvres tried, unsuccessful initially, cord pulsating and baby moving but all stopped before delivery. Prepared for compromised baby. Full term. No antenatal care. Resuscitation: 30 sec warmed, dried, HR less than 100, one paramedic airway, ventilating, commenced compressions, bradycardic, chest rise and fall observed, advice “load and go”, but not possible (stretcher, access).

SAAS Umbilical access successful but not secure, patient and partner screaming, very loud environment MedSTAR kids team arrived, compressions ongoing, initial access dislodged, umbilical access and concurrent Size 1 LMA. Improved heart rate. En-route to tertiary centre - baby started moving

SAAS Learning points Equipment: size 1 LMA Access to neonatologist/understanding of pre-hospital environment Potential formalisation of ‘primary’ response (in metropolitan areas) of MedSTAR kids teams Inclusive of Newborn Life Support teaching program in Intensive Care Paramedic training days

PROCESS

000 MPDS Response

EMERGENCY OPERATIONS CENTRE (EOC)

METROPOLITAN ADELAIDE

•Career staff •Highest level - Intensive Care Paramedic available •Neonatology advice/back up •Close to tertiary neonatal centres

COUNTRY AREAS

• Volunteers • Extended care paramedics (ECPs) • Perinatal Advice Line • Rural Emergency Responder Network (RERN)

Doctors • Retrieval service

MOVING FORWARD

WHAT WE HAVE BEEN DOING

• e-learning access for SAAS to Neonatal Life Support Training package (October 2016)

• Revised Neonatal Guidelines for SAAS

(December 2016)

• Neonatal Life Support (NLS) training provided for every Intensive Care Paramedic in South Australia ICP Training days (Starting 1st June 2017)

WHAT WE HAVE BEEN DOING

• New training equipment statewide for neonatal resuscitation training (ongoing)

• Review of operational neonatal resuscitation equipment (ongoing)

• Review of all cases (ongoing)

WHAT WE HAVE BEEN DOING

“Seek help early, as these cases are infrequently encountered and the advice of the on-call

neonatologist is available 24/7 via the EOC Clinician. “

THANK YOU

amy.keir@sa.gov.au cathrin.parsch2@sa.gov.au