1. ANATOMY OF A MEDICAL CALL or “How we do…what we do!” San Francisco Fire Commission Thursday July 28, 2005

2. What we’ll talk about The Language of EMS The Language of EMS Summary Statistics Summary Statistics Rules of the Game Rules of the Game A Typical Incident A Typical Incident Intake (the call to 911) Intake (the call to 911) Operations (what happens on scene) Operations (what happens on scene) The back-end The back-end Quality Improvement / Risk Management Quality Improvement / Risk Management Billing and Revenue / Medical Records Billing and Revenue / Medical Records The Other Players The Other Players

3. The Language of EMS ALS = Advanced Life Support ALS = Advanced Life Support Paramedic level of care Paramedic level of care BLS = Basic Life Support BLS = Basic Life Support EMT level of care EMT level of care Code 3 = Potentially life threatening event Code 3 = Potentially life threatening event Lights and sirens Lights and sirens Code 2 = Potentially non-life threatening event Code 2 = Potentially non-life threatening event Respond with the flow of normal traffic Respond with the flow of normal traffic

4. More Info EMT-local certification Minimum 120 hours of training Minimum 120 hours of training Non-invasive maneuvers Non-invasive maneuvers Bleeding control, basic airways, CPR, w/hold CPR Bleeding control, basic airways, CPR, w/hold CPR 1100 + in our Department 1100 + in our Department PARAMEDIC-California State license Minimum of 1400 hours of training Minimum of 1400 hours of training Invasive maneuvers Invasive maneuvers IVs, drugs, advanced airways, pronouncement IVs, drugs, advanced airways, pronouncement 270 in our Department 270 in our Department

5. San Francisco Fire Department Summary Statistics FY 2004 – 2005 102,000 Total incidents 102,000 Total incidents 70,773 Primary medical complaint 70,773 Primary medical complaint 47,234 Code 3 responses 47,234 Code 3 responses 20,720 Code 2 responses 20,720 Code 2 responses 48,126 transports (68 %) 48,126 transports (68 %)

6. Summary Stats FY 2004 – 2005 48,126 transports 48,126 transports SFGH – “The Mission / The Mish” St. Francis Hospital Pacific Medical Center – Pacific Campus St. Luke's Hospital UCSF Kaiser – San Francisco St. Mary’s Hospital Pacific Medical Center – RKD Campus VA Hospital Chinese Hospital Kaiser – South San Francisco Seton Hospital Pacific Medical Center – California Campus *McMillan Stabilization Center 38 % of our transports go to San Francisco General Hospital

7. Rule of the Game OUR AVAILABLE RESOURCES First Responders First Responders 42 Engine Companies 42 Engine Companies 24 ALS Paramedic staffed 24 ALS Paramedic staffed 18 BLS EMT staffed 18 BLS EMT staffed 19 Truck Companies (EMT staffed) 19 Truck Companies (EMT staffed) 2 Heavy Rescue Squads (EMT staffed) 2 Heavy Rescue Squads (EMT staffed) Transport units Transport units 19 ambulances (1 PM / 1 EMT) 19 ambulances (1 PM / 1 EMT) Dual H1 ambulances (2 PMs) (Tue – Fri: 6am – 2am) Dual H1 ambulances (2 PMs) (Tue – Fri: 6am – 2am) 4 Paramedic Captains (RCs) 4 Paramedic Captains (RCs)

8. Rules of the Game At Dispatch Cannot turn down any requests Cannot turn down any requests Code 3 requires 2 paramedics Code 3 requires 2 paramedics Call taking and dispatch is done at the ECD –by civilian PSDs Call taking and dispatch is done at the ECD –by civilian PSDs Call evaluation / triage– done with a nationally recognized system – MPDS (“Clawson system”) Call evaluation / triage– done with a nationally recognized system – MPDS (“Clawson system”) Software integrated into CAD Software integrated into CAD

9. Rules of the Game In the Field Response time goals (90 th percentiles): Response time goals (90 th percentiles): Code 3’s Code 3’s 1 st unit in 4:30 1 st unit in 4:30 1 st ALS in 7:00 1 st ALS in 7:00 Ambulance in 10:00 Ambulance in 10:00 Code 2’s Code 2’s Ambulance in 20:00 Ambulance in 20:00

10. Rules of the Game Patient Disposition Transport to appropriate ER Transport to appropriate ER Transport to McMillan Stabilization Center – 39 Fell St. Transport to McMillan Stabilization Center – 39 Fell St. Patient refusal Patient refusal Other Other MAP MAP Medical Examiner Medical Examiner Police Police POV POV

11. Rules of the Game Emergency Departments Trauma Center - SFGH Trauma Center - SFGH Specialty Centers Specialty Centers Burns Burns Re-implantation Re-implantation Pediatric Critical Care Pediatric Critical Care In custody – SFGH In custody – SFGH OB OB One Twist: Hospitals can close to ambulances – “diversion”

12. Rules of the Game Transport Transport Hospital notification – not so sick Hospital notification – not so sick Base Hospital contact – MD consult Base Hospital contact – MD consult Patient Refusal Patient Refusal Consult w/Base Hospital Consult w/Base Hospital Agreement of 2 paramedics Agreement of 2 paramedics Death in the Field Death in the Field

13. A Typical Incident INTAKE AT 9-1-1

14. A Call to 911 The Emergency Communications Department 1011 Turk Street

15. Where the Dispatch Comes From

16. A Call to 911 ECD receives 4,300-4,600 calls per day ECD receives 4,300-4,600 calls per day 1.6 million phone calls per year 1.6 million phone calls per year Emergency calls (3200-3400) Emergency calls (3200-3400) Non-emergency calls (800-1200) Non-emergency calls (800-1200) 85% Police 85% Police 15% Fire 15% Fire 8 to 20 Call takers on duty 8 to 20 Call takers on duty Call pick-up Call pick-up Answered @ 9 secs* Answered @ 9 secs* Interrogation Interrogation Between 1.5 - 3 minutes* Between 1.5 - 3 minutes**2003

17. MPDS Medical Priority Dispatch System “The Clawson System” Inter-nationally recognized Inter-nationally recognized Standard of Care Standard of Care Used world-wide Used world-wide London, Sydney, Los Angeles, San Francisco London, Sydney, Los Angeles, San Francisco ProQA software ProQA software 700 + call type codes 700 + call type codes Echo, Delta, Charlie Echo, Delta, Charlie Bravo, Alpha, (Omega) Bravo, Alpha, (Omega)

18. STEP 1: Call Entry Determine the Chief Complaint

19. STEP 2: Ask Key Questions

20. STEP 3: Confirm appropriate call type

21. STEP 4: Dispatch from CAD

22. Our Call Chief Complaint Chief Complaint Difficulty Breathing Difficulty Breathing 6E1 (6 –ECHO-1) 6E1 (6 –ECHO-1) Recommended Dispatch Recommended Dispatch Closest Engine Closest Engine ALS Engine (if 1 st closest is BLS) ALS Engine (if 1 st closest is BLS) For second paramedic For second paramedic Paramedic Captain Paramedic Captain Ambulance (1 PM / 1 EMT) Ambulance (1 PM / 1 EMT)

23. STEP 5: Give caller pre-arrival instructions (PADs) if indicated

24. A Typical Incident OPERATIONS: “What happens on scene”

25. The Dispatch Engine 32 – BLS Engine Engine 32 – BLS Engine Closest First Responder Closest First Responder Engine 11 – ALS Engine Engine 11 – ALS Engine Closest ALS resource Closest ALS resource Rescue Paramedic Captain 3 Rescue Paramedic Captain 3 Quartered at Station 11 Quartered at Station 11 Medic 12 Medic 12 Closest available ambulance Closest available ambulance

26. Getting “out the door”

27. Finding the patient

28. Getting to the patient’s side

29. Initial Assessment Scene Survey C -Spine A irway B reathing C irculation D etermining the Chief Complaint

30. Initial BLS Treatment Vital Signs Pulse B/P Respirations Oxygen

31. ALS Assessment & Treatment IV access Medications if indicated Albuterol MS Lasix

32. The Transport Decision Treat and Transport v. Scoop and Run

33. Patient condition dictates treatment Patient assessment is ongoing throughout incident Patient conditions and treatment can and often do change

34. Invasive and Advanced Interventions Advanced Lifesaving Airway Techniques Naso-tracheal intubation

35. Transport Code Code 3: for the truly ill (8-10%) Code 2: for most patients

36. En route to the ER Code 3 to Closest appropriate hospital Critical Patient SFGH Base Hospital Contact Verbal report from PM to MD

37. At the Emergency Room Transition care to ER staff Transition care to ER staff Verbal report that includes: Verbal report that includes: Patient condition Patient condition Treatment Treatment History / meds History / meds Anything else important Anything else important Complete and turnover PCR Complete and turnover PCR Patient Care Report Patient Care Report Clean and ready ambulance Clean and ready ambulance Head back to quarters Head back to quarters

38. A Typical Incident FOLLOW THROUGH: Continuous Quality Improvement Risk Management & Billing and Revenue Medical Records

39. Continuous Quality Improvement CQI Ongoing Performance Assessment Performance Measures Performance Measures Response Times Response Times Clinical Performance Clinical Performance Regulatory Compliance Regulatory Compliance Clinical Projects (mandated) Clinical Projects (mandated) Cardiac Arrest Cardiac Arrest Advanced Airway Advanced Airway Evaluation Evaluation Assess effectiveness of education and training by field performance Assess effectiveness of education and training by field performance

40. Risk Management Identify Potential Risks Identify Potential Risks Not Just a Financial Consideration Not Just a Financial Consideration Patient Safety Patient Safety Worker Safety Worker Safety Public Safety Public Safety Legal Considerations Legal Considerations Collaborate with the City Attorney’s Office Collaborate with the City Attorney’s Office

41. Risk Management Perform Investigations Perform Investigations Sentinel Events Sentinel Events Exception Reports / Near Miss Exception Reports / Near Miss Complaints Complaints Root Cause Analysis of Significant Events Root Cause Analysis of Significant Events System Problems System Problems Policy / Protocol Policy / Protocol Education / Training Education / Training Practice Practice Individual Individual Performance Improvement Plan Performance Improvement Plan Intersection of Risk Management with Education and Training

42. Billing & Revenue EMS Billing Function is Outsourced EMS Billing Function is Outsourced Advanced Data Processing Inc. (ADPI) Advanced Data Processing Inc. (ADPI) * Contract expires 12/05 – competitive bid process ongoing FY 2004-2005 FY 2004-2005 $ 32.5 Million Billed $ 32.5 Million Billed $ 15.9 Million Collected (Net*) $ 15.9 Million Collected (Net*) 49% remittance 49% remittance

43. Medical Records HIPAA Compliance HIPAA Compliance FF/PM Rhab Baughn FF/PM Rhab Baughn Medical Records Section Medical Records Section 1415 Evans 1415 Evans Joe Mareschi and Robert Rowbottom Joe Mareschi and Robert Rowbottom

44. Some Other Players Health Commission Health Commission Director of Public Health Director of Public Health Dr. Mitch Katz Dr. Mitch Katz EMSA EMSA Dr. John Brown / Mike Petrie / Nick Nudell Dr. John Brown / Mike Petrie / Nick Nudell Base Hospital Base Hospital Private Hospitals Private Hospitals Hospital Council Hospital Council Private Ambulance Services Private Ambulance Services Smaller Organizations Smaller Organizations Senior Action Network / Neighborhood Associations Senior Action Network / Neighborhood Associations Emergency Physicians Association Emergency Physicians Association

45. What we do best Shortness of Breath Shortness of Breath Asthma Asthma COPD COPD Cardiac Emergencies Cardiac Emergencies Slow and fast rhythms Slow and fast rhythms Sudden cardiac arrest Sudden cardiac arrest Psychiatric Emergencies Psychiatric Emergencies Dementia Dementia Crisis Crisis Altered Levels Insulin Shock Heroin Overdose SF #1 in US Trauma Auto v Pedestrian SF #1 Auto/Ped deaths 217 / 219 Homeless Emergencies Hypothermia Seizures MOST program “WE HELP PEOPLE WHO NEED OUR HELP”

46. That’s All Folks! Thank you for your attention!