Chapter 2 EMS Systems Objectives Relate to prehospital care as extension of hospital care Differentiate between situations in which EMT-I should: Attempt to stabilize patient on scene Require rapid and immediate transport to hospital Objectives Describe the integration of prehospital care into the continuum of total patient care with the emergency phase of hospital care Discuss citizen access and mechanisms of obtaining it List members of EMS team 1
Objectives Identify typical components of EMS system Recall: KKK Ambulance Standards American College of Surgeons Essential Equipment list Objectives Discuss replacement of supplies and equipment Define and describe medical direction Discuss role of medical community in overseeing prehospital care Define protocols and standing orders Objectives Describe the relationship between physician on the radio and EMT-I at the scene Define physician responsibility for medical direction Describe retrospective evaluation of patient care, including run report review, continuing education, skill practice, and skill deterioration 2
Historical Background Napoleon U.S. Civil War Vietnam Aeromedical services Early civilian systems The White Paper 1966 Accidental Death and Disability, The Neglected Disease of Modern Society Injury most neglected disease in America Emphasized need for organized prehospital care Evolution of Modern EMS Dr. J. Frank Pantridge Belfast, Northern Ireland Insert fig 2-1 Dr. James V. Warren Ohio State University Dr. Eugene Nagel University of Miami Dr. Leonard Cobb Seattle, WA Dr. J. Michael Criley Los Angeles Dr. Eugene Nagel hooked up to first telemetry transmitter 3
EMS Act of 1973 Provided federal monies to establish EMS systems across U.S. DOT established: Minimum training standards Equipment standards Evolution of EMS Systems 1986 White Paper Revised Injury continued to be issue 1990 Trauma Systems Development Act Federal monies to develop trauma systems Elements Incident occurrence Recognition System access and dispatch Prehospital care Patient stabilization and transport Delivery to hospital Preparation for next event 4
Incident occurrence and recognition Bystander care Relieve airway obstruction CPR Control bleeding Provide comfort and reassurance System access and dispatch 9-1-1 OR Local sheriff, police, or fire department dispatcher OR Private ambulance services or volunteer systems directly Emergency Medical Dispatchers (EMD) Training Computer-aided dispatch Priority dispatch Pre-arrival instructions System status management Prehospital care Treatment patient receives before arrival at hospital An extension of hospital care Medical direction physician legal responsibility for advanced management skills 5
Prehospital care Provide definitive care ASAP if life threats Care can often be started and completed in the field Stabilization can only be accomplished in the operating room Differentiate between patients who can be stabilized on scene and those who require transport Prehospital care Patient transport may not be necessary May be false alarm Patient has gone to hospital on his/her own Patient refuses treatment and/or transport Ambulance transport not warranted Hospital emergency care and recuperation Upon arrival at hospital, patient receives additional treatment in ED If required, patient admitted After release from hospital, patient may need follow-up treatment and/or physical therapy 6
The emergency department EMS team extends to ED Physicians Nurses Specialized technicians The emergency department ED physicians Licensed physicians with special training and experience in emergency medicine American College of Emergency Physicians (ACEP) and National Association of EMS Physicians (NAEMSP) encourage ED physicians to take active role in EMS systems The emergency department ED nurses Assess patient on arrival (triage) and determine need for emergency care Prehospital care providers have more direct contact with ED nurses than any other hospital employee 7
The emergency department Other healthcare professionals Respiratory therapists Radiology technicians Rehabilitation specialists Other technical and administrative personnel EMT-I in the ED Take vital signs Document patient information Transport patients within hospital Clean and bandage wounds Perform CPR Restock supplies Splint fractures Draw blood Place intravenous lines Sometimes perform endotracheal intubation Manpower Communications Administration Transportation Equipment/supplies procurement and inventory Facilities Funding Consumer information and education Medical direction Medical record keeping Quality improvement Research Training Critical care units Public safety agencies Disaster linkage Mutual aid 8
Manpower Dependent on variety of team members EMS personnel Day-to-day patient care Administrative System response configuration EMT-B and EMT-I or EMT-P on same unit Tiered response system EMT-Bs sent to all calls; ALS only dispatched if necessary Communications Procedures and equipment Computer-aided dispatch Most rapid system access Priority dispatch Determines type of response necessary Prearrival instructions Instructions for immediate care System status management Manages available resources 9
Administration Direct and maintain system Provide overall direction Develop and administer policies Prepare and monitor budgets Hire and promote employees Investigate complaints Conduct hearings, issue discipline, process grievances Communicates with media, community Maintain documents, prepare schedules Procure and maintain equipment Monitor and modify system performance Manage patient billing system Transportation Emergency response vehicles Ambulance should meet current KKK standards Staff or supervisory car Equipment trucks, rescue trucks, all-terrain vehicles Boats Fixed-wing aircraft or helicopters Transportation Vehicle fleet management program Develops specifications for new vehicles Conducts routine repair work and repairs Performs preventive maintenance 10
Equipment/supplies procurement & inventory ACSC Trauma Essential Equipment list ET tubes Laryngoscope handles and blades Syringes Stylette IV equipment Additional equipment per local needs Equipment/supplies procurement and inventory Inventory control process to safeguard system Hospital may retrieve and store equipment Backboards Splints Facilities Base stations Headquarters Communication centers Training facilities 11
Funding Financial support from: Taxes Billing patients Subscriptions Donations Grants Consumer information and education Prepare public to respond to emergencies Programs Recognize S/S of serious illness/injury Access EMS Provide life-saving interventions Education campaigns Prevent disease Reduce unnecessary use of EMS Recruit personnel Boost image Medical direction Medical supervision of an EMS system and the field performance of EMTs Day-to-day activities guided by Direct (on-line) medical direction Care rendered under direct orders Radio or telephone Indirect (off-line) medical direction Written instructions Protocols Standing orders 12
Medical direction EMS physician involvement (indirect) Prospective phase primarily administrative; duties include training, protocol development, system design Immediate phase both clinical and administrative; provides patient care, participates in prehospital research, performs concurrent review of EMT activities, gives radio direction Retrospective phase quality control and risk management Medical direction Protocols A set of written policies and procedures Standing orders Field interventions that are completed before contacting medical direction Medical direction EMS systems usually influenced by combination of direct and indirect medical direction Commonly, protocols followed for initial care of life-threatening problems (e.g., cardiac arrest, severe bleeding, major trauma, shock) Once care provided to certain point, EMT-I required to contact medical direction for further instructions State law determines type of medical direction 13
Medical record keeping Accurate and thorough documentation essential Key element in QI activities Quality improvement An essential component Evaluation of EMS performance Purpose Identify areas of needed improvement Implement necessary corrections Based on comparison of care given with accepted standards Most often completed by management and physicians Quality improvement Documentation Primary component Patient care reports checked for Completeness Accuracy of charting and assessment Adherence to system treatment protocols Patterns of error or system-related problems 14
Quality improvement Direct observation To determine levels of performance Usually done by riding with EMTs Analysis of response time data reveals Operational efficiency Need for redeployment of units Need to acquire additional units Other data evaluated Dispatch tapes Prehospital care data Incident reports Hospital records Quality improvement Corrective action taken when improper care revealed Communicate proper or exceptional performance to help reinforce behavior Must be linked with ongoing professional education Research Historically, treatment protocols drawn from hospital setting Many prehospital protocols not evidence-based Need to determine which protocols and techniques are beneficial Benefits Immediate potential to save lives Limit morbidity by improving patient care Can prove EMS care makes a difference 15
Training Functions of training program Conduct basic and advanced training Provide ongoing education Maintain CE records Prepare and submit paperwork for recertification Critical care units Provide advanced/highly specialized care during interfacility transport Staffing Paramedics Nurses Physicians Critical care units May be Ground units Helicopters Fixed-wing air medical transport units 16
Public safety agencies Interactivity with multiple agencies Policies define roles and responsibilities of each Mutual aid Providers cross geographic boundaries to assist Should be via formal agreement May be reciprocal Disaster linkage Coordinate response to MCI or disaster Types of systems Fire service Third service Private services Hospital-based systems Volunteer systems 17
Summary EMS evolved from battlefield care to sophisticated prehospital patient care system EMTs provide initial care; patient is then transported to ED Medical direction typically provided for all levels of prehospital care (direct, indirect, or both) EMS physicians and ED nurses often actively involved in EMS and part of EMS team Evaluation and research are critical to EMS Questions? 18