1. From here to there: navigating the geography of time. Thomas Judge, CCTP Norm Dinerman, MD, FACEP, Sandra Benton, MSN, CCRN Kim McGraw, RN, CCTP Kevin Burkholder, CCTP

2. Geography: pre-hospital considerations Location of event: time zero to: closest cardiac system hospital equidistant: cardiac system hospital or cardiac intervention center? cardiac intervention center direct—bypass closest hospital Essential information:  BLS or ALS service?  Time of response– time/mileage to closest hospital vs. time/mileage to cardiac intervention center

3. Determine: Glasgow Coma Scale Systolic Blood Pressure Respiratory Rate Determine: Glasgow Coma Scale Systolic Blood Pressure Respiratory Rate Calculate: Revised Trauma Score (RTS) or Pediatric Trauma Score (PTS) Calculate: Revised Trauma Score (RTS) or Pediatric Trauma Score (PTS) Is RTS <11 or PTS <8? Determine: if any of the following exist: Paralysis; Amputation proximal to wrist or ankle; Penetrating injury to chest, abdomen, head or neck; Two or more proximal long bone fractures; Unstable pelvic fracture; Open or depressed skull fracture; Burn associated with trauma Determine: if there is associated fatality in same vehicle compartment Determine: if there is associated fatality in same vehicle compartment YES NO I. OLMC confirms RTS/PTS II. OLMC considers patient transport to Trauma Center, using following guidelines: a) If transport time by ground or air to Trauma Center is less than 30 minutes, patient should go to Trauma Center directly; b) If transport time to Trauma Center is greater than 30 minutes, determine the difference in transport time between the Trauma Center and the most accessible hospital: 1) If difference is less than 10 minutes, consider transport to Trauma Center; 2) If difference is greater than 10 minutes, consider transport to most accessible hospital; III. If, upon arrival in the ED, a) Facility is not a Trauma Center, and; b) Patient continues to satisfy criteria of Assessments One and Two, and; c) Patient can be stabilized for further transport, then receiving ED clinician should provide only life-saving procedures (avoiding unnecessary diagnostics) prior to transport to Trauma Center unless he/she judges clinical situation to not warrant such transfer. I. OLMC confirms RTS/PTS II. OLMC considers patient transport to Trauma Center, using following guidelines: a) If transport time by ground or air to Trauma Center is less than 30 minutes, patient should go to Trauma Center directly; b) If transport time to Trauma Center is greater than 30 minutes, determine the difference in transport time between the Trauma Center and the most accessible hospital: 1) If difference is less than 10 minutes, consider transport to Trauma Center; 2) If difference is greater than 10 minutes, consider transport to most accessible hospital; III. If, upon arrival in the ED, a) Facility is not a Trauma Center, and; b) Patient continues to satisfy criteria of Assessments One and Two, and; c) Patient can be stabilized for further transport, then receiving ED clinician should provide only life-saving procedures (avoiding unnecessary diagnostics) prior to transport to Trauma Center unless he/she judges clinical situation to not warrant such transfer. TRANSPORT TO TRAUMA SYSTEM PARTICIPATING HOSPITAL If pre-hospital providers are unable to definitively manage the airway, maintain breathing or support circulation, begin transport to most accessible hospital and simultaneously request ALS intercept or tiered response. MAINE EMS TRAUMA TRIAGE PROTOCOL

4. Time Modeling Study for MMC Helipad: Assumptions for air vs. ground decision support models Grid model: EMS arrival + 2 minutes = time zero Ground: time zero +17 minutes + drive time to trauma center Air: time zero + 10 minutes launch + flight time to scene + 10 minute scene time + flight time to trauma center

5. LOM called by ambulance at scene--2 min. decision time--total 19 min. on scene time 10 min. LOM alert and launch Flight time to scene 10 min. LOM intervention/packaging time Flight time from scene to MMC,CMMC, EMMC Scenario B; Helipad at MMC Decision Support Time Modeling

6. Scenario C; Helipad at MMC and 10 minute “Jump” on LOM through early mobilization at time of EMS dispatch Decision Support Time Modeling LOM called at dispatch--save 10 min. alert and launch time Total 19 min. on scene time Flight time to scene 10 min. LOM intervention/packaging time Flight time from scene to MMC, CMMC, EMMC

7. NECA ALGORITHM (For hospitals outside the Bangor area) Algorithm for Fibrinolytic Eligible Patients ♥ Thrombolytic therapy (TNK or Retevase) ♥ ASA (chew 4 baby aspirin) ♥ Heparin (2) ♥ Beta-Blocker (3) ♥ NTG IV boluses PRN (4,5) Call NECA 947-4940 Transfer Emergently to EMMC Consider LifeFlight helicopter 1-888-0421-4228 Call NECA 1 hour after starting lytic therapy if patient still has persistent chest pain with ST-elevation Transfer Emergently to EMMC Consider LifeFlight helicopter 1-888-421-4228 ♥ Thrombolytic therapy (TNK or Retevase) ♥ ASA (chew 4 baby aspirin) ♥ Heparin bolus & infusion ♥ Beta-Blocker (3) ♥ IV NTG infusion (5) HIGH RISK Having any one of these criteria:  Anterior MI  Age 75 years and older  CHF / Pulm Edema  Hypotension or Shock LOW RISK Having none of the high risk criteria

8. Geography: system hospital considerations High Risk Rapid transfer to intervention center Failed lysis / rescue Other issues– transfer (LVAD, IABP, AICD, Pedi, etc.) Essential information  Time Goal – Standardized Order Set / Preparation  Transportation Plan (stability y/n ?)  Time of transfer – time/mileage to closest to cardiac intervention center  Enroute – expected complications / deteriorates

9. Geography: manage time and system Parallel process at time of EMS first info  Destination decision  Transfer needed?  Skills needed? Capability of EMS Agency-scope of practice / equipment, RN needed  Transfer service activated— Time to Respond  Initial Stabilization / Intervention / Preparation  Transfer  Limitations: weather, service availability

10. Rumford Community Hospital N=8 ED 75% ICU 25% Over BST Benchmark 13% Triage to Request –(4) 40 minutes

11. Rumford Community Hospital N=8 AveragesCMMCMMC BST1815 Tone to Rcvg7295 Bedside to Rcvg 3763 Ground Times48108

12. Geography: unresolved questions Do all lysis patients get transferred– when? What are consensus time goals for decision trees? Definition of stability? Scope of practice needed. Scope of practice across spectrum Measurement predictive high performance