Emergency Medical Services Council Health Services Building MC L963 525 Portland Avenue South Minneapolis, MN 55415-1569 612-348-6001, Phone chd.ems@co.hennepin.mn.us Medical Standards Committee Thursday, June 07, 2018, 9:30 a.m. - 11:30 a.m. Edina Fire Station #1 6250 Tracy Avenue, Edina 55436 Draft Minutes Present 1. Todd Joing, M.D., Fairview Southdale Hospital 2. Doug Kayser, Ridgeview Ambulance Service 3. David Ladmer, M.D., Methodist Hospital 4. Charles Lick, M.D., Allina Health EMS 5. Michelle London, M.D., Minneapolis Children s Hospital (Chair) 6. Paul Nystrom, M.D., Edina Fire Department 7. Lisa Pearson, UMMC 8. Kevin Sipprell, M.D., Ridgeview Ambulance 9. Angela Walker, Hennepin EMS Guests Absent 1. Wade Brennom, M.D., Abbott Northwestern Hospital 2. Ellen Cales, M.D., Mercy Hospital 3. Jeff Ho, M.D., Hennepin EMS 4. Wendy Lynch, Hennepin EMS 5. John Lyng, M.D., North Ambulance Service Staff 1. Matthew R. Maxwell Welcome and Introductions Chair Michelle London called the meeting to order at 9:37 a.m. with a quorum present. After introductions, the proposed June 7, 2018 agenda and meeting summary from March 1, 2018 were approved. Report from Ambulance Medical Directors Subcommittee Doctor Kevin Sipprell, Chair of the Ambulance Medical Directors (AMD) Subcommittee, provided a brief report on the following work of the Subcommittee: Opioid Study The five ambulance services instituted protocol changes over the course of roughly one year to reduce the frequency in which opioids are administered for pain complaints. Intent of the change was to target drug seeking patients, and reduce opioid administration to patients with chronic, but non-acute, conditions and pain complaints. Page 1 of 6 D R A F T June 7, 2018
Lori Bollins, epidemiologist with Allina Health, has taken a lead role and is working with the services to collect relevant data and publish results. External Medical Control Physician Database EMS Unit staff are creating an external facing SharePoint database of medical control physician information. Database will only contain first and last name and assigned medical control numbers. Access will be limited to hospital ED medical directors, and they will be limited to view only medical control physicians at their hospital. Known Outbreak of Transmittable Respiratory Illness (patient is breathing) The subcommittee recommended the following changes (underlined text represents proposed language; strikethrough text represents proposed deleted language): To be used for patients with known or suspected transmittable respiratory illnesses (e.g. Severe Acute Respiratory Syndrome (SARS), tuberculosis, epidemic influenza, etc.), in the presence of a known outbreak. This would include patients who have a febrile illness with cough. Standing Orders Protect yourself and crew with gowns, gloves and N95 mask/powered Air Purifying Respirators (PAPR) and eye protection. Begin oxygen therapy by mask. If oxygen is not needed then place a surgical mask on the patient For patients in moderate to severe respiratory distress, may administer on-site terbutaline 0.25 mg SC for patients less than 60 years of age AND no history of cardiac disease For wheezing give albuterol metered dose inhaler (MDI) 2 puffs or via breath actuated nebulizer (i.e. AeroEclipse), may repeat x 1. Additional treatment may be given every 15 minutes thereafter as needed If available, consider Continuous Positive Airway Pressure (CPAP) when two or more of the following are present: Retractions or accessory muscle use Pulmonary edema Respiratory rate greater than 25/minute SpO2 less than 92% Administer CPAP (device dependent, per service medical director) Assess patient response If the patient s condition worsens, (e.g. patient becomes hypotensive, decreased SpO2) discontinue CPAP Contact receiving hospital for isolation room preparations For patients in moderate to severe respiratory distress, may administer on-site terbutaline 0.25 mg SC or epinephrine 0.5 ml (formerly 1:1,000) IM for patients less than 60 years of age AND no history of cardiac disease. Page 2 of 6 D R A F T June 7, 2018
After Obtaining Verbal Orders If not already given, consider terbutaline 0.25 mg SC May repeat albuterol immediately for moderate to severe distress Known Outbreak of Transmittable Respiratory Illness (patient is not breathing) The subcommittee recommended the following changes (underlined text represents proposed language; strikethrough text represents proposed deleted language): To be used for patients with known or suspected transmittable respiratory illnesses (e.g. Severe Acute Respiratory Syndrome (SARS), tuberculosis, epidemic influenza, etc.), in the presence of a known outbreak. This would include patients who have a febrile illness with cough. Standing Orders A. Protect yourself and crew with gowns, gloves and N95 masks/powered Air Purifying Respirators (PAPR) and eye protection. B. Insert oral airway and begin positive pressure ventilation C. Insert ET tube or other airway control device as authorized, as soon as possible. Use face shield (or Powered Air Purifying Respirator if wearing one) for your eye protection during intubation May administer terbutaline 0.25 mg SC or epinephrine 0.5 ml (formerly 1:1,000) IM D. See the Table of Contents for the EMSRB/MDH Exposure Response Guide for further information Page 3 of 6 D R A F T June 7, 2018
Do Not Resuscitate Guideline The Committee approved the following recommended DNR guideline for EMS Council review: Are valid* DNR orders with the patient? Yes No Did the patient (prior to arresting), immediate family or caregiver (prior/post arrest) tell you to ignore the orders and perform life saving measures? Has the pt's imediate family or caregiver indicated valid* DNR orders exist? Yes No Yes No Perform life saving measures Provide comfort measures only; no life saving measures Contact medical control while starting basic life support CPR * Valid DNR orders - The DNR or POLST form must be signed by the patient/proxy, witness, and physician or advance practice provider (APP). In the nursing home, DNR orders written in the order section of the medical record are valid if signed by the physician (A DNR form may be used, but is not required in the nursing home.). STEMI Policy The Committee continued its discussion on the draft Seven-County Metro Region EMS System Transport Policy for STEMI Patients. London briefly reminded the Committee that, at its last meeting, members reached shared agreement on what constitutes a STEMI but not the definition of a STEMI Receiving Center. London reminded the Committee that a survey of current hospitals providing STEMI care indicated only one hospital has a certification from a nationally recognized certifying body for the provision of emergency care for STEMI patients. Also, at the previous meeting the Committee had requested information pertaining to the number of national certifying entities, certification cost, and involvement to obtain certification. Matthew Maxwell presented a chart showing current national certifying organizations, estimated cost for certification, requirements for site inspections and associated site inspection cost, and other details. Per Maxwell, certification by one four of the organizations Page 4 of 6 D R A F T June 7, 2018
listed (ACC/SCPC, AHA, ACE, and TJC) would meet criteria delineated in the Minnesota state STEMI statute. The Committee discussed what role the EMS Council and EMS System should have in a STEMI system. Overall, there was agreement that the purpose of the EMS STEMI policy is to provide disposition guidance for paramedics, but absent an existing STEMI designating system managed and regulated by a third party entity (e.g. state of Minnesota or an certifying body) the current local policy is the only construct that delineates which hospitals are appropriate destinations for acute STEMI patients. There wasn t consensus among Committee members on how much involvement the EMS System should have in defining what constitutes a STEMI receiving center. Numerous Committee members felt this was outside the scope of the EMS Council, which is primarily an ambulance policy setting body, but recognized that absent a third party STEMI receiving center designating organization any hospital could self-identify as a STEMI receiving center. Sipprell added that the ambulance medical directors have a vested interest in assuring patients transported by ambulance are brought to appropriate facilities. The Committee agreed on the following draft policy. Also, the Committee recommended the draft be submitted to the existing STEMI receiving centers for public comment. Feedback from the STEMI receiving centers will be reviewed by the Committee at its next meeting. PURPOSE To provide guidelines to ambulance services in the Hennepin County EMS System for the appropriate and timely transport of 9-1-1 patients identified with ST elevation acute myocardial infarctions (STEMI), to a STEMI Receiving Center. STEMI PATIENT A patient shall be identified as a STEMI patient for the purpose of this policy if they meet all of the following criteria. 1. Patient presents with concern for acute coronary syndrome. 2. 12-lead findings that are consistent with STEMI STEMI RECEIVING CENTER A hospital shall be considered an appropriate destination (Attachment A) for the purpose of receiving 9-1-1 emergent STEMI patients from the Hennepin County EMS System if one of the following is met: The hospital is designated as a STEMI Receiving Center by the State of Minnesota Department of Health in accordance with MN Statute 144.4941. The hospital has committed in writing (and renews in writing every two years), and assured the Hennepin County EMS Council, it meets current national standards and best practices for the treatment and care of STEMI patients. INFORMATION SHARING Sharing of information between the receiving hospital and transporting agency related to STEMI patients, including patient outcomes and time intervals, for purposes of care improvement, educational feedback, or peer review is encouraged and is considered a Page 5 of 6 D R A F T June 7, 2018
best practice by the EMS Council. This activity is supported by federal HIPAA regulations as acceptable sharing of patient information. EMS DISPOSITION: Ambulance crews shall transport/divert all patients meeting the STEMI inclusion criteria from the scene directly to a STEMI Receiving Center. Minnesota Department of Health Hospital Closure Data Reviewed the latest report. No further discussion Future meetings, Thursday 9:30-11:30 a.m., at Edina Fire Department: September 6, 2018 December 6, 2018 Adjourn The meeting adjourned at 11:10 a.m. Page 6 of 6 D R A F T June 7, 2018