Sierra – Sacramento Valley EMS Agency

Sierra – Sacramento Valley EMS Agency
2018 Regional Training Module

S-SV EMS 2018 Regional Training Module
Regional Training Module Agenda S-SV EMS Specialty Systems of Care 2017 S-SV EMS Focused QI Audits & QI Report Cards EMS Aircraft Utilization EMS Ethics and Legal Matters

S-SV EMS 2018 Regional Training Module
Training Module Objectives Provide a review/update of the S-SV EMS STEMI, stroke and trauma systems Provide a review of the 2017 S-SV EMS focused QI audits and identified educational reminders Provide instruction on appropriate EMS aircraft utilization Provide a review of EMS Ethical and Legal Matters

S-SV EMS Specialty Systems of Care

Specialty Systems Of Care – STEMI
S-SV EMS STEMI System Data (1/1/17 – 6/30/17) (SRC = STEMI Receiving Center) SRC STEMI Patients: 366 SRC EMS arrival: 196 (54%) SRC walk in arrival: 99 (27%) SRC interfacility transfer arrival: 71 (19%) SRC Arrival to Device Time (median) EMS patients: 60 minutes Walk in patients: 72 minutes

S-SV EMS STEMI System Data (1/1/17 – 6/30/17) EMS Times (median) EMS patient contact to 12 lead: 5 minutes EMS 12 lead to patient transport: 5 minutes EMS patient contact to SRC device time: 96 minutes S-SV EMS system goal: 90 minutes

2017 EMS STEMI Patient Over-Triage Audit Number of reviewed cases: 87 False positive activations by EMS 12 lead: 30 (38%)

2017 EMS STEMI Patient Over-Triage Audit (cont.) Tips to reduce false positive 12 lead STEMI activations: Input patient’s correct age/gender into the monitor prior to 12 lead acquisition Appropriately prep the skin prior to electrode application Utilize 4x4 gauze to wipe area prior to electrode placement Utilize fresh packaged (not bulk) electrodes for 12 lead EKGs Ensure correct lead placement Bundle branch blocks, a-fib and artifact can result in false positives Consider re-acquisition of 12 lead if significant artifact

2017 EMS STEMI Patient Primary Symptom Audit Number of reviewed cases: 79 AUDIT DATA ELEMENT MALE FEMALE % Of Patients 58% 42% Average Patient Age 65 72 Chief Complaint – ‘Chest Pain’ 52% 49% Atypical Presentation (Chief Complaint Other Than Chest Pain) 48% 51% Most Common Atypical Complaint SOB, Weakness SOB, Abd. Pain, N/V

Specialty Systems Of Care – Stroke
S-SV EMS Stroke System Data (1/1/17 – 9/30/17) “Stroke/CVA” is one of the top 20 EMS primary impressions 911 Patients: 1375 Male: 719 (average age: 70) Female: 656 (average age: 75) Median Stroke Patient EMS Scene Time: 11 minutes Stroke Patient Educational Reminders: Blood glucose level, time last known well and pt. anticoagulant use should be determined, relayed to the receiving hospital and documented on the PCR

Specialty Systems Of Care – Stroke
EMS Stroke System Information/Updates Several S-SV EMS designated stroke receiving centers are in the process of obtaining Joint Commission ‘Thrombectomy- Capable Stroke Center’ (TSC) Certification May eventually lead to alternate destination of certain types of stroke patients (large vessel/large artery occlusion) S-SV EMS is evaluating additional stroke assessment tools to better identify these types of patients in the prehospital setting

Specialty Systems Of Care – Trauma
S-SV EMS Trauma System Data (1/1/17 – 6/30/17) Total Trauma Registry Patients*: 2449 Adult Trauma Patients: 2333 (95%) Pediatric Trauma Patients: 116 (5%) Trauma Center Arrival by EMS: 1860 (76%) Ground Ambulance Arrival: 87% EMS Aircraft Arrival: 13% *Does not include all EMS trauma patients, only those entered into the trauma registry by the trauma centers based on specified criteria

S-SV EMS Trauma System Data (1/1/17 – 6/30/17) Top 10 Causes of Injury (93.8% of EMS trauma patients) Fall: 52.3% MVA: 18.9% Assault: 7.9% Auto vs. Ped: 2.9% ATV/PWC/ Snowmobile: 2.7% Stabbing: 2.1% Sports Related: 2% Struck (by blunt object): 1.8% Bicycle: 1.8% Motorcycle: 1.4%

EMS Trauma System Information/Updates Shasta & Tehama County Spinal Motion Restriction Pilot Project (October 2016 – October 2017) Resulted in 90% reduction of prehospital backboard utilization (508 of 562 patients) with no exacerbation of injuries Currently evaluating S-SV EMS system-wide trauma protocol spinal motion restriction revisions

S-SV EMS Trauma System Information/Updates Tension Pneumothorax (T-2) protocol revised to reduce the number of inappropriate needle thoracostomy procedures Reviewing 100% of tourniquet and hemostatic dressing applications to ensure appropriate utilization Implementing a pilot project with several S-SV EMS prehospital providers on the use of pelvic binders for trauma patients with suspected pelvic injuries and hypotension Evaluating/addressing the over-administration of IV fluids to non-hypotensive trauma patients in the prehospital setting

2017 S-SV EMS Focused QI Audits & QI Report Cards

2017 QI Focused Audits ALS Provider Regional EMS QI Audits
Conducted quarterly Provider QI personnel required to perform a thorough PCR review of applicable calls based on the quarterly focus Patient data is submitted to S-SV EMS for system wide compiling/evaluation and utilized for educational purposes as well as LEMSA policy/protocol revision as necessary

2017 QI Focused Audits 2017 Q1 – Cardiac Arrest Pt. Treatment (249 pts.) Bystander CPR: 43% Bystander AED (shocks): 2% BLS Provider AED (shocks): 27% Prehospital ROSC: 30% Identified Issues: Inconsistent medication administration intervals Patient survival to hospital discharge data not consistently available S-SV EMS is currently exploring participation in the national Cardiac Arrest Registry to Enhance Survival (CARES)

2017 QI Focused Audits 2017 Q2 – Pediatric Medication Admin. (231 pts.) Correct Dose Administered: 88%* Incorrect Dose Administered: 12% (all were under-dosed)* Top 3 Pediatric Medications Administered Fentanyl (22%) Albuterol (22%) Zofran (16%) *Reminder: A length based pediatric resuscitation tape is required for calculating all pediatric medication doses

2017 QI Focused Audits 2017 Q3 – Pain Management – Cardiac (277 pts.)
Average Pain Scale: Initial – 6, Final – 4 (33% decrease) 18% of patients received opioids (primarily morphine) Identified Issues: No pain scale documented on 5% of pts. Inconsistent documentation of vital signs before and after medication administration S-SV EMS protocol (C-8) was not followed on 33% of patients reviewed (primarily due to lack of NTG and opioid administration when indicated)

2017 QI Focused Audits 2017 Q3 – Pain Management – Trauma (350 pts.)
Average Pain Scale: Initial – 8, Final – 6 (25% decrease) 55% of patients received opioids (primarily fentanyl) Identified Issues: No pain scale documented on 7% of patients S-SV EMS protocols (M-8/P34) were not followed on 20% of patients reviewed (primarily due to lack of pain medication administration when indicated)

S-SV EMS QI Report Cards
Utilized by S-SV EMS to provide feedback & education to EMS personnel (non-disciplinary) Includes pertinent hospital patient outcome information Copied to provider QI representative personnel Process in place to allow EMS personnel to provide additional comments back to S-SV EMS

EMS Aircraft Utilization

EMS Aircraft Utilization Factors The decision to use prehospital EMS aircraft is complex and a number of important geographical, physiological and operational factors need to be considered Utilization is the decision to dispatch air resources and whether to ultimately use those resources to transport It is important that EMS personnel utilize consistent and appropriate criteria when requesting a prehospital EMS aircraft for assistance with patient care and transport

EMS Aircraft Utilization Factors (cont.) A patient being transported by EMS aircraft should be critically ill/injured (life or limb) EMS aircraft utilization should provide a significant reduction in arrival time to the most appropriate facility and/or provide necessary critical care interventions not available by ground providers (e.g. RSI, TXA, surgical cric)

EMS aircraft should be considered for the following circumstances: Patients meeting trauma triage criteria Time critical medical patients (STEMI, stroke, etc.) MCIs Patients inaccessible by other means Ground ambulance resources not readily available When additional/specialty care provider resources are needed (e.g. RSI, TXA, surgical cric.)

EMS aircraft should not be used for the following circumstances: Patients with CPR in progress Hazmat patients who cannot be completely decontaminated Patients who are potentially violent or who have behavioral emergencies (flight crew discretion)

EMS Aircraft Types ‘Air Ambulance’ Aircraft specifically constructed, modified or equipped, and used for the primary purpose of responding to calls and transporting critically ill or injured patients Medical flight crew has a minimum of 2 ALS attendants (Usually 1 RN & 1 Paramedic)

S-SV EMS Region Air Ambulance Bases Calstar 3 (Auburn) Care Flight 3 (Truckee) Enloe Flightcare (Chico) LifeNet 3-4 (Montague) PHI 4-3 (Redding) REACH 5 (Redding) REACH 7 (Marysville)

EMS Aircraft Types ‘ALS Rescue Aircraft’ Aircraft whose usual function is not prehospital emergency patient transport but which may be utilized for prehospital emergency patient transport when use of an air or ground ambulance is inappropriate or unavailable (closest air resource, hoist rescue, etc.) Medical flight crew has a minimum of 1 ALS attendant (Paramedic)

ALS Rescue Aircraft CHP H14/H16 (Redding) CHP H20/H24 (Auburn) CHP H30/H32 (Napa)

EMS Aircraft Requesting Process All EMS aircraft shall be requested through the Incident Commander (IC) or the applicable Public Safety Answering Point (‘PSAP’ – 911 dispatch center) If ‘Air Rescue’ services are not needed/requested, an ‘Air Ambulance’ resource will routinely be assigned An ‘Air Rescue’ resource (CHP) may be utilized for patient transport if they are the closest and/or most appropriate air resource based on incident specific circumstances

EMS Aircraft Resource Coordination All EMS aircraft requests received from a PSAP are managed by the applicable EMS Aircraft Coordination Center CAL FIRE Grass Valley Emergency Command Center Colusa, Nevada, Placer, Sutter and Yuba counties CAL FIRE Oroville Emergency Command Center Butte, Glenn, Shasta and Tehama counties CAL FIRE Yreka Interagency Command Center Siskiyou County

EMS Aircraft Utilization Considerations S-SV EMS data indicates that the closest based EMS aircraft is unavailable to respond to approx. 25% of calls when requested (already committed to another call, mechanical issues, weather issues, etc.) EMS aircraft based further from the incident may be assigned (if available) in these instances, resulting in increased ETAs Due to safety considerations, the average EMS aircraft dispatch to enroute time in the S-SV EMS region is 9 minutes (this time may be longer for some providers as a result of current FAA regulations)

EMS Aircraft Utilization Time Factors *A standardized dispatch to on scene calculation is utilized to provide an initial ETA, and is often updated by the flight crew once enroute. Once airborne, EMS aircraft travel approx. 2 air miles per minute. CHP excluded from dispatch to enroute as they are routinely in the air at time of dispatch. Dispatch/Response/Trans. Step Average Time (per S-SV EMS data) Dispatch/Coordination Processing Varies based on aircraft availability Dispatch to Enroute* 9 minutes Enroute to On Scene* 17 minutes At Patient to Depart Scene 14 minutes Depart Scene to At Destination* At Destination to Patient ED Arrival 4 – 8 minutes based on destination

EMS Aircraft Utilization Considerations If EMS personnel believe that a patient may benefit from utilization of an EMS aircraft, it should be requested early and through the appropriate process (IC/PSAP) EMS personnel are required to continually re-evaluate incident conditions/information available to them to make decisions in the best interest of the patient If conditions change such that EMS aircraft utilization is no longer necessary/appropriate, the EMS aircraft resource may be cancelled at any time (even after arrival at scene) EMS personnel should contact the base hospital for consultation whenever necessary

EMS Ethics and Legal Matters

EMS Ethics The Code of Ethics for EMS Practitioners
Issued by the National Association of EMTs (NAEMT) Originally adopted in 1978, revised in 2013 Basic ethical concepts include: Do no harm Conserve life Alleviate suffering Promote health Act in good faith Act in the patient’s best interest

EMS Legal Matters California Good Samaritan Law1
Individual providing aid is protected from liability if they: Acted in good faith Acted within their scope of practice/training (if applicable) Off duty EMS personnel may provide BLS care only – ALS care requires medical authority/control within an organized EMS system Did not act negligently Did not accept compensation for assistance provided 1CA H&S Code, Div. 2.5, §

EMS Legal Matters EMS Personnel Medical Authority
EMS personnel function under the authority of a physician ‘Offline Medical Control’ – Following established S-SV EMS policies/protocols (as written) Function under the authority of the S-SV EMS Medical Director ‘Online Medical Control’ – Following a base hospital physician order outside S-SV EMS policies/protocols, but still within applicable scope of practice Function under the authority of the base hospital physician who provided the specific order Base hospital physician consultation/approval is required for any deviation from established S-SV EMS policies/protocols

EMS Legal Matters Standard of Care
Laws/regulations establish scope of practice S-SV EMS establishes medical control policies/protocols “Every local EMS Agency shall have a full or part time physician functioning as the Medical Director to ensure medical accountability”1 Also derived from the ‘peer standard’ What a reasonable and prudent similarly trained/certified/licensed provider would do in the same or similar circumstance 1CA H&S Code, Div. 2.5, §

EMS Legal Matters Standard of Care (cont.)
The following may also be used to establish standard of care in a legal proceeding: EMS course curriculum EMS textbooks Employer policies Expert testimony Deviation from the standard of care can lead to allegations of negligence

EMS Legal Matters EMS Personnel Liability
“….a firefighter, police officer or other law enforcement officer, EMT-I, EMT-II, EMT-P, or registered nurse who renders emergency medical services at the scene of an emergency or during an emergency air or ground ambulance transport shall only be liable in civil damages for acts or omissions performed in a grossly negligent manner or acts or omissions not performed in good faith.”1 1CA H&S Code, Division 2.5, §

EMS Legal Matters EMS Personnel Liability (cont.)
“No EMT-II or mobile intensive care paramedic rendering care within the scope of his duties who, in good faith and in a non-negligent manner, follows the instructions of a physician or nurse shall be liable for any civil damages as a result of following such instructions.”1 1CA H&S Code, Div. 2.5, §

EMS Legal Matters Negligence
Something was not done, or was done incorrectly Four requirements must be met to prove negligence: There was a legal duty to act There was a breech of duty Injury/harm occurred The breech of duty was the proximate cause of injury/harm

EMS Legal Matters Negligence (cont.)
A duty to act occurs when there is a legal obligation to provide care On duty EMS personnel who are dispatched to or come across an incident that requires EMS care (including assessment to determine if a medical emergency exists)

EMS Legal Matters Negligence (cont.) Breach of duty includes:
Violation of standard of care or scope of practice Failure to act or acted inappropriately Patient abandonment Termination of care without the patient’s consent or without assumption of care by another appropriate medical provider Transferring care to a lesser trained/certified/licensed medical provider without providing an appropriate assessment or when the patient’s condition requires a higher level of care

EMS Legal Matters Patient Autonomy
A patient has the right to direct their own care EMS providers must respect and honor the patients rights, including: Consent for treatment Refusal of EMS care

EMS Legal Matters Patient Autonomy (cont.) Types of consent:
Informed Consent – Risks and benefits explained Expressed Consent – Verbal/nonverbal permission granted Implied Consent – Patient is unable to provide expressed consent so implied consent is assumed Unconscious/unresponsive Altered mental status Unemancipated minor Involuntary Consent – Court order, 5150, etc.

EMS Legal Matters Patient Autonomy (cont.)
Withdrawal of consent may be done by any competent adult (responsible for their own healthcare) at any time: Withdrawal of consent must be informed Not applicable to involuntary consent (court order, 5150, etc.)

EMS Legal Matters Refusal of EMS Care
Significantly higher liability of EMS litigation Multiple EMS personnel certification/licensure actions involve these type of incidents when LEMSA policies/ procedures are not followed S-SV EMS Refusal of EMS Care Policy (850) is considered the ‘standard of care’ for patient refusal situations EMS personnel have a requirement/obligation to understand and follow S-SV EMS policies/protocols Law enforcement and/or base hospital consultation should be utilized prior to patient release when necessary

EMS Legal Matters Patient Restraint
Scene and provider safety come first Use of force must be reasonable for the situation Patients who are a danger to themselves or others may be appropriately restrained as indicated in S-SV EMS Patient Restraint Mechanisms Policy (852) If you restrain a patient, you are 100% liable for their safety, they must be properly monitored and you must document the type of restraint and reason why restraint was necessary

EMS Legal Matters Misc. Legal Matters False Imprisonment
Restraint of a person in a bounded/fixed area without justification or consent

EMS Legal Matters Misc. Legal Matters Assault Battery
A violent physical or verbal attack A threat or attempt to inflict offensive physical contact or bodily harm A patient threatened with the possibility of a painful procedure in order to gain compliance with EMS personnel may claim assault if they had a reasonable anticipation of bodily harm Battery An offensive touching or use of force on a person without their consent

EMS Legal Matters Emergency Medical Treatment and Active Labor Act (EMTALA) Also known as: ‘COBRA’, ‘Anti-dumping statute’ Enacted in 1985 in response to concerns that some EDs were refusing to treat indigent or uninsured patients, or inappropriately transferring them to other facilities

EMS Legal Matters EMTALA (cont.) Enacts 3 major hospital requirements
Hospitals are required to provide a Medical Screening Examination (MSE) to any patient who presents to the ED If the hospital determines that the individual has an emergency medical condition, they must provide further medical examination and treatment to stabilize the medical condition If the hospital is unable to stabilize the patient, they must provide an appropriate transfer to another facility

EMS Legal Matters EMTALA (cont.) Medical Screening Examination (MSE)
Performed by qualified medical personnel (physician) Is NOT the same as ED Triage Triage determines the order to be seen MSE determines if an emergency medical condition exists

EMS Legal Matters EMTALA (cont.)
Applies to anyone who “presents” on the hospital campus The hospital campus includes the parking lot, sidewalk and driveways within 250 yards of main hospital buildings Applies to all EMS transported patients Once a ground ambulance or EMS aircraft arrives on the hospital campus, the patient must receive an appropriate MSE at that hospital prior to any subsequent transfer, even if they were accidently transported to the wrong facility

EMS Legal Matters EMTALA Exception
“If as part of the EMS protocol, EMS activates helicopter evacuation of an individual with a potential emergency medical condition (EMC), the hospital that has the helipad does not have an EMTALA obligation if they are not the recipient hospital, unless a request is made by EMS personnel, the individual or a legally responsible person acting on the individual’s behalf for the examination or treatment of an EMC” 13/5/2014 DHHS CMS Letter available from S-SV EMS upon request

EMS Legal Matters EMTALA Exception (cont.)
This exception is applicable to EMS patients who meet criteria for transport to a designated STEMI, stroke, or trauma center, when EMS aircraft is deemed the most appropriate method of transport and another hospital’s helipad is being utilized to facilitate such transport If the EMS aircraft’s arrival to the helipad is delayed, or the patient’s condition deteriorates (unmanageable airway, hemodynamic instability, etc.), the patient shall be immediately brought to the ED at that facility for MSE and stabilizing treatment prior to transfer

EMS Legal Matters Possible Penalties for Violating EMTALA:
Hospital may be fined $25,000 - $50,000 per violation Physician may be fined $50,000 per violation Hospital’s Medicare provider agreement may be terminated Physician may be excluded from Medicaid/care programs A patient who suffers personal injury from the violation may sue the hospital in civil court A receiving facility, having suffered financial loss as a result of another hospitals violation, can bring suit to recover damages

Sierra – Sacramento Valley EMS Agency

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