Transcript EMS Base Station Meetings Fall 2013

EMS Base Station Meetings
Fall 2013
WHAT, HOW AND WHY
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 months
 Discuss opportunities of improvement through case
studies
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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
State Quality Core Measures
 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 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 2013)
Q1
Q2
Number of STEMI Activations
13
12
14 min
9 min
8 min
8 min
4 min
2 min
12 min
8 min
27 min
25 min
30%
50%
78 min
77 min
56 min
41 min
Average time on scene
(15 min)
(Time in Minutes
by Quarter)
Number of STEMI Activations
Time from 911 to Pt. Contact (10 Min)
Average time on scene (15 min)
Time from 911 to Pt. Contact (10 Min)
Time from Pt Contact to ECG (5min)
Time from ECG to SRC Contact (10
min)
Time from Pt. Contact to ECG (5min)
Time from ECG to SRC Contact (10 min)
Time from
Pt Arrival
Contact to Arrival
at SRC
Time from Pt. Contact
to
at SRC
False Positive % (<30%)
Time EMS to Intervention (E2B) (90120min)
Time from Door to Intervention (D2B)
(<90 min)
False Positive % (<30%)
Q1
13
14
min
8 min
4 min
12
min
27
min
30%
78
min
56
min
Time EMS to Intervention (E2B) (90-120min)
Q2
12
9 min
8 min
2 min
8 min
25
min
50%
77
min
41
min
Time from Door to Intervention (D2B) (<90 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 defibrillator
 Early, advanced life support followed by post
resuscitation care
Data Overview
Arrests and Outcomes
Total number of cardiac arrest transported
to a hospital
Number survived to hospital admission
52
21
40%
Number survived to discharge
8
15%
Number discharged with normal/functional
neurologic status
Number of organ donors
7
13.5%
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
Number of patients surviving to discharge with
CPR prior to FR) 6/8)
Number of patients surviving to discharged with
AED use (4/8)
11
21%
6
75%
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
Average time from notification to first responder
CPR (30 /52 CPR times recorded)
7 min
(1-17
min)
(2-13
min)
Average time from notification to ALS on scene
8 min
Average time from notification to ROSC
24 min
(1-25
min)
(7-50
min)
What Now? (Goals)
 Data collection – request PCR from all providers
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(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 CAD
Improve out of hospital survival – “Pit-crew CPR”
Trauma 2012-13
Trauma Call Volume
1040
1009
793
775
Total Trauma
Trauma Alerts
Trauma Consults
340
184
33
2012Q3
25
2012Q4
100
94
32
15
2013Q1 2013Q2
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
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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 listed
 Age >65 or <14 yrs.
 Two or more proximal long bone fractures
 Anticoagulation 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 Hours
SVRMC Fax line for all PCRs - 805-596-7509
Prehospital Performance
 Transports > 30 min
 Responses > 20 min
 Scene 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 Situations
Consider EMS Air Resources
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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
30
25.29
25
20
13.54
15
10.77
10
11.75
9.95
6.20 6.85 6.69
5
3.26 2.28
0.98
2.45
0
0 to < 6 to < 11 to < 14 to < 18 to < 21 to < 25 to < 30 to < 40 to < 55 to < 65 to < 75 to <
6
11
14
18
21
25
30
40
55
65
75
111
SVRMC Trauma Registry Volume by MOI
PEDESTRIAN-OTHER
DROWNING-SUBMERSION
SUFFOCATION
POISONING
HOT_OBJECT-SUBSTANCE
OTHER-SPECIFIED-NOT-CLASSIFIED
*BL
MACHINERY
MV_TRAFFIC-OTHER
NATURAL-ENVIRONMENTAL
ADVERSE-EFFECTS
UNSPECIFIED
OTHER-SPECIFIED-CLASSIFIED
MV_TRAFFIC-PEDALCYCLIST
FIREARM
CUT-PIERCE
MV_TRAFFIC-OCCUPANT
TRANSPORT-OTHER
OVEREXERTION
NATURAL-BITES_STINGS
MV_TRAFFIC-MOTORCYCLIST
PEDALCYCLIST-OTHER
STRUCK-BY-AGAINST
FALL
MV_TRAFFIC-PEDESTRIAN
0.49
0.33
0.16
0.49
0.65
1.79
1.47
0.33
0.33
0.33
0.16
0.98
0.81
2.28
1.14
2.93
8.14
0.81
0.33
0.00
4.89
3.75
15.31
7.65
40.88
3.58
5.00
10.00
15.00
20.00
25.00
30.00
35.00
40.00
45.00
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….
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 pts
0123: 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 deficit
0146: Report to the TC 8 minute ETA- BP 110/46- 108-14GCS- 14
Case # 2 Outcome
 Tier 2 activation- no documentation of criteria met
 Stable in ED, FAST neg, CT, admitted to trauma
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service/surgeon on SDU
DX- Basilar skull fracture, orbital fx, L ptx- small, small
liver laceration, fx sacrum, coccyx, metatarsal fx
TX: NPO, serial hgb, serial exam
W/in 24 hours developed increasing abdominal pain and
distention
To OR next am- laceration + repair to sigmoid colon, adm
to ICU
Paramedic Evaluation + Assessment
SB Position
Driver or Passenger?
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 ranch
 Falls from > 20ft adults or > 10 feet or 2-3 times the
height in children
Considerations
 Lower speed with sudden deceleration ( MC vs wall)
 Landing surface impacted
 Protective gear
 Age
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 assess
o Index of Suspicion
o
o
Patient w/o distracting injuries that c/o of pain in pelvis,
back or groin
History – a marker for considerable transfer of energy
 Front seat head-on
 Vehicle impact on their side with intrusion
 Pedestrian accidents
 Motorcycle
 Fall 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 fracture
Wounds/bruising over pelvis
Bleeding from rectum, vagina or urethra
Neurologic 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-GCS15
 1038- arrival at TC
 Is this a trauma patient? What step criteria is met, if
any?
V- Vital Signs
Important to share with TC
BP < 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
4
3
2
1
Open
To voice
To pain
No response
5
Coos, babbles
4
Irritable, cry, consolable
3
Cries persistently to pain
2
1
Moans to pain
No Response
6
Normal, spontaneous
movement
Withdraws to touch
Withdraws to pain
Decorticate flexion
Decerebrate extension
No response
5
4
3
2
1
Child 1-4 yrs
EYES
Open
To voice
To pain
No response
VERBAL
Oriented, speaks, interacts,
social
Confused speech, disoriented,
consolable
Inappropriate words,
inconsolable
Incomprehensible , agitated
No Response
Motor
Normal, spontaneous
movement
Localizes pain
Withdraws to pain
Decorticate flexion
Decerebrate extension
No response
Age 4-Adult
Open
To voice
To pain
No response
Oriented and alert
Disoriented
Nonsensical speech
Moans, unintelligible
No Response
Follows commands
Localizes pain
Withdraws to pain
Decorticate flexion
Decerebrate extension
No response
Treatment Plan
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
1.
Treatment Priorities
 A- airway
 B- 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/symptoms
 Physical exam often unreliable
 Do not rock or aggressively palpate
 Avoid excessive log rolling
 Consider splinting if obvious
 Bind the pelvis if hypotensive
T-Treatment- Splint Fractures
Transfer of Care
 Team Ready
 Transfer the patient to the stretcher first
 Paramedic bedside report- to the team “Moment of
Silence”
 Additional details to the trauma scribe
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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 president
 Defibrinated
 Lou Garritt's Disease
 Drug Attic
 himlich maneuver
 patient trapped under steeringling
 Upper rear biceps femoris area
 Found actively sieving
Documentation
More…..
 orbital region of the head
 light headlessness
 anginal respirations
 head contraindicate to mechanical fall
 100 y/o -- ATV roll-over
 Pt does have a gauge reflex
 Pt. 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 SVRMC
Stabilization with rapid re-triage
 Transfer process and Phone # 805-596-7509
Destination
 Multi-Patient
 Multi-Incident
 Mass-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 treatment
 MOI
 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