1. Paul Hinchey MD, MBA, FACEP Jose Cabanas MD, MPH, FACEP

2.  Update on important new EMS literature  Therapeutic hypothermia  EMS 12-lead ECG  Discuss medication related events  Understand the extent of medication errors and their impact on patient care  Discuss common strategies to prevent medical errors  Update on clinical performance improvement activities

4.  What is optimal target temperature for PCAC Therapeutic Hypothermia?  Total 939 patients in randomized controlled trial  36 International ICUs across Europe  Study endpoint: mortality/neuro outcome  80% VF/VT; 20% Non VF/VT NEJM (2013)

5.  32-33 vs. 35-36 TH  Unwitnessed asystole cases not included  24% intravascular; 76% surface cooling  28 hours of total cooling NEJM (2013)

8.  In unconscious survivors of OHCA of presumed cardiac cause, TH at a targeted temperature of 33°C did not confer a benefit as compared with a targeted temperature of 36°C.  Preventing Hyperthermia appears crucial.  No changes in our current process for PCAC

9.  Does Prehospital TH have benefits?  Randomized clinical trial1,359 patients  Seattle King County Medic 1  583 with VF; 776 non-VF  Almost all patients cooled on ED arrival JAMA (2013)

10.  EMS cooling: up to 2L of 4C° LR  Mean core temp decrease by 1.20 C° to ED  EMS patients took 1 hr less to get to 34°C  Study endpoints: mortality and neuro status  EMS pts: 7-10mg pavulon + 1-2 mg valium JAMA (2013)

12.  No difference in Neuro Outomes

13. EMS TH higher cases of pulmonary edema. (p<.001) Remember Control group did NOT receive paralytics.

14.  Prehospital TH reduced core temperature and reduced the time to reach a temperature of 34°C.  No improvement in survival or neurological status.  This is one study, no change in our system at this time.

15.  How often are STEMI patients initial ECG non-diagnostic?  Do repeat ECGs have real value in routine evaluation of CP patients?  41,560 STEMI patients in ACTION Registry (2007-2010)

16.  For patients with an initial non-diagnostic ECG (11%), 72.4% (N= 3,305) had an ECG diagnostic for STEMI within 90 minutes.  No significant differences in the administration of guidelines-recommended treatments for STEMI.

18.  1/10 STEMI cases not apparent in first 12- lead ECG.  ACS cases evolve – repeat 12-leads!  Prehospital ECG’s save approx. 20-30 minutes in reperfusion time.

19.  Do repeat 12-lead ECGs make a difference?  Do repeat prehospital ECGs make any difference in STEMI diagnosis?  Canadian Study Prehosp Emerg Care 2012; 16:109-114

20.  Retrospective Analysis of 325 consecutive prehospital STEMI’s  EKG on-scene, repeat en-route and pre ED entry  275 STEMI’s in First EKG (84.6%)  30 STEMI’s in second EKG (93.8%)  20 STEMI’s in third EKG (100%) Prehosp Emerg Care 2012; 16:109-114

21.  1/10 STEMI cases not apparent in first 12- lead ECG.  ACS cases evolve – repeat 12-leads!  Prehospital ECG’s save approx. 20-30 minutes in reperfusion time.

23.  1999 Institute of Medicine (IOM) report:  3-4% of hospital patients are harmed by the health care system  7% of hospital patients are exposed to a serious medication error  50,000 – 100,000 deaths/ yr from medical mistakes

24. Serious Safety Event Event that reaches the patient & results in (death, life-threatening consequences, or serious physical or psychological injury Precursor Safety Event Event that reaches the patient & results in minimal to no harm Near Miss “Good Catch ” An event that almost happened, but error caught by a detection barrier Precursor Safety Event Serious Safety Event Near Miss Safety Event “Good Catch” Patient Safety Event ©2010 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED. Courtesy Dr. Edmond – SETON HRO

25. Some holes due to active failures Other holes due to latent conditions Successive layers of defences, barriers and safeguards Hazards Losses System defences

27.  Wrong medication  Wrong dose / route  Unrecognized clinical deterioration  Wrong procedure  Tunnel vision / decision-making  Treatment delay

28. What Kinds of Errors do Human Make? 3. Auto-Pilot 3 errors/1,000 acts 25% of healthcare errors 2.By the Rules 1 error/100 acts 60% of healthcare errors 1.Figuring it Out 30-60 errors/100 acts 15% of healthcare errors Knowledge-based Rule-basedSkill-based

30. “Any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer” National Coordinating Committee-Medication Error Reporting and Prevention (NCC MERP); accessed at http://www.nccmerp.org/aboutMedErrors.html; Jan. 2012.

31. Figure 2. Commonly studied medication errors as causes of adverse drug events (ADEs): percent of ADEs for each cause: Reducing and Preventing Adverse Drug Events To Decrease Hospital Costs. March 2001. Agency for Healthcare Research and Quality, Rockville, MD

32.  Emergency situation  No written order  No external crosscheck  No electronic decision support  High‐risk medications  Drug shortage issues and constant substitutions

33.  EMTPs completed pediatric patient simulation scenarios  Failure to use Broselow tape: 50%  Incorrect use of Broselow tape: 47%  Incorrect dosing:  Epinephrine: 68-73%  Diazepam: 47%;  Midazolam 60%

37.  We continue to see confusion with dosage calculation  1mcg/kg first dose (max 100mcg)  25mcg every 10 minutes if needed – max total 300mcg  Goal is to reduce confusion  Protocol committee looking at other potential COG changes

38.  Most providers have memorized the five rights of medication administration  Right patient, Right route, Right dose, Right time and Right medication.  These 5 “Rights” focus mostly on individual performance.  System-wide issues may impact the ability for providers to perform the 5 “Rights”

39.  Standardization in medication administration procedure  Use of memory aids and checklists  Risk-reduction strategies to minimize opportunities for error  Medication storage and packaging  Redundancies and independent backups  Team-work crosscheck

40.  Performance improvement team actively working in identifying additional ways to eliminate medication related events in our system  More information to come with 2015 COG update.

41. STEMI Update Cardiac Arrest Update Clinical Performance Indicators Clinical Audits (Surveillance)

43. Performance Improvement Activities

44.  17,730 PCR’s reviewed (2013)  560+ calls DMO Line  211 clinical events  45% self report rate  Medical Director meetings  CY 2012 = 22  CY 2013 = 33

45.  PCR’s Reviewed: (n=13,495)  Trauma Activations (n=181)  Stroke Activations(n=415)  STEMI Activation/Feedback (n=271)  ACS (n=2260)  Altered Mental Status (n=5550)  Seizure (n=3513)  Stroke (n=635)  Cardiac Arrest (n=670)

46.  NTI (n=5)  OTI (n=22)  Surgical Airway (n=1)  Diltiazem (n=42)  Versed (n=605)  Fentanyl (n=3,000)  Tourniquet (n=13)  Pelvic Binder (n=3)  Needle Decompression (n=13)  CPAP (n=305)  Pacing (n=24)  Cardioversion (n=5) July-Dec 2013 High Risk Low Frequency Events (n=4,025)

50.  43, 801 STEMI PCI patients  Median D2B of 83 min (IQR 6-109 min)  Examined D2B time vs. Mortality  2005-2006; 600 US Centers

51.  Consecutive Patients  No Transfers  No Pre PCI thrombolytic treatments  Analysis repeated excluding patients in shock  Analysis repeated using only D2B < 6 hours

53. Limit Scene Time Identify STEMI early Activating the PCI team makes a difference

54.  Minimize on scene interventions  Shorten time-to-First 12-lead  Minimize total Scene Time  Remember prehospital STEMI Bundle ▪ ASA, 12-lead (activation), PCI Center (< 90 balloon) ▪ NNT = 15 Harm avoided: Stroke, 2 nd MI or Death

57.  84,625 in hospital arrests 2000-2009  79.3% AS or PEA  20.7% VF or VT  Survival to D/C 13% to 22.3%

59.  Asystole and PEA survival about 13-14%  40% significant, 17% severe disability  VF / VT survival 40%  25% Significant, 8% Severe Disability New Engl J Med 2012; 367:1917-20

60.  AHA Consensus Statement addressing four key areas:  Metrics of CPR Performance  Monitoring and feedback  Team-level logistics issues  Emphasis on CQI for resuscitation

61.  Chest compression fraction (CCF),  Chest compression rate  Chest compression depth  Chest recoil (residual leaning)  Ventilation.

62.  Goal is to maximize the amount of time chest compressions generate blood flow  CCF is the proportion of time that chest compressions are performed during a cardiac arrest  Data on out-of-hospital cardiac arrest indicate that lower CCF is associated with decreased ROSC and survival

63.  Chest

64.  2013 Non-VF patients from ROC Network  64% Asystole, 28% PEA  Median Compression Rate: 110/min  ROSC 24.2%  2% Survival to D/C  Increasing CCF = ROSC  Target a CCF of 80%

66. 89%

70. As of January 2014

71. The clinical measures presented above have been approved by the EMS System Medical Director * *Indicates incomplete quarter National CARES 10.1%

72. The clinical measures presented above have been approved by the EMS System Medical Director * *Indicates incomplete quarter National CARES 30.8%

73. Clinical Performance Indicators

74. 16:39 09:42

75. 15:32 10:57

76. 19:02 11:52

77.  19 minutes on-scene, 10 minutes to first 12 lead. NTG OS  23 minutes, 15 minutes to 12 lead,  19 minutes on-scene, 9 minutes to obtain12 lead  19 minutes, 5 minutes to 12 lead.  3 NTG on the scene prior to transport  15:35 on-scene, 10 minutes to 1st 12 lead  16 minutes on the scene, 6 minutes to the first 12 lead.  IV initiated prior to leaving the scene

78. 96%

79. 94%

81. 96%

83.  D2B of ≤ 90 minutes now reads “an ideal of FMC -to-device time. STEMI System goal of ≤ 90 minutes” (1B)  FMC of 120 minutes or less is new target for patients who arrive at a non-PCI center (1B)  D2B now officially transitioning to “E2B”

84. 88%

85. 92%

86.  Paul.hinchey@austintexas.gov Paul.hinchey@austintexas.gov  Jose.cabanas@austintexas.gov Jose.cabanas@austintexas.gov