Transcript EMS System Introduction PPT

Mesa County EMS System
Introduction and Expectations
Introduction
• Welcome to the Mesa County EMS
System. We hope you have a productive,
positive experience caring for the sick and
injured in our region. We strive to make
sure you are well informed and performing
best practice medical care. This
presentation is designed to give you the
information needed to hit the ground
running.
Introduction
• Medical Director – Bill Hall, MD
• Mesa County EMS Coordinator – Mike Hill
• Pay close attention to the information
contained in this presentation as you will
be held to it during your probationary
period and time working as a health care
provider in Mesa County.
Introduction – Website
• ems.mesacounty.us
• This is where you find the official EMS
Guidelines (Protocols), squad review
schedule, and ALS skills schedule.
• You can also find the contact information
for the medical director and EMS
coordinator
Introduction –
MD-Provider Relationship
• Each provider works under the auspices of
the Mesa County Medical Director
• The medical director, at their sole
discretion, may terminate supervision of
any provider in the system.
• This is done according to the due process
stipulations in the EMS Guidelines
• Please review Guidelines 9000 and 9170
Probation Process – County File
• Everyone who begins probation needs a
file at the Mesa County EMS Coordinators
office
• This includes copies of:
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Signed agreement by agency director
Copy of Colorado certification
Copy of CPR card
Copy of ACLS/PALS if ALS provider
• This needs to be turned in PRIOR to
seeing any patients.
Probation Process – E-mail
• Every probationer needs to get on the
Mesa County website and sign up their email address
• We use this e-mail “blast” system to inform
providers of any time dependent
information that comes out
• This may include class cancellations, care
updates, closures, etc.
Probation Process - Patient
Contacts / Ride Time
• After all of your paperwork is turned in to
the EMS Coordinator, you may begin ride
time and patient contacts
• This should primarily be with your agency
• If you have joined one of the smaller
agencies, you may contact GJFD, or
Clifton FD to arrange ride time to get your
contacts in
Probation Process - Patient
Contacts / Ride Time
• This is completely at the discretion of
GJFD and CFD
• Professional behavior is expected at all
times
Probation Process - FTOs
• It is preferable to have the same FTO for
the duration of your probation
• This is rarely possible so we have
developed an objective evaluation system
• This involves scoring every shift . It is not
a test. Your FTO will fill this out for each
shift you work
Probation Process - Evaluations
• These forms will be used by each agency
so even if you ride with another agency it
should be scored the same
• There will also be a major evaluation after
every 5th shift
• The goal is to see improvement in areas
which were weak and to objectively target
those areas for further education
Probation Timelines
• BLS – 2 months or 15 charts, whichever comes
last
– After every 5 charts you should meet with your
agency AQD and go over progress
– After your 15th chart or 2 months have been
completed, your FTO will make an appointment with
the MD
– Submit 8 charts for review covering the entire time
span for MD review, including first and last PCR
– Need to complete probation workbook
Probation Process – Timelines
• ALS – Supervised – 3 months or 20 charts
– Monthly meetings with FTO and MD.
• Your FTO will make the meeting appointments
– Charts to be submitted as directed
• 4-8 charts
• Must be in 10 days in advance of meeting
• Must include written evaluation scores
– Critical thinking skills check off
– Probation workbook
Probation Process
• Critical Thinking Check Offs - ALS only
– This is a sit down with MD for a discussion
about care issues
– This is to test critical thinking skills and
knowledge of critical care protocols
• This must be completed prior to finishing
“supervised” probation
Probation Process – Timelines
• ALS – Unsupervised – 2 months or 15
charts
– Acting independently without FTO
– Monthly meetings with MD will be made by
you
– Charts to be submitted as directed
– Must include written evaluation scores
Probation Process –
MD meetings
• MD Meetings – occur during MD office
hours
• Chart submissions – Need to be in 10
days before meeting date
– Need to include written evaluation scores
– Missing deadline or evaluations may cancel
appointment
• Meetings are held at Sheriff’s Office, 215
S. Rice.
Probation Process
• End of Probation
• Once all requirements are completed the
provider will finish probation and be
officially “on protocol”
• A Mesa County challenge coin is
presented to all providers who complete
probation.
GJRCC – Dispatch
• Grand Junction Regional Communication
Center uses the Medical Priority Dispatch
System
• Determinant Codes are derived from
questioning which helps determine the
severity of the call
• The severity of the call helps determine if
the risk of lights and sirens response is
warranted
GJRCC – Dispatch
• Response Modes are defined by the
determinant codes
• ONLY Delta and Echo codes are dispatched
Code 3 (lights and sirens), along with a single
Charlie code (Crash)
• Code 3 dispatches are permissive – you may go
Code 3 but do not have to if they are not needed
• Upgrading responses without proper notification
from dispatch is a protocol violation
GJRCC – Dispatch
• MCI procedures are different from
dispatch.
– You should be aware of the way an MCI is run
at the scene
– During MCI operations, regular EMS traffic
REQUIRES contacting dispatch prior to
leaving scene in order that alternate
destinations may be given
GJRCC – Dispatch
• Field Feedback Forms to dispatch are an
important QA tool for dispatch
• They are available by e-mail:
[email protected]
• Please make sure you put “Quality
Management” in the subject line in order
for Peer review protection
GJRCC – Dispatch
• Diverts occur infrequently in Mesa County
• Most of the diverts currently are due to
psychiatric patients
• You may be diverted from other facilities to
St. Mary’s by agreement for specialty care
– STEMI, CVA, trauma
• Review protocols on how this works
Philosophy of Care
• Approach / Professional Conduct
– Care for the patient how you would wish for
your family to be care for
– Professional conduct is expected in the care
of all patients and interactions with public and
any other providers in the health care system.
• Unprofessional behavior will not be
tolerated, especially if it occurs in front of a
patient
Philosophy of Care
• Patient advocate vs. protocol advocate
– Protocols are now called guidelines
– They are just that, and you may deviate from
them if the patient’s condition calls for it
– Sound pathophysiology and documentation
will make any guideline deviations easier
– Posess the ability to back up every decision
you make regarding treatments/procedures!
• Always advocate for the patient first!
Philosophy of Care
• That being said, your safety takes
precedence over patient care!!!
– Get law enforcement involved if patient is
threatening. Do not take down patients
yourself
– Search your patient and belongings before
letting them into your vehicle. This is not law
enforcement but just sound safety practice
Philosophy of Care Documentation
• Patient care report (PCR) performs three
functions:
– Provides report of care performed and
prehospital history to inform future providers
– Provides a record of care performed for
medico-legal purposes (CYA)
– Provides a record for billing purposes
• The record is written after the call, so you
know what has already occurred
Philosophy of Care Documentation
• Chart Review starts first with A:
– What did you think was going on with patient?
– What are you treating?
• Next the P:
– Did you treat the A appropriately?
• Lastly S and O:
– Does the history and physical exam lead the
reader to the same conclusion (A)
Philosophy of Care Documentation
• Proof reading is important!
• Was the problem in “A” thoroughly
evaluated in the “S” and “O” and
appropriately treated in the “P”
• The PCR is a story, not to be made with
false statement, but may be crafted to take
reader on the same journey you went on.
Philosophy of Care Documentation
• History (HPI) is the “S” or subjective
– Need pertinent information regarding current
illness or injury
– PQRST
– Patient PMH which relates to current illness
• Trauma
– How were forces applied to patient?
– Blood thinners, beta blockers
Philosophy of Care Documentation
• Physical Exam = “O” or objective
• Obtain a baseline set of vital signs
including sats, on every patient even if
handed off by another provider
• Heart sounds, lung sounds and neuro on
every patient, every time.
– Breathing easily is not a lung exam!
– Heart sounds - murmurs, regular, etc.
– Both of these exams are best done on bare
skin
Philosophy of Care Documentation
• Physical Exam (cont.)
• Whatever body system or body part is
involved in the patients chief complaint
needs to be thoroughly evaluated
– Example: Fall with hip pain – need evaluation
for shortening, rotation, distal pulses,
movement and sensation
• CMS x 4 is insufficient as exam of that leg
– Headache needs a stroke scale and good
neuro exam (neurologic system)
Philosophy of Care Documentation
• Assessment – “A” = your diagnosis
• What do you think is going on, and more
specifically what are you treating?
– Do not be flippant, needs to be billable
– No points for the longest differential
– Do not put down things you cannot possibly
know for sure in the field
– CP, not possible ACS. Abd pain, not appy.
• Needs to be in same ballpark as Provider
Impression
Philosophy of Care Documentation
• Treatment – “P” or plan
– S, O and A are all what you see on arrival,
everything after that goes into P.
– Chronological treatment and response during
rest of time with patient
• Need to make sure it treats the “A” !!
• If you deviate from the guidelines, need to
document why
• Pain complaints should be treated or
explained why not
MCEMSS Care Guidelines
• Cardiac Care – STEMI , Pit Crew
• CPR is performed using the ”Pit Crew”
approach.
– Team members have set functions prior to
arrival on scene
– No advanced airway management for first 15
minutes, OPA and BVM only.
• STEMI is diagnosed and called from the
field using 12 lead ECGs
– Know appropriate language for calling in
MCEMSS Care Guidelines
• Trauma
– Load and go – 10 minutes or less scene times
for critical patients
– Call in with minimum info for triage in ED
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Mechanism
Vitals – BP, HR, Oxygen sats
Neurologic status
Airway status
• Early notification for critical patients!
MCEMSS Care Guidelines
• Trauma
– Spinal Immobilization
• Mesa County and the Trauma system has
endorsed protocols which reduce use of
backboards and c-collars
• Please make sure you know how this applies to
your trauma patients
– Exposure
• It is vitally important that you know what injuries
your patient has, and you need to see them.
MCEMSS Care Guidelines
• Stroke/CVA - taken primarily to St. Mary’s
which is the designated stroke center
• Stroke alert criteria
– < 6 hrs known onset
– Obvious stroke, know the Cincinnati Stroke
Scale (CSS) and other signs of stroke
• TIAs or unusual symptoms – call EDP and
notify to meet at door for evaluation.
Usually not a stroke alert.
MCEMSS Care Guidelines
• Sepsis is an alert at the “Severe Sepsis”
level
– Positive SIRS (HR> 100, RR> 20, T<96 >101
– Known or suspected infection
– Evidence of end organ dysfunction
• Hypoxia over baseline
• AMS
• Hypotension
MCEMSS Care Guidelines
• Non-Transport – standing order and call-in
– Review protocols so you are aware of what is
appropriate for standing order
– In general, neurologic problems, chest or
abdominal complaints require a call in.
– Must document name of physician spoken to
• Problem patients – EMS abusers / intox
– Have specific destination protocols and
paramedic initiated refusals – must call in
MCEMSS Care Guidelines
• Medical Control is primarily through
Colorado West EPs at St. Mary’s Hospital
– Main base station.
– All pronouncements and refusals
– Any questions which are not clear
• May contact receiving hospital for prearrival orders
• The VA hospital in GJ does not have the
ability to give orders. Call St Mary’s
MCEMSS Care Guidelines
• Procedures - Need to document the
following for procedures
– Criteria / reasons for performing procedure
– Proper procedure mechanics (sterile, etc)
– Number of attempts and reasons for failure
– Mitigation of any complications
– Results of procedure / patient reaction
• Not documented = not done!
MCEMSS Care Guidelines
• Restraints / LE / Handcuffs
– All patients who require physical restraint (for
combative behavior) must get chemical
restraint as well. This does not apply to
restraint for care purposes, such as tying
hands after intubation.
– Patients may not be transported in ambulance
with handcuffs without LEO present in
ambulance
MCEMSS Care Guidelines
• Transport Modes are dictated by patient
condition, not dispatch code
• Code 2 – non emergent
• Code 3 lights and sirens (emergent)
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Hemodynamic instability (not potential)
Advanced airway management with ongoing hypoxia
AMS secondary to trauma
STEMI, severe sepsis, and acute CVA are considered
unstable
MCEMSS Care Guidelines
• Hospice
– Review Guidelines regarding how hospice
services in the Mesa County work.
– May administer medications and leave patient
in care of hospice nurse
• Hospice nurse interactions
– Hospice nurse has the ability to dictate
transport decisions. Call in if questions
– Professional interactions at all times
Transfer of Care
• This is a time of great risk, as information may
be lost if not performed appropriately
• This may occur in field, as in from a first
response agency to transport, or from BLS to
ALS like a rendezvous or HEMS transfer.
• It also occurs when you leave a patient in the
Emergency Department or floor bed of hospital
• Each of these situations has different
documentation requirements
Transfer of Care - Field
• If passing patient to another provider you
are responsible for giving all pertinent
information for proper care of patient
• If accepting patient from another provider
– You are responsible for patient now
– You must know what is going on
– You must perform a baseline set of vitals and
another exam
– Telling ED “I don’t know” because you didn’t
evaluate patient yourself is unacceptable
Transfer of Care - Hospital
• Radio reports – these are used to help
charge nurses triage patient in the ED and
assign appropriate resources
– Pt age, brief HPI / mechanism of injury
– Vitals – BP (or surrogate), HR, RR (status),
Oxygen sats, neurologic status
– ETA, transport mode
– Should take < 45 seconds
• Nurse may ask questions which are
required for proper triage, please answer
Transfer of Care - Hospital
• Alerts – STEMI, SEPSIS, Stroke, Trauma
• Know criteria for each alert
• Know procedure for calling in each alert
which may add things to basic report
• Know how to document appropriately in
the EMR for each alert
Transfer of Care - Hospital
• Handoffs – this is the process of direct
patient transfer in the ED or to a higher
level of care for transport
– Treating provider needs to have direct
communication with provider / RN assuming
care
– Alerts should be done in an environment with
an EMS time out for report
• Radio report information plus treatments
and response
Charting
• ePCRs – documentation is required in the
appropriate areas, not just the narrative
– Alerts
– ALL procedures – BG, airway, meds
• Provider impression – used in Mesa
County for QA purposes
– Not all conditions listed
– Find best fit (i.e. abd pain for NV)
Charting
• Timeliness – expectation by the medical
director is that chart is left with the patient
in the ED.
– Exceptions – second call, computer failure, or
lack of ANY OTHER provider in ASA to
respond (not just lack of ALS).
– Need to document as appropriate why the
chart was not left in the ED.
– If not left with patient, need to completed and
faxed back to the ED as soon as possible
Charting - QA
• Chart Reviews – Trauma, STEMI, CVA,
Sepsis
• Benchmarks – CP, Seizure, AMS
• Airway management
• Speak to your agency AQD about the
required elements which will be reviewed
during QA procedures
Charting – Legal Issues
• You may not see your chart again for 3-5
years if a suit is filed.
• Make sure your documentation will stand
up for you to defend what you did
• If it is not written, it was not done
• Even simple documentation mistakes can
call into question the entire chart
• PROOF READ YOUR CHARTS!
Medico-Legal / HIPPA
• Medical information about patients may
only be shared with other medical
providers on the call, or QA personnel
• Do NOT take pictures or videos of patients
You may take pictures of the scene (such
as vehicle damage)
• Identifiable dissemination of medical
information is grounds for termination
Medico-Legal / HIPPA
• Educational programs will present deidentified patient information
• This will still be considered protected, but
HIPPA allows for this to be discussed for
QA and educational purposes
• It should still not be discussed outside of
educational activities, especially with the
public
Continuing Education
• Squad Reviews (SR) are presented in a
trimester format, same presentation every
4 months
• You must attend one SR every trimester
• Make up for missing is a 4-5 page paper,
and is not pleasant. Do not miss SR.
• There are 2-3 presented per month at
various locations. See EMS website for
current schedule.
Continuing Education
• BLS Skills Days are given annually by
your agency.
• Every BLS provider is required (and ALS
is recommended) to attend one annually
• You may attend at another agency
• This is to practice skills not taught in EMT
classes, are higher risk or may not be
done often.
Continuing Education
• ALS Skills Days are presented 4 times per year
in late summer and fall.
• These are presented by the medical directors,
flight nurses, and various MDs from the area.
• These are REQUIRED annually by every ALS
provider and you must contact Dr. Hall to sign up
• Failure to attend results in BLS status until next
ALS skills attended (at least 7.5 months).
Continuing Education
• Careflight SRs are reviews held in
conjunction with St. Mary’s Careflight
HEMS service
• These are held when cases are present
for review.
• These are optional, but may be substituted
for the regular SR for that trimester.
Continuing Education
• Bi-Monthly EMS Lectures at SMH are held
in Jan, Mar, May, July, Sep, and Nov.
• These are provided by St. Mary’s and are
free to attend.
• One hour of CME and usually lunch.
• Taught by our local specialty physicians
on various topics
Continuing Education
• Local, State, National Conferences are
encouraged.
• Grant funds from the State may be
available to help defray costs through the
CREATE grant program
• Plan ahead to ensure funding assistance
is obtained – requests required 45 days in
advance of need for funding
Continuing Education
• Local Training will occasionally be
provided for courses such as HazMat,
Difficult airways, etc.
• Most of these are voluntary but if we don’t
get attendance it is hard to continue
offering these classes
Certifications
• It is the responsibility of every provider to
know when their National and State
certifications expire
• Each agency tries to keep track, but the
ultimate responsibility is yours
• No provider will be allowed to provide
patient care with an expired certificate
Certifications
• Ramifications of certificate expiration:
– Medicare fraud investigation for billing by an
expired provider
– Possible criminal violations for practicing
medicine without a license
– NO support from the medical director for any
care provided
• DO NOT LET YOUR CERTIFICATION
LAPSE!!!!!
Disciplinary Actions
• Mesa County has instituted a “Culture of Safety”
program to encourage reporting of care mishaps
and near misses
• Self reporting of the instances to the EMSMD
and the EVENT national database will not result
in any disciplinary action
• Report must be made before anyone else
– i.e. the EMSMD should not find out about it otherwise
prior to reporting by the provider
• Chart will be submitted for PEER review.
Disciplinary Actions
• Some infractions are too egregious for the
Peer Review / Safety system
• Notice will be provided to the provider as
soon as the EMSMD is aware of the
infraction
• Please review the policies under the
Guideline for Due Process - 9170
Disciplinary Actions
• Removal from patient care activities may
be requested pending investigation of the
incident
• This is not punishment, but protection for
the provider, agency and EMSMD
• This is similar to removal from duty for an
officer involved shooting, just SOP
Disciplinary Actions
• If required, a meeting with provider,
EMSMD and agency supervisors will be
scheduled as soon as possible to resolve
any issues.
• Determination of sanctions or remediation,
if needed, will be made by the EMSMD in
conjunction with your agency Chief
• Acceptance of this determination is
required to continue with Mesa County
EMS
Conclusion
• This has been a quick introduction to
some of the issues you need to be aware
of when becoming a provider in the Mesa
County EMS System
• Over the coming probationary period, use
your time to improve your documentation
skills and learn from your FTO
• Feel free to contact any of the medical
directors for questions
Conclusion
• Good luck and congratulations on your
new position with the Mesa County EMS
System
• We look forward to having you become a
valued member of our system and hope
you will continue to strive for the life long
learning which comes with a profession in
medical care.