Every community in the United States had a different constellation of resources, history, culture, and personalities. This varied mix is what makes every EMS system so unique. This variety is actually a strength since it offers a crucible for new ideas and new programs. Local programs can be a wonderful source of innovation and a testing ground for new ideas. Clearly every community would have to pick and choose from this action plan and adapt the ideas to meet local needs.
In my role as medical director for King County EMS I meet annually with all the other 35 county EMS medical directors for Washington State. Washington unlike many other states does not have a state EMS director but rather delegates this control to physicians at the county level. I never cease to be amazed by the variety of these county EMS systems and the challenges each medical director faces. There is no way my fellow county EMS directors could lift whole cloth all of the following recommendations. Thus they are offered not in the naive view that all must be or even could be instantly adopted. I am acutely aware that in many communities perhaps none of these recommendations may be possible to implement. But at least they can point the way.
|Local Action Plan||Difficulty of Implementation|
|1. Political leadership||Very difficult|
|2. Administrative leadership||Very difficult|
|3. Medical leadership||Very difficult|
|4. Establish a tiered-response system||Very difficult|
|5. Comprehensive cardiac arrest registry||Difficult|
|6. Ongoing QI||Difficult|
|7. Improve paramedic, EMT, and dispatcher skills||Difficult|
|8. Hypothermia||Moderately difficult|
|9. Community involvement||Difficult|
|10. Preventive measures||Difficult|
The first three actions in the local action plan entail leadership – political, administrative, and medical. These are all rated very difficult to implement. If good leadership is absent it cannot be created overnight. Realistically it is very difficult to replace a mediocre EMS director or medical director or recall a mayor who is inattentive to EMS matters. On the other hand it only takes one of these three positions to crystallize change.
1. Political Leadership:
In the beginning is leadership. Without it the opportunity for improvement is a non-starter. Political leadership is the only way to achieve unity of command and accountability. As a starter, there must be a political decision to have one agency run the EMS program. It cannot be split between two or more agencies. There are exceptions to this. For example Rochester, Minnesota has a combined police and fire department EMS program and King County EMS has a combined fire department and health department model. As a general rule, however, the system should be totally integrated with personnel accountable to one administrator and one medical director. The only realistic way to accomplish this is to place responsibility for EMS within one agency. In my mind, the logical agency is the fire department. Fire departments historically are in the rescue business and they provide the first-in response for medical emergencies in most communities. It doesn’t make sense to have the fire department provide the basic level of care and then have a separate agency provide the advanced level of care. Fire departments, when they have capable leadership, run a very tight ship with high training standards and clear accountability. As a quasi-military organization fire departments know how to get the job done. This is not to say that private or other public models cannot work. It all comes down to leadership and quality of the personnel.
2. Administrative Leadership:
Clearly competent administrative direction is important. Organizations demand a lot of it director. He or she must set high standards of performance. The director must be savvy in the ways of political bureaucracies, a tiger in acquiring and defending resources, a fiscal expert, a sensitive manager of human resources, and a leader with an uncompromising vision. Perhaps most importantly the administrative leader must work closely with the medical director and support the medical model. Ideally the administrative director and medical director should meet regularly (weekly?) to jointly administer and plan all aspects of the program.
The administrative director and the medical director together must set in place a long-term plan to create and maintain a culture of excellence. Some would argue that such a culture is mandatory to achieve a quality EMS system. An equal number would claim that creating a culture of excellence is extremely challenging. No doubt. Nevertheless, a culture of excellence, as hard as it is to define or measure, is likely a key factor that separates a great system from the merely good. The medical director has to clearly state and constantly promote high expectations. The administrative and medical leadership must enhance training and ongoing continuing education and make medical QI the means to constantly improve. Excellence also requires “buy in” from all members of the extended EMS family – dispatchers, EMTs, and paramedics. When the EMS providers recognize sincere mission driven leadership (rather than lip service) they are likely to both respond as well as contribute to the positive culture.
3. Medical Leadership:
The political leadership must appoint a medical director and make sure he or she has the authority to supervise a medical model of EMS care. The EMTs and paramedics must be accountable to the medical director. Ideally the medical director should have an academic appointment and be jointly appointed by the administrative director and dean or department chairperson. An academic appointment insures that the director will have knowledge, credibility, and accountability (to the dean or chairperson). Also an academic physician is generally one who is committed to furthering knowledge and will likely have knowledge of epidemiologic principles and research methodologies. This is not to say that every medical director must conduct research, far from it, but that the director must understand the benefits and limitations of data and know how to interpret (and not over interpret) data. Furthermore an academic medical director has access to all the expertise of an academic medical center. Many is the time I have turned to colleagues in cardiology, anesthesiology, trauma surgery, endocrinology, biostatistics, epidemiology, preventive medicine, health services, pediatrics and toxicology to help answer questions and guide policy. I would be lost if I could not readily obtain this expertise.
What can a community do if it is geographically distant from an academic medical center? Many centers offer clinical appointments to individuals who are in a service role in the community or help with the teaching mission of the university. I think many deans or chairpersons of departments of emergency medicine would welcome a conversation with elected officials or EMS administrative directors to help establish a clinical appointment for that community’s medical director. A medical center may also help coordinate a consortium of regional EMS medical directors to help guide and share experiences. It is also realistic for communities to partner with academic medical centers. Academic medical centers are in a logical position to do this since they often staff the region’s trauma center. A partnership between local communities and academic medical centers could be a win-win situation. The medical center can provide clinical expertise, communications expertise, data base management, managerial expertise, and work cooperative with local medical directors to establish regional consortia of EMS programs. Academic medical centers after all have a mission to serve the community and the good will and reciprocity would more than compensate for the investment of human and dollar resources.
4. Establish a tiered-response system:
Many communities already have tiered-response systems with EMTs (usually fire fighters) providing the first-in response and paramedics (often fire fighters but also likely to be private or third public agency paramedics) providing the second-in response. But what if your community has a single layer system, such as all paramedic responders? Some communities have made the change from a single layer to a tiered-response system and others have added police as the first-in tier to augment the fire department response. Rochester utilizes police to in this way to assist the fire department as first-in response and in fact the police arrive first on scene half the time. I think the model of police equipped with AEDs to augment the existing EMS system offers great promise and can theoretically be implemented in almost any community. Changing and reconfiguring a system will be challenging to say the least. However, nothing is impossible. If there is police department leadership as there was in Rochester, change can happen almost overnight.
5. Comprehensive cardiac arrest registry:
A cardiac arrest registry is the means to take the temperature of the entire system. If cardiac arrest is managed well then more than likely all other conditions will be managed well. In this sense cardiac arrest serves as a surrogate for the entire system. The registry was mentioned above under Immediate Steps. It is here as well in a comprehensive version. The expanded version includes not only data abstracted from the EMT and paramedic incident reports but information from the dispatch center and the electronic recording of the AED. To be maximally effective it must include voice recordings of the resuscitation. A comprehensive registry must contain all relevant information about the resuscitation including hospital outcome information.
The registry must have sufficient resources and the full support of the medical and administrative directors. It must be viewed as a core function and not be held hostage to funding cuts or elimination during lean fiscal times. Link to Data Collection Forms A community without an ongoing cardiac arrest registry could import the King County forms, make specific adjustments as needed and have the makings of a cardiac arrest registry. The resources include staff time to gather the information from run reports, (electronic or paper), dispatch center reports, AED recordings, hospital records, and death certificates. Clearly small communities will not have the volume of events to justify full-time dedicated staff. However, several small communities can join together to have a registry at the county or regional level.
6. Ongoing quality improvement:
Continuous quality improvement is the means to always do better. The medical director, with the support of the administrative director, has the responsibility to conduct QI audits of the system. Medical QI can involve any aspect of EMS care but as it relates to cardiac arrest, the substrate for ongoing QI is the cardiac arrest registry. Without QI the cardiac arrest registry is just a collection of facts. However, with QI the registry becomes the basis for improvement. QI undertakings can occur at the system level or at the specific action level. At a system level appropriate QI questions might be what is the overall rate of survival from witnessed VF? What are the key determinants of survival: Time to dispatch? Time from collapse to CPR? Time from collapse to defibrillation? Time from collapse to advanced life support? Answers to these questions may identify areas needing attention but more likely it will be necessary to bore down to the specific actions within resuscitation attempts. There are dozens of possible QI projects involving the spectrum of resuscitation care and the dozens of sequential steps from calling 911 to transporting the patient to the hospital. For example, how often are telephone CPR instructions offered? Do dispatchers recognize agonal respirations? How long does it take to recognize and begin telephone instructions? What percentage of cardiac arrests has rapid dispatch? How long does it take from arrival at patient’s side to deliver the first shock? What is the density of CPR between two shocks? How long does CPR stop prior to a defibrillatory shock? Does CPR occur for two minutes between shocks? What medications are used in resuscitation and what is the clinical response? How many attempts are required for intubation? How often are rescue central lines or interosseous lines used? When is hypothermia started? The number of possible QI projects is limited only by accurate data and resources. Every link of care in the chain of survival and every sub link can be studied. An EMS system should never become complacent. There are always opportunities for improvement. Ongoing QI is the vehicle to improve the system.
7. Improve paramedic, EMT, and dispatcher skills:
Paramedic skills improve with training, continuing education but most efficiently with actual performance. The fundamental flaw with all-paramedic systems is the relative infrequency any paramedic has to perform advanced airway interventions or interosseous lines. Interosseous lines are used when peripheral intravenous lines are difficult to place. (Some programs authorize central lines when peripheral IVs cannot be started). The issue of performance is subtler than mere psychomotor skill in the procedural aspects of advanced care. It involves the confidence and knowledge to act quickly and decisively and administer the proper dosages. Perhaps most importantly the ultimate measure of a paramedic’s skill is the persistence and doggedness not to give up and to keep going until that patient achieves a perfusing rhythm. Many fire departments staff their EMS program with dual trained paramedic/fire fighter. These programs assume that service is improved because every call, regardless of the seriousness of the emergency, will have a paramedic in attendance. It will but the effect will be to reduce the skill level of each paramedic in the program. It is probably a flawed concept to dual train an individual to be a fire fighter and a paramedic and expect stellar performance in each sphere of the job. Do we dual train doctors with police? Do we dual train rocket scientists with baristas? The examples could become more and more ridiculous. The point is to allow paramedics to learn the skills they need and hone them as professionals. This is not to say they cannot work within a fire department only that they should not (except in emergencies) be asked to perform the duties of fire fighters. In all of Seattle and most of King County the paramedics are members of a fire department and they are respected and looked up to for the knowledge and skills they bring to medical emergencies.
There is probably an optimal ratio of paramedics to population. My colleagues and I empirically observe that a paramedic is able to maintain his or her resuscitation skills when this ratio is one paramedic for approximately every 8,000 to 10,000 people. King County has approximately 2 million residents and there are 255 paramedics in the city and county.
EMT care provides the solid foundation for all subsequent care in a resuscitation. If the foundation is of poor quality the entire structure is jeopardized. EMTs can do so much to either definitively treat the ventricular fibrillation or prime the body for successful intervention by paramedics. It is the details of CPR and defibrillation that often determines the outcome. Training, training, and training are the keys to EMTs performing quality CPR and defibrillation.
Emergency dispatchers are partners in the EMS team. Their role is critical in mobilizing the EMTs and paramedics and seeing that telephone CPR begins before the EMS personnel show up. Training and practice and review of these skills are as important as the quality of CPR and defibrillation. A highly trained dispatcher can easily save 30 – 60 seconds in the initial dispatch and through telephone CPR increase the likelihood of survival.
Hypothermia is the standard of care for resuscitated VF patients who arrive in coma to the hospital. Cooling of the body for 24 hours post resuscitation offer the promise of a modest improvement in survival and every indication to date shows no harm. The American Heart Association and the International Liaison Committee on Resuscitation have endorsed it. Despite then national (and international) endorsement hypothermia is not uniformly practiced. Even in Seattle and King County as of 2007 only half the hospitals were consistently offering this therapy. There are many reasons for the slow adoption ranging from cost to staffing to unfamiliarity to skepticism. Whatever the reason the EMS agency has an obligation to work with the receiving hospitals and begin hypothermia. Future studies may define whether hypothermia should be used for all patients, not just VF patients, and whether paramedics in the field should initiate it. A study led by Dr. Francis Kim at the University of Washington is currently studying the potential benefit of prehospital hypothermia for resuscitated VF patients. This is a randomized trial and results will not be known until 2012.
9. Involve the community:
It is the rare system that is willing to involve community members in monitoring its operation and performance. But what could be more logical? Cardiac arrest is a community problem and every member of the community has a stake in making the system as good as it can be. A community board of directors or community advisory board should be apprised of plans and be given the tools to oversee the performance. The board could recommend QI projects in partnership with the medical director. The more transparent the system is in terms of goals and performance the better the community will be served. Needless to say the board could also serve a very useful role in communicating new programs to the citizens and even help raise special funds or grants to enhance the system.
Community involvement also means enlisting the community in the chain of survival. Wide scale training of the general public in CPR and when to call 911 can have large, and sustained, dividends as was noted in the early years of the Seattle Medic One program. It is likely that the large number of citizens trained in CPR in Seattle and King County is an important factor, not only in initiating CPR before the arrival of the fire department, but in promptly calling 911. Many communities have well intentioned CPR awareness events - for example, mass training during half time at a football game, CPR Sunday with free training at local fire stations - but many of these efforts have little follow though. The EMS agency is the logical organization to assume the responsibility to mount a massive CPR training program. The agency could appoint a board comprised of cardiac arrest survivors, community leaders, fire fighters, religious leaders, news editors, etc, to oversee the program. The effort should be across the community spectrum – CPR training in schools as well as free training in senior centers, churches, civic organizations, and businesses. Innovative training methods can assist the program. Why not use the back of driver licenses to have illustrations of the steps of CPR? How about CPR instructions (suitable for taping inside or outside cupboards) mailed with utility bills? Couldn’t EMTs leave a free CPR DVD in every home they visit? I’m sure a concerted and ongoing effort by the EMS agency in conjunction with a community board could accomplish much.
10. Preventive actions:
If we prevent heart disease today we may stave off a cardiac arrest 10 years in the future. This may seem to be an oblique way to treat cardiac arrest but ultimately preventive medicine is the only long term answer. EMTs and paramedics must be convinced by their medical director that identifying a new case or an under-controlled case of hypertension or diabetes is as much a part of their job as defibrillating VF. Ideally EMTs and paramedics could leave specific written instructions with patients when they encounter abnormally high blood pressure of blood glucose.