3. AMBULANCE DIVERSION
● Practice of redirecting or limiting destination of an ambulance carrying a patient to a hospital as its
destination
● Part of EMS system, where it is accepted practice for hospitals to signal the system that their ED is
crowded and there is likely to be a significant delay, or lack of patient care services if additional
patients were to arrive by ambulance during that time
4. HOSPITAL BYPASS
● The practice of directing prehospital providers to transport patients needing specialty care to a
specialty center instead of the nearest hospital.
● Sometimes means significant increases in travel time and is usually in cases where time to
definitive care is believed to be the primary clinical factor affecting patient outcomes. (eg, major
trauma, ST-elevation, acute stroke)
5. PATIENT DEMAND
● Refers to the right of the patient to choose their hospital destination, even when the prehospital
provider advises a different destination, or in some systems, even when the chosen hospital is on
diversion.
6. ALTERNATIVE DESTINATIONS
● Not new concept, not widely accepted
● Many systems only allow ambulances to transport 911 calls to an emergency department.
● Some systems allow for use of clinical judgement and/or specific criteria to determine the
appropriateness of treating the patient and leaving them in their homes vs transporting to an
urgent care center, doctors office, or psychiatric facility.
7. AMBULANCE OFFLOAD DELAY
● Time between arrival of the ambulance and the time that the patient is both off the stretcher and
EMS report has been given.
● Relatively new quality measure in the United States, has been evaluated in Canada for sometime
due to the fact that is represents a delay in patient care that is sometimes significant.
11. 1. Not even an iceberg could sink
our friendship!
12. 1. Not even an iceberg could sink
our friendship!
1. The entrance is guarded by a
fire-breathing, nearsighted
dragon with a fear of heights.
13. 1. Not even an iceberg could sink
our friendship!
1. The entrance is guarded by a
fire-breathing, nearsighted
dragon with a fear of heights.
1. If I were a dinosaur, I'd be an
Ankylosaurus: I have a tough,
armored exterior with a leafy,
loving heart of gold!
18. 84 yo female has syncopal episode at home. EMS is called and upon arrival patient is alert and oriented
appears confused and tired complaining of mild shortness of breath. Medical history is limited secondary
to mental status. Vital signs reveal HR 22, BP 80/50, RR18, O2 98% room air, Temp 37c. Lungs are clear
to auscultation bilaterally. EKG is performed and reveal sinus Brady.
IV is started and med box is opened, what do you reach for?
A. Ceftriaxone
B. Atropine
C. Epinephrine IM
D. Duonebs
19. 84 yo female has syncopal episode at home. EMS is called and upon arrival patient is alert and oriented
appears confused and tired complaining of mild shortness of breath. Medical history is limited secondary
to mental status. Vital signs reveal HR 22, BP 80/50, RR18, O2 98% room air, Temp 37c. Lungs are clear
to auscultation bilaterally. EKG is performed and reveal sinus Brady.
IV is started and med box is opened, what do you reach for?
A. Ceftriaxone
B. Atropine
C. Epinephrine IM
D. Duonebs
21. 84F from home EMS for syncopal episode
Hx limited 2/medical condition
EMS vitals: BP80/50, HR 20’s sinus brady
PE: Eldery female, AOx3 complaining of mild SOB/fatigue
IV fluids started, POC glucose normal
Atropine is given. Still confused and HR22
What do you grab next?
A. Equate Shake
B. Dilaudid
C. Dopamine
D. Her cane
22. 84F from home EMS for syncopal episode
Hx limited 2/medical condition
EMS vitals: BP80/50, HR 20’s sinus brady
PE: Eldery female, AOx3 complaining of mild SOB/fatigue
IV fluids started, POC glucose normal
Atropine is given. Still confused and HR22
What do you grab next?
A. Equate Shake
B. Dilaudid
C. Dopamine
D. Her cane
26. Arrives to ED
Patient arrives AOx3 HR 20’s
BP 80/50 taken manually
PE: Elderly female in moderate distress, cold and clammy skin, faint pulses, trace pedal edema bl
Atropine already given. Dopamine drip running and being titrated.
12 lead EKG is being obtained
Patient reports taking Beta Blocker for some unknown reason. What should you consider giving??
A. Glucagon
B. Calcium
C. Turkey Sandwich
D. Both A and B
27. Arrives to ED
Patient arrives AOx3 HR 20’s
BP 80/50 taken manually
PE: Elderly female in moderate distress, cold and clammy skin, faint pulses, trace pedal edema bl
Atropine already given. Dopamine drip running and being titrated.
12 lead EKG is being obtained
Patient reports taking Beta Blocker for some unknown reason. What should you consider giving??
A. Glucagon
B. Calcium
C. Turkey Sandwich
D. Both A and B
28.
29.
30.
31. Arrives to ED
Patient arrives AOx3 HR 20’s
BP 80/50 taken manually
PE: Elderly female in moderate distress, cold and clammy skin, faint pulses, trace pedal edema bl
Atropine already given. Dopamine drip running and being titrated.
12 lead EKG reveals complete heart block.
Glucagon and calcium given.
Patient remains bradycardic and hypotensive. Cardio consulted and heading bedside. You want to start push dose
epinephrine but cannot remember how.
So, how do you even push dose epi ???
Ambulance Diversion:
It is important for us to have a background History of ambulance diversion as well as to consider the evidence based results of implementing Diversion.
First described by Lagoe Jastremski in 1990, as an approach to alleviating emergency department crowding In an urban environment. Since that time diversion has become common across the entire nation in one form or another by most EMS systems.
To define it simply ambulance diversion is when the ED is closed to all incoming ALS and BLS traffic. Exceptions to this rule can include patient demand and specialty services such as trauma, burn unit etc. It was proposed to have benefits including a decrease in mortality and morbidity by avoiding crowded emergency departments and decreasing wait times by increasing efficiency and utilizing resources.
Some detriments to this approach include complex patients being transported to facilities both unfamiliar with their history and lacking in patients primary physicians, also increased turnaround times for EMS personnel traveling outside of normal service areas.
Multiple studies have been conducted across several decades and have shown to have either no effect on mortality and morbidity or a possible slight increase. Majority of studies indicate diversion can result in increased turn around and therefore response times for EMS personnel as they were unable to access the closest appropriate hospital during times of diversion.
Practices to decrease diversion times have been shown to be successful allowing patients greater access to primary hospitals where their medical records and primary providers are located.
Hospital Bypass:
The practice of directing prehospital providers to transport patients needing specialty care to a specialty center instead of the nearest hospital.
Sometimes means significant increases in travel time and is usually in cases where time to definitive care is believed to be the primary clinical factor affecting patient outcomes. (eg, major trauma, ST-elevation, acute stroke)
A 2009 study out of Toronto evaluated the effect of hospital bypass coupled with prehospital stroke notification system led to an increase in patient arrival within the treatment window leading to an increase in patients who received TPA from 9.5% up to 23.4%. There was no comparison of outcome between groups, only that the TPA group had a rankin score of less than 2 28% of the time.
Regarding trauma patients some studies have shown some benefit to morbidity and mortality. One 2006 study showed significant clinical outcome benefit to direct transport of traumatic brain injury patients to a level one or two trauma center. However systematic review from 2011 as well as a more recent review from 2013 showed mixed results and the authors concluded that there was inconclusive evidence to support or refute the benefit of bypass with direct transport to a level one or two trauma center.
So why the variability? This is likely due to the different EMS systems and geographic variability Confounding generalization of current global studies. This is important for EMSmedical directors to take into consideration before making decisions concerning the institution of hospital bypass.
Patient Demand:
Refers to the right of the patient to choose their hospital destination, even when the prehospital provider advises a different destination, or in some systems, even when the chosen hospital is on diversion. Depends on many factors, patient condition, proximity to preferred hospital vs closest hospital. Proximity to ambulance zone and turnaround time. Patients may benefit from being taken to hospital with known history and primary provider privileges.
Alternative Destination:
In some systems if a patient does not require emergency care and it is determined that the patient should seek primary care services rather than emergency care some systems allow providers to decline treatment and transport and provide the patient with a list of available resources and clinics instead.
EMS Handoff:
Patient handoff is an integral component of quality patient care and is increasingly identified as a potential source of medical error. We now have a safe patient sign out sheet. But why dont we have a written note left by EMS? How many times are critical patients dropped off by EMS intubated, sedated or in some other condition where they are unable to provide further history and you have to go by EMS verbal report to understand what took place in the prehospital setting.
One study looked to investigate this EMS to ED handoff of critically ill patients and what they found was pretty interesting.
A quantitative analysis of the information transferred from EMS providers to ED physicians during handoff of critically ill and injured patients was analyzed.
Methods: This study was conducted at an urban academic medical center with an emergency department census of greater than 100,000 visits annually. All patients were taken immediately to the ED resuscitation area upon EMS arrival. Handoff from EMS to ED providers occurring in the resuscitation area was observed and audio recorded by trained research assistants and subsequently coded for content. The emergency department team as well as EMS were blinded to study design.
Results: Ninety patient handoffs were evaluated. In 78% (95%CI = 70.0-86.7) of all handoffs, EMS provided a chief concern. In 58% (95%CI = 47.7-67.7) of handoffs EMS provided a description of the scene and in 57% (95%CI = 46.7-66.7) they provided a complete set of vital signs. In 47% (95%CI = 31.3-57.5) of handoffs pertinent physical exam findings were described. The EMS provider gave an overall assessment of the patient's clinical status in 31% (95%CI = 21.6-40.3) of cases. Significantly more paramedic handoffs included vital signs (70% vs. 37%, χ2 = 9.69, p = 0.002) and physical exam findings (63% vs. 23%, χ2 = 14.11, p < 0.001). Paramedics were more likely to provide an overall assessment (39% vs. 17%, χ2 = 4.71, p < 0.05).
Conclusions: While patient handoff is a critical component of safe and effective patient care, our study confirms previous literature demonstrating poor quality handoff from EMS to ED providers in critically ill and injured patients demonstrating the need for further training in the provision of patient handoff.
So why is this the case? Can it be improved? Let’s dig a bit deeper into this.
Telephone Game:
Many psychology experiments have shown that our short term memory can hold only a limited number of separate items with the average being about 7 items plus or minus two. What is a EMS ED provider hand off all but a game of memory recall. How much do we actually recall? How much of what we dictate is accurate based on the HPI provided by EMS. Was this information given first hand? Second hand? Lets try a little experiment. Remember the game of Telephone ?
We are gonna try a few phrases and see how much of it remains after transfering between a few of us.
Telephone Game:
Many psychology experiments have shown that our short term memory can hold only a limited number of separate items with the average being about 7 items plus or minus two. What is a EMS ED provider hand off all but a game of memory recall. How much do we actually recall? How much of what we dictate is accurate based on the HPI provided by EMS. Was this information given first hand? Second hand? Lets try a little experiment. Remember the game of Telephone ?
We are gonna try a few phrases and see how much of it remains after transfer between a few of us.
Phrases
Not even an iceberg could sink our friendship!
The entrance is guarded by a fire-breathing, nearsighted dragon with a fear of heights.
If I were a dinosaur, I'd be an Ankylosaurus: I have a tough, armored exterior with a leafy, loving heart of gold!
In high school, I was voted most likely to become a cat lady.
EMS Telephone game:
Patient is a 65yo female hx hypertension, CAD post CABG, COPD on 2L, PE, with a syncopal episode coming from home. Patient reported she was dizzy with nausea vomiting when she began to feel chest pain that was sharp that started around 8am before losing consciousness. On scene multiple empty pill containers were seen around her bed. VS: HR80, BP 102/66, RR 20, 38c, 92% 2L. Patient was initially alert and oriented however became unresponsive and pulseless. RLE swelling and rhonchi appreciated on exam.
ACLS was initiated with PEA initially on Monitor. 10mins CPR performed with 2mg epi given with ROSC. Patient was intubated with KING tube placed, given 30mg etomidate and 100mg succinylcholine. Has 18gauge peripheral IV in the L forearm with 200cc fluid bolus given. Also given zofran 4mg.12 lead showed some Twave inversions but otherwise normal sinus.
She seems pretty sick.
Doc, anything else you need from us before we jet?
65yo Female
Scene: Home, multiple pill bottles seen
Gen: Obese female lethargic
CC: syncopal episode
Hx: HTN, CAD post CABG, COPD 2L, PE (anticoagulated?)
VS: HR80, BP 102/66, RR 20, 38c, 92% 2L
Allergies: ?
PE: RLE swelling and rhonchi
ROS: + CP, dizzy, N/V
EKG: NSR, Twave inversions
EMS Course: Unresponsive, PEA arrest, ACLS 10mins w/ROSC, intubation w/king tube
Meds: 2mg epi, 30mg etomidate, 100mg succinylcholine, 200cc NS bolus
EMS Telephone game:
Patient is a 65yo female hx hypertension, CAD post CABG, COPD on 2L, PE, with a syncopal episode coming from home. Patient reported she was dizzy with nausea vomiting when she began to feel chest pain that was sharp that started around 8am before losing consciousness. On scene multiple empty pill containers were seen around her bed. VS: HR80, BP 102/66, RR 20, 38c, 92% 2L. Patient was initially alert and oriented however became unresponsive and pulseless. RLE swelling and rhonchi appreciated on exam.
ACLS was initiated with PEA initially on Monitor. 10mins CPR performed with 2mg epi given with ROSC. Patient was intubated with KING tube placed, given 30mg etomidate and 100mg succinylcholine. Has 18gauge peripheral IV in the L forearm with 200cc fluid bolus given. Also given zofran 4mg.12 lead showed some Twave inversions but otherwise normal sinus.
She seems pretty sick.
Doc, anything else you need from us before we jet?
65yo Female
Scene: Home, multiple pill bottles seen
Gen: Obese female lethargic
CC: syncopal episode
Hx: HTN, CAD post CABG, COPD 2L, PE (anticoagulated?)
VS: HR80, BP 102/66, RR 20, 38c, 92% 2L
Allergies: ?
PE: RLE swelling and rhonchi
ROS: + CP, dizzy, N/V
EKG: NSR, Twave inversions
EMS Course: Unresponsive, PEA arrest, ACLS 10mins w/ROSC, intubation w/king tube
Meds: 2mg epi, 30mg etomidate, 100mg succinylcholine, 200cc NS bolus
How can we improve on this?
Couple different factors affect our ability to accurately depict or remember a HPI. Some our own limitations while others are simply limitations to human communication.
EMS has 24hrs to submit their patient encounter note. Only if requested will EMS provide note for evaluation.
Most EMS providers are overworked and underslept. Sleep deprivation directly impacts memory recall.
How can we improve on this? Simply have a note already written by the person who directly saw/interacted with the patient. Limit distractions when obtaining a history, consider writing them down, echoing your understanding back to EMS and confirming relevant facts or asking for missing information.
EMS Case The Brady Lady:
84 yo female has syncopal episode at home. EMS is called and upon arrival patient is alert and oriented appears confused and tired complaining of mild shortness of breath. Medical history is limited secondary to mental status. Vital signs reveal HR 22, BP 80/50, RR18, O2 98% room air, Temp 37c. Lungs are clear to auscultation bilaterally. EKG is performed and reveal sinus Brady. IV is started and med box is opened, what do you reach for?
Ceftriaxone
Atropine
Epinephrine IM
Duonebs
How much? Atropine 0.5-1mg q3-5min up to 3mg total
May not work in 2nd/3rd degree heart block, heart transplant
Block is below AV node so atropine will accelerate sinus rate, leading to worsening of block and increased fatigue of AV nodal cells
EMS Case The Brady Lady:
84 yo female has syncopal episode at home. EMS is called and upon arrival patient is alert and oriented appears confused and tired complaining of mild shortness of breath. Medical history is limited secondary to mental status. Vital signs reveal HR 22, BP 80/50, RR18, O2 98% room air, Temp 37c. Lungs are clear to auscultation bilaterally. EKG is performed and reveal sinus Brady. IV is started and med box is opened, what do you reach for?
Ceftriaxone
Atropine
Epinephrine IM
Duonebs
How much? Atropine 0.5-1mg q3-5min up to 3mg total
May not work in 2nd/3rd degree heart block, heart transplant
Block is below AV node so atropine will accelerate sinus rate, leading to worsening of block and increased fatigue of AV nodal cells
EMS Case The Brady Lady:
Atropine is given. Still confused and HR22
What do you grab next?
Equate Shake
Dilaudid
Dopamine
Her cane
If atropine is ineffective, IV infusion of dopamine (5 to 20mcg/kg/minute) or epinephrine (2 to 10 mcg/minute) may also be considered prior to temporary pacing **UptoDate
Alternative is isoproterenol for ACLS bradycardia 2-10mcg/min/Heart Block 2-20mcg/min
EMS Case The Brady Lady:
Atropine 0.5-1mg q3-5min up to 3mg total is given. Still confused and HR22
What do you grab next?
Equate Shake
Dilaudid
Dopamine
Her cane
If atropine is ineffective, IV infusion of dopamine (5 to 20mcg/kg/minute) or epinephrine (2 to 10 mcg/minute) may also be considered prior to temporary pacing **UptoDate
Alternative is isoproterenol for ACLS bradycardia 2-10mcg/min/Heart Block 2-20mcg/min
https://www.youtube.com/watch?v=ZMGHyjIAjUs&t=2s
EMS Case The Brady Lady:
Atropine given, Dopamine started. Transcutaneous pacing attempted but failed?
But how do you even transcutaneous pace?
Be cautious of pad placement, typically place pad on apex of heart/right upper chest. Set HR80 with pacing threshold between 40-80mA
If unstable, start at 80mA and titrate down.
Look for QRS complex and T-wave following pacer spike.
Always check for pulse to confirm mechanical capture.
EMS Case The Brady Lady:
Patient arrives to the ED!
Patient arrives AOx3 HR 20’s
BP 80/50 taken manually
PE: Elderly female in moderate distress, cold and clammy skin, faint pulses, trace pedal edema bl
Atropine already given. Dopamine drip running and being titrated.
12 lead EKG is being obtained
Patient reports taking Beta Blocker for some unknown reason. What should you consider giving??
Glucagon
Calcium
Turkey Sandwich
Both A and B
Next Slide
EMS Case The Brady Lady:
Patient arrives to the ED!
Patient arrives AOx3 HR 20’s
BP 80/50 taken manually
PE: Elderly female in moderate distress, cold and clammy skin, faint pulses, trace pedal edema bl
Atropine already given. Dopamine drip running and being titrated.
12 lead EKG is being obtained
Patient reports taking Beta Blocker for some unknown reason. What should you consider giving??
Glucagon
Calcium
Turkey Sandwich
Both A and B
Glucagon
Acts independently of Beta-adrenergic receptors in cardiac tissue
Half-life is 20 min, thus, if effective, need to start drip quickly after bolus
Adult: 5 mg IV bolus over one minute, rebolus if no response after 10mins
If effective start infusion at 2-5mg/hr
Tachyphylaxis occurs quickly with glucagon so frequent monitoring of heart rate and blood pressure is necessary as the drip might need to be uptitrated
Consider giving zofran as nausea and vomiting is common
Calcium
Beta-antagonism decreases intracellular calcium leading to smooth muscle relaxation; supplementation may reverse hypotension by increasing intracellular calcium levels
Calcium gluconate 3g (30-60mL of 10% soln)
Calcium chloride 1-3g IV bolus (10-20mL of 10% soln (requires large IV/central line)
Preferred over calcium gluconate because it provides triple the amount of calcium on a weight-to-weight basis [2]
Give Calcium 1g Q5min to titrate to BP effect
If effect in BP is seen can give as a drip at 10-50mg/kg/hr
Aim for calcium level of 14mg/dL and measure at least 30 minutes after administration
EMS Case The Brady Lady:
You are handed this EKG, what do you see?
In complete heart block, there is complete absence of AV conduction, with none of the supraventricular impulses conducted to the ventricles. The perfusing rhythm is maintained by junctional or ventricular escape rhythm
How do you treat manage this?
Simple really, always ABCs, follow your ACLS bradycardia algorithm **uptodate
Avoid atropine in wide-complex bradycardia and consider chronotropes such as epinephrine, dobutamine, dopamine, isoproterenol. Consider transcutaneous vs transvenous pacing
Be sure to watch for signs and symptoms of hemodynamic instability such as hypotension, altered mental status, signs of shock, chest pain, and evidence of acute pulmonary edema resulting from bradycardia and reduced cardiac output.
EMS Case The Brady Lady:
You are handed this EKG, what do you see?
In complete heart block, there is complete absence of AV conduction, with none of the supraventricular impulses conducted to the ventricles. The perfusing rhythm is maintained by junctional or ventricular escape rhythm
How do you treat manage this?
Simple really, always ABCs, follow your ACLS bradycardia algorithm **uptodate
Avoid atropine in wide-complex bradycardia and consider chronotropes such as epinephrine, dobutamine, dopamine, isoproterenol. Consider transcutaneous vs transvenous pacing
Be sure to watch for signs and symptoms of hemodynamic instability such as hypotension, altered mental status, signs of shock, chest pain, and evidence of acute pulmonary edema resulting from bradycardia and reduced cardiac output.
EMS Case The Brady Lady:
You are handed this EKG, what do you see?
In complete heart block, there is complete absence of AV conduction, with none of the supraventricular impulses conducted to the ventricles. The perfusing rhythm is maintained by junctional or ventricular escape rhythm
How do you treat manage this?
Simple really, always ABCs, follow your ACLS bradycardia algorithm **uptodate
Avoid atropine in wide-complex bradycardia and consider chronotropes such as epinephrine, dobutamine, dopamine, isoproterenol. Consider transcutaneous vs transvenous pacing
Be sure to watch for signs and symptoms of hemodynamic instability such as hypotension, altered mental status, signs of shock, chest pain, and evidence of acute pulmonary edema resulting from bradycardia and reduced cardiac output.
EMS Case The Brady Lady:
Patient remains bradycardic and hypotensive. Cardio consulted and heading bedside. You want to start push dose epinephrine but cannot remember how.
So, how do you even push dose epi ???
EMS Case The Brady Lady:
Patient remains bradycardic and hypotensive. Cardio consulted and heading bedside. You want to start push dose epinephrine but cannot remember how.
So, how do you even push dose epi ???
Consider overlap between cardiogenic shock and symptomatic bradycardia
Consider dosing of dopamine for ACLS up 50mcg/kg/min if needed as patient may be in shock!
