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When it matters most…

When it matters most…. Key Components of Prehospital Medicine Systems Robert J. Burgess Senior Director, July 11, 2014. Objectives. Introduce Sunnybrook Centre for Prehospital Medicine Review EMS in Ontario Describe key components of successful prehospital medicine systems

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When it matters most…

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  1. When it matters most… Key Components of Prehospital Medicine SystemsRobert J. BurgessSenior Director,July 11, 2014

  2. Objectives Introduce Sunnybrook Centre for Prehospital Medicine Review EMS in Ontario Describe key components of successful prehospital medicine systems Offer thoughts towards an evolving EMS system

  3. Oversee medical care for over 450,000 patients Dispatch paramedics to over 40,000 911 requests for paramedic service Manage a provincial disaster medical team (EMAT) with 8 deployments in the past 10 years

  4. Size: 1,076,395 km² • 250,000 lakes and about one-third of the world's fresh water. • Geography: urban, boreal forest, tundra • Population: 13.6 M (40% of Canada) • 94% in southern 15% of province

  5. Larger than France and Spain,combined. • Almost 1/3 the size of India. • About the same size of the US statesTexas & Montana, combined

  6. Structure of Government

  7. Background – EMS in Ontario 53 EMS agencies co-funded by municipalities and the province 8 Base Hospital programs funded by the province 22 Land ambulance dispatch centres. 11 operated by the province 5 operated through hospitals 3 operated through municipalities

  8. Background – EMS in Ontario 1 Provincial Air Ambulance Operator (Ornge) 1 Air Ambulance Dispatch Centre

  9. Background – EMS in Ontario Approximately 7000 paramedics Over 1.9 million requests for land ambulance service resulting in more than 900,000 transports (47%) Reference: http://www.health.gov.on.ca/english/public%5Cprogram/ehs/ehs_dt.html

  10. EMS structure in Ontario

  11. Levels of Prehospital Medicine

  12. Educational Structure

  13. Education - Competency

  14. First Response

  15. Primary Care

  16. Advanced Care

  17. Critical Care

  18. What Level of Paramedic?

  19. Operational Measures

  20. Clinical Measures “the magnitude of benefit is associated with a treatment bundle.”

  21. Clinical Performance - Evidence • ST-Elevation Myocardial Infarction (STEMI). • Aspirin (ASA), if not allergic • 12-Lead electrocardiograph (ECG) with prearrivalactivation of interventional cardiology team as indicated • Direct transport to percutaneous coronary intervention (PCI) capable facility for ECG to PCI time < 90 minutes Evidence-Based Performance Measures for Emergency Medical Services Systems: A Model for Expanded EMS Benchmarking J. Brent Myers, Corey M. Slovis, Marc Eckstein, Jeffrey M. Goodloe, S. Marshal Isaacs, James R. Loflin, C. Crawford Mechem, Neal J. Richmond, Paul E. Pepe (doi: 10.1080/10903120801903793)

  22. Clinical Performance

  23. Clinical Performance – Quality Assurance The chart review… Observation Patient safety

  24. Clinical Performance – Quality Assurance DATA!

  25. Dispatch Performance – Response Times ? “Overemphasis upon response-time interval metrics may lead to unintended, but harmful, consequences (e.g., emergency vehicle crashes) and an undeserved confidence in quality and performance”.

  26. Dispatch Performance – Then what matters? “the most important predictive elements for optimal outcome: time elapsed until initiation of basic chest compressions and time elapsed until defibrillation attempts”

  27. Dispatch Performance – Then what matters? “With the exception of basic CPR and AED response (in the case of cardiac arrest), there is insufficient evidence to strongly recommend a specific ALS (paramedic) response-interval target as part of an evidence-based model for performance evaluation of an EMS System”.

  28. Dispatch Performance – But something must fit….

  29. Thoughts towards an EMS system (2014…..) Robust public access defibrillation program with emphasis on quality of compressions in CPR Identification of “first response” capabilities Accredited education and annual continuing medical education Primary Care Paramedic as standard Collect and analyze data!!

  30. Thoughts towards an EMS system (2014……) Focus on evidence-based clinical measures Promote and establish systems of care Integrate the system to overcome geography, other barriers

  31. Thoughts towards an EMS system (2014……) Don’t……. Leap to advanced or critical care levels without data-driven decisions Focus solely on response time measures

  32. Thanks…….

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