What We ll be Talking About

Transcription

1 What We ll be Talking About The Language of EMS Summary Statistics Rules of the Game A Typical Incident Communications (the call to 911) Field Operations (what happens on scene) Post-Incident Activities An unusual incident/special event EMS Frequently Asked Questions 911 San Francisco: Anatomy of an Emergency Medical Response Clement Yeh MD San Francisco Fire Department San Francisco Department of Emergency Management John Brown MD San Francisco Emergency Medical Services Agency UCSF/SFGH Department of Emergency Medicine Learning Objectives Review basic structure and terminology of prehospital care Understand the different levels of prehospital providers Review the components of a typical emergency response scenario

2 EMS Terminology BLS = Basic Life Support EMT level of care ALS = Advanced Life Support Paramedic level of care Code 2 = Potentially non-life threatening event Respond with the flow of normal traffic Code 3 = Potentially life threatening event Rapid response with lights and sirens 2013 SF EMS Statistics 120,718 Total Calls 92,875 Medical Incidents 51% dispatched Code 3 73% Transport 95.8% Code 2 Transport 4.2% Code 3 Transport EMS Providers EMT-local certification Minimum 120 hours of training Non-invasive maneuvers Bleeding control, basic airways, CPR, w/ hold CPR 1063 in SF Fire Department/1953 total in SF EMS System PARAMEDIC-California State license Minimum of 1400 hours of training Invasive maneuvers IVs, drugs, advanced airways, pronouncement 276 in SF Fire Department/454 total in SF EMS System Destinations SFGH St. Francis Hospital California Pacific Medical Center Pacific Campus St. Luke's Hospital UCSF Parnassus Campus UCSF Mission Bay Campus Kaiser San Francisco St. Mary s Hospital California Pacific Medical Center RKD Campus VA Hospital Chinese Hospital Kaiser South San Francisco Seton Hospital Pacific Medical Center California Campus *SF Sobering Center 33% of transports go to SFGH

3 SFFD Resources Rules of the Game First Responders 43 Engine Companies 27 ALS Paramedic staffed 16 BLS EMT staffed 19 Truck Companies (EMT staffed) 2 Heavy Rescue Squads (EMT staffed) Transport units Dynamically deployed 43 ambulances (1 PM / 1 EMT) Peak staffing ~26 ambulances 4 Paramedic Captains (RCs) At Dispatch Request for aid cannot be refused Code 3 requires 2 paramedics Call taking and dispatch is done at the ECD by civilian PSDs Call evaluation / triage done with a nationally recognized system Medical Priority Dispatch System Software integrated into CAD Private Ambulance Resources 5 Ambulance Companies 110 permitted private ambulances Basic life support, advanced life support, special event teams and critical care transport Rules of the Game In the Field Response time goals (90 th percentiles): Code 3 s 1 st unit in 4:30 1 st ALS in 7:00 Ambulance in 10:00 Code 2 s Ambulance in 20:00

4 Transport Options Patient Disposition Options: Transport to appropriate Emergency Department Transport to SF Sobering Center Patient refusal Other MAP Medical Examiner Police POV Other Transport Options Transport Hospital notification Base Hospital contact MD consult Patient Refusal Consult w/base Hospital Agreement of 2 paramedics Death in the Field Destination Options Emergency Departments Trauma Center - SFGH Specialty Centers Burns Re-implantation Pediatric Critical Care In custody SFGH OB Hospitals can close to ambulances: Diversion A Typical Incident Hello...911? Part I: communications

5 A call to ECD 1011 Turk St A Call to 911 ECD receives 4,300-4,600 calls per day 1.6 million phone calls per year Emergency calls ( ) Non-emergency calls ( ) 85% Police vs 15% Fire/EMS 8 to 20 Call takers on duty Call pick-up 9 secs* Interrogation Between minutes* Where the Dispatch comes from A call to 911 Audio Clip

6 Medical Priority Dispatch System Internationally recognized Standard of Care Used worldwide London, Sydney, Los Angeles, San Francisco ProQA software call type codes Echo, Delta, Charlie Bravo, Alpha, (Omega) STEP 1: Verify Location and Phone Number Most Important information! Common Chief Complaints Breathing Problems (11.9%) Falls (8.9%) Unconscious / Syncope (8.8%) Sick Person (8.7%) Chest Pain / Cardiac (7.1%) Traffic/Transportation Accidents (5.9%) Unknown Man Down (5.8%) STEP 2: Call Entry Determine the Chief Complaint

7 STEP 3: Ask Key Questions STEP 5: Dispatch From CAD Our Call STEP 4: Confirm appropriate call type Chief Complaint Difficulty Breathing 6D1 (6 DELTA-1) Recommended Dispatch Closest ALS Responder Dual Paramedic ALS Ambulance Single Paramedic ALS Ambulance + ALS Engine - BLS First Responder (with Defibrillator) - Paramedic Rescue Captain

8 The Dispatch STEP 6: Give caller pre-arrival instructions (PADs) if indicated * This is why it is so important to answer all dispatcher questions! Medic 85: Closest ALS Ambulance (DECCAN predictive software used to pre-position units closest to next anticipated call) 2 Paramedics A Typical Incident The Dispatch Part II: Operations What happens on scene... Audio Clip

9 Getting out the door... Or a small one Finding the patient... And if it s a really big incident

10 Initial BLS Treatment Getting to the patient s side... Vital Signs Pulse B/P Respirations Administer Supplemental Oxygen Initial Assessment Scene Survey C-Spine Airway Breathing Circulation Determining the Chief Complaint ALS Assessment and Treatment IV access Medications if needed Albuterol Morphine Nitroglycerine Aspirin

11 The Transport Decision Invasive and Advanced Interventions Treat and Transport or Scoop and Run Advanced Airway Techniques CPAP = Continuous Positive Airway Pressure ventilation Naso-tracheal intubation Oro-tracheal intubation En Route... Transport Priority The patient s condition dictates treatment Assessment is ongoing throughout incident Patient conditions and treatment can and often do change during transport Code 3: for the potentially unstable patient (5-10%) Code 2: for most patients

12 En Route to the ED Code 3 to Closest appropriate hospital Critical Patient St. Francis Base Hospital Contact Verbal report from PM to MD Which Emergency Department? Pediatric Critical Care (CPP California campus, UCSF Mission Bay campus) Burns center (SFH) Critical OB, Re-implantaion, Sobering are other specialty centers in SF Which Emergency Department? Regionalized systems of care Trauma center (SFGH) STAR centers (SFGH, UCSF, SMH, KSF, CPP Pacific campus) for cardiac patients Stroke centers (all of the above plus SFH, CPP Davies campus) En Route to the ED Audio Clip

13 At the ED An unusual incident Transition care to ER staff Verbal report that includes: Patient condition Treatment History / Medications / Allergies Anything else important Complete and turnover PCR Patient Care Report Clean and ready ambulance Head back to quarters Multi casualty incident responses Level zero through four Regional and state resources can be activated A Typical Incident Part 3: Post Incident Activity happily ever after CQI, Risk Management and Billing An unusual incident Regional resources: ambulance strike teams State resources: Mobile Field Hospitals Federal resources: DMATs and NDMS hospital system

14 An unusual incident November 1, 2010 Air medical evacuation to regional resources Two fixed medical helispots in SF 24 emergency helistops in SF World Series Celebrations October 29, 2012 Lessons Learned from Predictable Unusual 911 Incidents

15 October 28, 2012 October 29, 2014

16 Lesson Learned # 1: PREVENT Instant communication Mayor s Office, SFPD, SFFD message Keep it classy...or go to jail... Parade Route

17 Alternate Care Site Objectives Offload 911 System and EDs Provide on-site care for low acuity complaints Multi Casualty Incident capacity Alternate Care Site TRIAGE MINOR MEDICAL 12 Beds SOBERING 40 Floor Mats ACUTE CARE / PROCEDURES 2 Beds TRANSPORT OFFICER

18 Lesson #1: PROFESSIONALS DMAT, Dept. Public Health Rock Med Haight-Ashbury Free Clinics Event Medical Specialists California Medical Assistance Team A sister organization to the CA-6 Disaster Medical Assistance Team Similar capabilities to Rock Medicine Medical evaluation, stabilization, sobering Rock Med Philosophy Lesson #2: PATIENTS Anticipate agitated & intoxicated patients Intense Psychedelic Reaction Acute Crowd Syndrome Designate Time Out and Take Down areas Criteria for sedation / transport

19 Patients 2010 Patients responses into the Civic Center crowd 55 patients treated at 2 field care sites (CalMAT and American Red Cross) 21 patients transported on to hospital 47% Female Male 53% Patients 2012 Diagnoses Patient Count by Median Age = 22 yo ETOH Syncope Respiratory Assault/Lac Seizure MJ Abdominal Crowd Syndrome IPS Panic Attack 6%0% %% %4% 4% 6%6% 7% 7% 11% 9% 20% 20%

20 Patients patients from ACS 66 patients from first aid station 12 ambulance transports to ED 4 transported by sobering center van Lesson #3: PROCESS Rehearse Scenarios Acute Medical w/ Transport IPR: Talkdown/Sedation Define transport criteria Paths for entry/egress De-mobilization plan Patients patients brought to CalMAT facility by EMS crews from Civic Center Plaza 3 patients transferred to local hospitals, 1 to sobering center 14 medical/injury complaints, 5 primarily intoxication with alcohol Contrast with Boston Marathon Bombing Nature of event and threat to crowd Injuries more severe in Boston 4 deaths 58 severe injuries 264 overall dead and injured Security challenges to transportation Single EMS but multiple hospitals

21 Continuous Quality Improvement CQI Ongoing Performance Assessment Performance Measures Response Times Clinical Performance Regulatory Compliance Clinical Projects Evaluation Assess effectiveness of education and training by field performance Risk Management FAQ: What About Cell Phones? Due to wireless routing 70-80% cell phone 911 calls go directly to the SF dispatch center (ECD). The remainder go to CHP dispatch and are routed to the ECD. No address information is transmitted automatically from cell phones ECD 7 Digit number: (415) Billing & Revenue FAQ: Do I need to call for that pothole? Fiscal Year $ 20.2M revenues 23% accounts collected is a relatively new unified number for non-emergency city services The digit number is: (415) Transfers to and from 911

22 FAQ: Where can I get more information? EMS Agency: EMS Agency Page DEM: John Brown: john.brown@sfgov.org Clement Yeh: clement.yeh@sfgov.org Acknowledgements San Francisco Fire Department SF Department of Emergency Management SF EMS Agency UCSF-SFGH Emergency Medicine Waves of the future WiFi 911 requests Mobile device apps for Automatic External Defibrillators and CPR instructions Data transmission from ambulances to multiple sites in specialty care centers Improved use of social media in disasters

23 Questons?