EMERGENCY MEDICAL CARE COMMITTEE MEETING AGENDA Thursday April 16, 2015 at 8:30 A.M. Health Campus Second Floor Large Conference Room 2180 Johnson Avenue, San Luis Obispo MEMBERS CHAIR Dr. Tom Hale, Physicians, 2013-15 VICE CHAIR Dr. Rachel May, Emergency Physicians, 2013-15 Bob Neumann, Consumers, 2013-15 Bob Perrault, City Government, 2014-16 Tom Sherman, Consumers, 2014-16 Frank Kelton, Pre-hospital Transport Providers, 2013-15 Michael Talmadge, EMS Field Personnel, 2014-16 Ken Johnson, Public Providers, 2014-16 Aaron Nix, Sheriff s Department, 2014-16 Mark Lisa, Hospitals, 2013-15 Julia Fogelson, R.N., MICNs, 2013-15 EX OFFICIO TBD EMS Division Director Dr. Tom Ronay, LEMSA Medical Director STAFF Kathy Collins, Specialty Care Systems Coordinator Vicci Stone, EMS Specialist Tracy Eby, Administrative Assistant AGENDA ITEM LEAD Call To Order Introductions Public Comment T Hale Action/Discussion Approval of minutes (attached) T Hale Reports Announcements Adjourn to Closed Session 9:00-10:30 Reconvene to Open Session Adjourn EMS Agency Staff Report Core Measures (attached) Nominations for EMCC Vacancies update June EMCC date EMS Medical Director Report Declaration of Future Agenda Items Consideration of EMS Director Candidates (pursuant to Government Code section 54957(b)) Report on Closed Session 2015 Meeting dates May 21, 2105 June 18, 2105 September 17, 2015 October 15, 2015 November 19, 2105 Health Campus 2 nd floor, Large Conference Room Kathy Collins Tom Ronay T Hale T Hale T Hale
Draft Emergency Medical Care Committee Meeting Minutes Thursday, March 19, 2015 8:30 A.M. Health Agency Second Floor Large Conference Room 2180 Johnson Avenue San Luis Obispo Members CHAIR Dr. Tom Hale, Physicians VICE CHAIR Dr. Rachel May, Emergency Medicine Physicians Bob Neumann, Consumers Bob Perrault, City Government Tom Sherman, Consumers Michael Talmadge, EMS Field Personnel Ken Johnson, Public Providers Aaron Nix, Sheriff s Department Mark Lisa, Hospitals Frank Kelton, Pre-hospital Transport Providers Julia Fogelson, R.N., MICNs Ex Officio Kathy Collins., Interim EMS Division Director Dr. Thomas Ronay, LEMSA Medical Director Staff Dr. Penny Borenstein, County Health Officer Vicci Stone, EMS Specialist Todd Spanton, EMS Specialist Tracy Eby, Administrative Assistant Guests See sign in AGENDA ITEM / DISCUSSION ACTION CALL TO ORDER Introductions Roundtable introductions including members of the public Meeting called to order at 0833 Public Comment no comment Approval of January 2015 meeting minutes Motion to approve F. Kelton / second B. Neumann; carried DISCUSSION/ACTION ITEMS MICN Training Sent out background information with the agenda packet to facilitate the MICN discussion today. Discussion started in December 2013 with Steve Lieberman, Kathy Collins, Julie Fogelson and Jill Urmy on the feasibility of building an on-line MICN course. Jill was tasked with putting the course content from the EMSA current course into Healthstream. Due to various factors, the project was put on hold. One of the factors is that Healthstream is no longer going to be the shared platform within all local hospital learning systems. The impetus for the discussion today is a September deadline after which Dignity will lose their local administrator rights to the program, then requiring uploading to be done on through the national headquarters. J. Fogelson and J. Urmy expressed strong desire to re-start the pilot on-line MICN class before the lock out date in September so as to not lose the work that J. Urmy has done in uploading the content to the platform. EMCC Nominations Committee nominations time is upon us. P. Borenstein will contacting the nominating bodies to ask for new nominations or continued commitment from current members. SLO Medical Association has merged with Santa Barbara County Medical Association, not sure if the bylaws will need to be updated to reflect the name change. Tenet is no longer a member of the Hospital Council of Northern & Central California. Do we need to look at a different rotation pattern if they take issue with nominating a non-member. EMS Agency Staff Reports EMS Director Update Initial top 3 candidates did not pan out, we are now in the process of going back to the list. The remaining candidates may or may not be vetted through this group again. It may be that we have to go back out again for a new recruitment. Received one BLS to ALS application since the approval of the new policy last month. Currently in process of review. Specialty Care Report Overall the system has seen an increase in calls and in transports. With the implementation of the trauma system we have really improved the system and patient survival rate. Some dramatic cases in the last year have had patients surviving injuries that 5 yrs ago would have been fatal. The STEMI center continues to function well, activations are creeping up. Kudos to our internal transfer process, paring down a 107 min time to 85 mins. This is for walk-in patients, including North County over the hill transfer times. Core Measures are reported back to the State, we do a great job and comparing our stats with other counties, we come out well. High Performance CPR Gave a brief history behind the idea and science supporting the move Motion to approve J. Fogelson / second F. Kelton; carried Report only, no action required Report only, no action required
towards this method of pre-hospital running of cardiac arrest calls. Will involve the whole system from dispatch to first responders, law enforcement, EMS personnel and hospital staff. Have gained funding and equipment pledges from French, San Luis Ambulance and EMSA Inc to help fund the program. Will have a field staff coordinator position with a cadre of core instructors. Stroke Late spring / early summer stroke program will be in place for all local hospitals. Trainings APR course next week, EMD initial course the week after. June will be the yearly airway lab with training aides in conjunction with SLOFIST. DPAK will have a presentation of the afteraction report on CHEMPAK. EMS Medical Director Report AHA is supportive of the high performance/ pit crew CPR concept. October 2015 AHA update will reflect this. Timing of the roll-out of our program is well-done. The State is working on stroke mandates similar to STEMI and Trauma guidelines. There are regional comprehensive stroke care centers, Cottage to our south is the nearest comprehensive stroke care center. There is legislation to remove the medical oversight requirements for AED. Ebola is still on the radar, 9-14 patients are the watch list in CA. Many are returning medical personnel from overseas. Community paramedicine pilot programs are in the training phases right now, should be interesting to watch the programs rollout into the field. LVADS keeping up to date on the products out there, seeing more patients with them. Will be putting out a guideline document for field staff. Thanks to Todd Spanton for the tour of Fort Hunter Liggett. Very cool to see the resources we have in our own backyard. We were at the tour during the St. Frattty s Day event, thanks to all the first responders, field staff, law enforcement and hospitals for all their work. Lessons learned and will be incorporating some of those items into our draft MCI policy Future Agenda Items none Next Regular Meeting April 16, 2015 at 0830 Health Agency 2 nd Floor Large Conference Room Adjournment Meeting adjourned at 1002 EMCC - Page 2 of 2
SLO EMSA Core Measures Report March 2015 The following information represents the each of the required core measures for 2015 and is presented in one of two formats: (1) a numerical percent (numerator divided by the denominator multiplied by 100 to obtain the percent value) (2) the 90 th percentile of the given numbers in their ascending order. For comparative purposes, this report includes information previously submitted to the State EMS Authority for the 2010, 2011, 2012, and 2013 reporting periods. In comparing data from previous years with the 2014 data, it should be noted that a number of the indicators were refined or redefined in 2014 and changes were incorporated into the epcr program to allow for more accurate data collection. TRA-1 On-scene time for severely injured trauma patients Patient population: Patients meeting Traumatic Injury with a GCS of less than 14, or BP leas than 90 mmhg or respiratory rate of less than 10 or greater than 29 for adults or less than 20 for children less than 1 year. (Note in 2012 and 2013 RTS of <5 was utilized as a screening indicator RTS was omitted in 2014) The epcr was modified in 2014 to capture the patient population with a single query of trauma patients meeting Step 1 trauma triage criteria meeting the definition described above. Measurement: The 90 th percentile of the on-scene time in minutes measured from patient contact to enroute for all patients including those requiring extrication (Beginning in 2014 the SLO EMSA was able to acquire EMS Authority request for time in minutes and seconds). Year Cases Included 90 th % of the On-scene Time in Minutes 2012 (*) 52 23 min 2013 99 22 min 2014 51 25.62 min (*)Time period reviewed: 9 mos. in 2012 representing the first 9 months of the trauma system operational. 2012 and 2013 data may be incomplete or inaccurate as the EMS agency did not track or have capability to obtain RTS or patients meeting Step One criteria without a data pull on each element and cross matching for duplicates. 2014 The PCR vendor added the ability to calculate RTS and the capability of running individual reports by the individual Trauma Triage Steps 1-4. TRA-2 Direct transport to a Trauma Center for severely injured trauma patients Patient population same as in TRA-1 Patient population transported directly to a trauma center.
2012 (*) 52 41 79% 2013 99 92 93% 2014 51 49 96% (*) Time period reviewed: 9 mos. of 2012 representing the first 9 months of the trauma system operational ACS-1 ASA Administration for Chest Pain Patients over 35 years old treated under SLO County chest pain protocol. Patient population identified above that received ASA from an EMS Provider. 2010 854 617 72.2% 2011 795 564 70.9% 2012 768 552 71.9% 2013 657 456 69% 2014 617 603 97% Data Challenges: In the reporting periods of 2010-2013 this indicator appears to accurately represent ASA administration by EMS personnel, it does not account for administered ASA prior to arrival when described in the narrative or identify other reasons for non-administration (e.g. allergies). In 2014 a hand-review of the cases where ASA was not documented to be administered by the EMS personnel identified 123 of the 617 cases where the narrative identified that ASA was administered prior to arrival or that patient was allergic to ASA. For the 2014 reporting period the numerator was adjusted to include ASA administered prior to arrival when documented in the narrative. The PCR vendor has been asked if the confounders of administration can be added. ACS-2 12 Lead ECG Performance Patients over 35 years old treated under SLO County chest pain protocol. Patients population identified above who received a 12 lead ECG.
2010 854 703 82.3% 2011 795 688 86.5% 2012 768 665 86.5% 2013 556 556 100% 2014 617 605 98% ACS-3 Scene time for Suspected Heart Attack (STEMI only) Population: Measurement: Patients over 35 years old meeting SLO County STEMI Alert criteria. 90 th percentile of the on-scene time in measured from patient contact to enroute minutes (in 2014 the SLO EMS was able to acquire EMS Authority request for time in minutes and seconds). Year Cases Included 90 th % of the On-scene Time in Minutes 2010 (*) 32 17 min 2011 71 21 min 2012 56 22 min 2013 61 21 min 2014 62 19.85 min (*) STEMI program began in August of 2010 thus 2010 data reflective of 5 mos. Time studies utilizing the 90 th percentile method may not reflective of actual performance thresholds, particularly with the small number of cases included. ACS-5 Direct transport to a PCI Center with a STEMI Patients over 35 years old meeting SLO County STEMI Alert criteria. Patient population identified above who were transported directly to the STEMI Center.
2010 (*) 29 28 95.7% 2011 80 78 97.5% 2012 70 67 96.6% 2013 61 60 98% 2014 62 60 97% (*) STEMI program began in August of 2010 thus 2010 data reflective of 5 mos. CAR-2 Out of Hospital Cardiac Arrest with ROSC Total number of cardiac arrest patients that received EMS resuscitative measures and were transported to a hospital. Patient population identified above who experienced a Return of Spontaneous Circulation (ROSC) any time during the call. 2010 244 50 20.1% 2011 241 66 27% 2012 214 50 23.4% 2013 209 48 23% 2014 215 46 18.6%
CAR-3 Cardiac Arrest Survived to ED Discharge Data collection for this population began in January 2013 Number of EMS patients who experienced cardiac arrest and were resuscitation was attempted by EMS personnel. Patient population identified above who survived to ED discharge. 2013 209 44 21% 2014 215 35 16% Data challenges: Outcome data will require hospital cooperation and internal policies to acquire. There is an additional time requirement of staff(s) at both the hospital and EMS to collect and track CAR-4 Out-of Hospital Cardiac Arrest Survival Data collection for this population began in January 2013 Number of EMS patients who experienced cardiac arrest and were resuscitation was attempted by EMS personnel.. Patient population identified above who were discharged to home, transferred to rehab or skilled nursing facility. 2013 209 14 6.7% 2014 215 13 6% Data challenges: Outcome data will require hospital cooperation and internal policies to acquire. There is an additional time requirement of staff(s) at both the hospital and EMS to collect and track STR-2 Glucose Testing for Suspected Stroke Patients Total number of patients over 18 years with primary or secondary impression/use of SLO County Suspected Stroke/Transient Ischemic Attack protocol. Patient population identified above documented to have received glucose testing.
2012 (*) 89 82 92% 2013 72 68 94% 2014 122 120 98% STR-3 Scene Time for Suspected Stroke Patients Population: Measurement: Total number of patients over 18 years with primary or secondary impression/use of SLO County Suspected Stroke/Transient Ischemic Attack protocol that were transported to a hospital. 90 th percentile of the on-scene time in minutes measured from patient contact to enroute (in 2014 the SLO EMSA was able to acquire EMS Authority request for time in minutes and seconds). Year Cases Included 90 th % of the On-scene Time in Minutes 2012 89 17 min 2013 72 16 min 2014 122 17.67 min STR-5 Direct Transport to a Stroke Center for Suspected Stroke Patients meeting Criteria No data: No Stroke Centers have been designated in SLO County RES-2 Bronchodilator Administration in Adults (Beta2 Agonist) In 2014 the definition was redefined to include the total number of patients over 14 years with primary complaint of shortness of breath- suspected asthma/copd. The current SLO County Respiratory Distress protocol does not differentiate types of respiratory distress thus we were unable to run a report. Patient population identified above documented to have received a bronchodilator (Albuterol) by EMS personnel.
2010 563 359 64% 2011 564 314 56% 2012 533 334 63% 2013 522 351 67% 2014 Unable to report due to new definition Data Challenges; Current protocols address Respiratory Distress is general staff is developing new protocols and working with the PCR vendor to identify bronchospasm separately from other respiratory distress complaints i.e. CHF PED-1 Pediatric Asthma Patients Receiving Bronchodilators The 2014 the definition was redefined to include the total number of patients less than 14 years with primary shortness of breath- suspected bronchospasm. The current SLO County Pediatric Respiratory Distress protocol does not differentiate types of respiratory distress thus unable to run a report. Patient population identified above with wheezing and documented to have received bronchodilator (Albuterol) by EMS 2010 31 20 65% 2011 29 18 62% 2012 31 20 65% 2013 17 12 71% 2014 Unable to report due to new definition The numbers are small and may not meet minimum of 30 cases per year reviewed to be statistically significant Data Challenges; Current protocols address Respiratory Distress is general staff is developing new protocols and working with the PCR vendor to identify bronchospasm separately from other respiratory distress complaints
PAI-1 Pain Intervention in Patients over 14 Years with Pain Scale of 7 or greater No data: In 2014 pain scale measurements were added to the epcr however reports could not be retrieved with current PCR data program nor is there an ability to effectively identify interventions. Pain scale measurements are documented in the PCR and the EMSA is working with PCR vendor to update the program. SKI-1 Endotracheal Success Rate Total number of endotracheal intubation procedures attempted. An attempt in SLO County is defined as an interruption of ventilation with insertion of endotracheal tube into the mouth. In 2014 the SLO EMSA began tracking the successful % of attempts and well as the successful % of patients intubated. Success is defined as completion on the first or second attempt. Prior to 2014 success was tracked by % of patient successes. Data is presented in both formats below Patient population identified above who were successfully intubated on first or second attempt. 2010 160 127 79% 2011 160 123 77% 2012 160 133 83% 2013 122 100 82% 2014 (patients) 118 102 86% 2014 (attempts) 166 102 61% SK-2 End Tidal CO2 or Capnography Documented on Intubated Patients The total number of all successful intubation procedures. Patient population identified above who were successfully intubated on first or second attempt and had a documented ETCO2 or capnography value.
2010 137 73 53% 2011 160 80 50% 2012 148 65 44% 2013 122 68 56% 2014 108 70 65% RST-1 Code 3 Ambulance Response Time by Zone RST-2 Code 2 Ambulance Response Time by Zone RST-3 Percent of Code 3 Responses Transported to a Hospital by Zone The SLO EMS Plan identifies zones that do not match the PCR response zones. A hand tally would be required to match the sub-zones of the PCR with the SLO EMS Plan response zones. Staff analysis feels data does not adequately review calls urban, remote, and rural nor provide meaningful information or ability to monitor response time requirements per contract agreement.