1. EMS and D2B in Pennsylvania Douglas F. Kupas, MD, FACEP Commonwealth EMS Medical Director Bureau of EMS PA Department of Health

2. CONFIDENTIAL Goals Understand EMS EMS STEMI Issues Teamwork & Communication –Interdisciplinary (beyond the hospital) –Regionalization Understand Overtriage/ Undertriage

3. CONFIDENTIAL EMS in Pennsylvania Physician Medical Oversight Scope of Practice Protocol vs. Orders Regionalization

4. CONFIDENTIAL EMS in Pennsylvania Physician Medical Oversight –ALS Service Medical Director –Medical Command Physician –Regional EMS Medical Director –Commonwealth EMS Medical Director Scope of Practice Protocol vs. Orders Regionalization

5. CONFIDENTIAL EMS in Pennsylvania Physician Medical Oversight Scope of Practice (Basic Life Support) –First Responders and EMTs –CPR and AED –Oxygen Protocol vs. Orders Regionalization

6. CONFIDENTIAL EMS in Pennsylvania Physician Medical Oversight Scope of Practice (Advanced Life Support) –Paramedics –NTG, ASA, morphine, dopamine –ECG rhythm –12 lead ECG (optional) –ACLS –Advanced airway management Protocol vs. Orders Regionalization

7. CONFIDENTIAL EMS in Pennsylvania Physician Medical Oversight Scope of Practice Protocol vs. Orders –Statewide and Regional Treatment Protocols –Direct orders from MCP Regionalization

8. CONFIDENTIAL Contact Medical Command 7 If pain continues after 3 doses of NTG and systolic pressure > 100, Administer first dose of Narcotic Analgesic (See box at right) Initiate IV NSS Obtain 12-Lead ECG (if available) 5,6,7 If STEMI suspected, notify receiving facility ASAP If not using Viagra-type drugs 8, Nitroglycerin 0.4 mg SL (Repeat as needed 7,9 )

9. CONFIDENTIAL EMS in Pennsylvania Physician Medical Oversight Scope of Practice Protocol vs. Orders Regionalization –IOM report on emergency care (2006) –PA EMS regions (16) –Regionalization of care

10. CONFIDENTIAL Pennsylvania EMS Regions

11. CONFIDENTIAL Case 10/4/07 History –58 y/o male –Chest pain & SOB at 22:30 –H/o CAD and stent –Took NTG without relief –Called EMS –Requested transport to local ED

12. CONFIDENTIAL Case EMS Response –Police AED –BLS and ALS ambulance EMS Care –Assessment ( 50, 16, 81/51 - 115/72, 95% ) –12-lead ECG – “inferior injury, probable early acute infarct” –Medical Command Contact –IV NSS –ASA –NTG –Morphine

13. CONFIDENTIAL Prehospital ECG

14. CONFIDENTIAL Case It’s All about Time –Onset of pain22:30 –Dispatch22:39 –At scene22:47 –Medical Command Contact23:01 –Transport23:02 –V.FIB23:13 –Arrived at PCI center ED23:29 Ambulance to Cath Lab –100% RCA reopened23:43 V.Fib in lab before vessel opened

15. CONFIDENTIAL Case It’s All about Time Times –Onset of pain22:30 –Dispatch22:39 –At scene22:47 –Transport23:02 –V.FIB23:13 –Arrived at PCI center23:29 –100% RCA reopened23:43 D2B = 14 minutesD2B = 14 minutes R2R = 73 minutesR2R = 73 minutes

16. CONFIDENTIAL EMS D2B Issues Identify STEMI PCI Center Designation Mode of Transport Data and Quality Improvement

17. CONFIDENTIAL 12-Lead ECG Indications –Chest Pain suspicious for ACS Interpretation –Computer –Paramedic –Physician Over-triage/ Under- triage Transmission

18. CONFIDENTIAL Identify STEMI Overtriage: Liberal use of EMS ECG Misinterpretation of ECG as STEMI –EMS or computer STEMI alert initiated by EMS Pseudo-MIs ( aortic dissection, tako-tsubo ) Undertriage: Failure to recognize STEMI on ECG –EMS or computer Delay due to lack of trust in prehospital ECG

19. CONFIDENTIAL

20. ECG Transmission History

21. CONFIDENTIAL Transmission/ Communications Compatibility/ Interoperability Technology –Fax vs High Tech –Vendors (caveat emptor)

22. CONFIDENTIAL “Center” Designation Trauma Center –Pennsylvania Trauma Systems Foundation –27 PA trauma centers –ACS acceptable overtriage = 50% STEMI / PCI Center –Mostly local, few regional systems –Excellent diagnostic/ triage tool = 12-lead ECG Stroke Center –JCAHO accreditation –Poor prehospital diagnosis –Most patients not tPA candidates

23. CONFIDENTIAL Center Designation Accreditation –? PaACC recommendations Qualifications –24/7 PCI ability –? Volume –? Ancillary resources –? Quality benchmarks –? Verification

24. CONFIDENTIAL Mode of Transport -Time is deceiving Bypass closest hospital –Role of non-PCI hospitals Ground vs. Air –Air is not always faster –Medical Scene Call Protocol Lights and Sirens –Generally minimal time saved –Safety and patient anxiety

25. CONFIDENTIAL System Issues D2B to R2R Data Collection Quality Improvement Time is Relative

26. CONFIDENTIAL Time is Relative 911 Dispatch Center EMS monitors/ equipment Hospital clocks Staff wrist watches

27. CONFIDENTIAL National Progress Minneapolis Heart Institute –Level 1 Heart Attack Program –Cath lab to balloon = 13 min –Ground/Air = 30%/ 70% North Carolina RACE –Reperfusion for AMI in North Carolina EDs –5 regions/ 68 hospitals

28. CONFIDENTIAL PA Progress Commitment to 12-lead ECG –Many EMS services –Ability to effectively transmit ECGs = poor Local EMS- Hospital Cooperation –Many STEMI systems in place Statewide EMS Data Regional Systems –6-county, 37-EMS service,17-hospital, 9-STEMI center system in process

29. CONFIDENTIAL Future Statewide STEMI receiving facility designation EMT/BLS 12-lead ECG NEMSIS uniform data QI integration

30. CONFIDENTIAL Summary Understand EMS Teamwork & Communication –Interdisciplinary –Regionalization –Interoperability Understand Overtriage/ Undertriage Current areas of excellence and opportunities for improvement

31. CONFIDENTIAL Questions