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2017 PSOW - Suzanne Martens Presentation

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2017 PSOW - Suzanne Martens Presentation

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2017 PSOW - Suzanne Martens Presentation

  1. 1. Wisconsin Department of Health Services Division of Suzanne Martens, MD, FACEP, FAEMS, MPH, EMT WI EMS/Trauma Medical Director Paramedic Systems of WI 2017
  2. 2. Overview 2  EMS Activities/Topics  EMS Office Suggestions  Assisted Medications Protocol  DEA Points  Future Goals  Narcotic Diversion Example
  3. 3. Since last year….
  4. 4. Reminder of Just Culture 4 Assume Good Intent Just Culture – Not Blame. Also not carefree. A just culture has zero tolerance for reckless behavior.
  5. 5. Since Last Year…. 5  New slide background!  Working towards easier legal name change  Elite QA reports to follow advanced skills and interfacility transfers  PAC/EMS Board updates
  6. 6. PAC Projects/Updates 6  Expanded pressor recommendations  Dopamine, Epi, Norepi, Vasopressin, Phenylephrine  Push-dose pressor option  Defining minimum meds/skills for Paramedic  Will continue for other scope levels  Example of using Elite to define med use/need  Support of the CARES registry  Elite QA problems
  7. 7. Suggestions from the EMS Section
  8. 8. Suggestions from the Section 8  Stay within Scope of Practice  DEA certification current?  With agency address and Medical Director  Review your Op Plan; have another person look at it  Special Events need to be added to the Op Plan  If recurring, list as such and save time/work  What is your QA/CQI plan?  Check Medications use  If not using them, just an added cost to stock and maintain them  Medical Directors need E-licensing accounts  RN/PA/Physician as staff need E-licensing accounts
  9. 9. Additional Suggestions from Me
  10. 10. Additional Suggestions 10  Recheck the extent of your agency’s scope of practice  An agency CANNOT perform an interfacility transport unless the 911 response is covered  The Bedside Report is NOT a substitute for actual training and Op Plan updates
  11. 11. Topics to Consider in Protocols 11  EMR-EMT ambulance staffing  Selective Spinal Immobilization/Spinal Motion Restriction  D10 instead of D50  IM Epi  Highly potent Opioid considerations, planning, media-driven hysteria  Not “Narcan resistant” … any more than a large fire is “water resistant”
  12. 12. Assisted Medication Protocol
  13. 13. Assisted Prescribed Emergency Medications with Medical Control Contact (Adult/Peds) 13  Background  More people are being treated as an out-patient or with home care  EMS will encounter more people with complex medications  The Physicians Advisory Committee (PAC) acknowledged that this scenario will become more frequent; the exact list of medications cannot be maintained as current  Protocol was not officially posted
  14. 14. Assisted Prescribed Emergency Medications with Medical Control Contact (Adult/Peds) 14  Reference:  Treating Patients with Immediately Life-Threating Conditions Requiring Previously Prescribed Medications Not Routinely Carried by EMS, Prehospital Emergency Care, 21:1, 86-87  The NAEMSP® believes:  State and/or local entities with jurisdictional authority to regulate EMS practice in a specific area of service should enact regulations that enable EMS providers to assist with administering emergency prescribed medications carried by a patient via routes of delivery that are:  1) within the provider’s scope of practice; and  2) approved/allowed by the jurisdictional authority that governs the area in which the EMS provider is giving care.
  15. 15. Assisted Prescribed Emergency Medications with Medical Control Contact (Adult/Peds) 15  To provide guidelines and authorization for the use of emergency medications not commonly used. For emergency use only. This protocol is not to be used for interfacility transfers.  The patient must exhibit the signs and symptoms for which the medication is prescribed.  Medical Control must be contacted and approve the use of the medication.
  16. 16. Assisted Prescribed Emergency Medications with Medical Control Contact (Adult/Peds) 16  EMR / EMT / AEMT / INTERMEDIATE / PARAMEDIC  Routine Medical Care  Other treatments will be in accordance with protocols particular to presentation.  May allow patient/caregiver/school healthcare giver to administer medication(s) by mouth, rectally, intranasally or injection.  The route is the most pertinent consideration. Assist the pt.
  17. 17. Assisted Prescribed Emergency Medications with Medical Control Contact (Adult/Peds) 17  Identify the medication(s) that is requested by patient, patient’s caregivers or school official(s)  Patient, Caregiver or Schools must provide the medication(s) to be administered  Patient, Caregiver or Schools must provide a written copy of the physician order and care plan for attachment to the patient care report  This documentation by the patient’s primary physician should list the following:  Name of the patient  Name of the physician  Document must be signed by the physician  Contact phone number of the physician  Name of medication(s)  Signs and symptoms for which the medication(s) is/are prescribed  Dosage of the medication(s)  Number of repeat doses of the medication(s)  Route(s) of administration(s)  Potential side effects of the medication(s)
  18. 18. Assisted Prescribed Emergency Medications with Medical Control Contact (Adult/Peds) 18  Contact Medical Control to see if the medication(s) may be given and to discuss any issues regarding administration.  As long as the provider and the service have the “Medication Administration Route” for the patient’s medication within their scope of practice, they may administer the drug by that route with Online Medical Control Approval.
  19. 19. Assisted Prescribed Emergency Medications with Medical Control Contact (Adult/Peds) 19  Copies of the care plan and physician order must be attached to the patient care report  If the medication(s) is/are not administered, documentation must include reasons for withholding  Whenever medication is administered under these circumstances, transport is mandatory [emphasis added]
  20. 20. Assisted Prescribed Emergency Medications with Medical Control Contact (Adult/Peds) 20  Examples of conditions needing rare medication administration:  Adrenal Crisis  Indications:  Patient has a known history of adrenal insufficiency or Addison’s disease.  Presents with signs and symptoms of adrenal crisis including any or some of the following: Pallor, headache, weakness, dizziness, nausea and vomiting, hypotension, hypoglycemia, heart failure, decreased mental status, or abdominal pain.  Assist with administration of patient’s own hydrocortisone (Solu-Cortef) in its prescribed dosage.  Typical dosages are 100 mg IV or 1-2 mg/kg pediatric dosage maximum of 100 mg or sometimes:  0-3 years old: 25 mg IV  3-12 years: 50 mg IV  12 years and older: 100 mg IV
  21. 21. Assisted Prescribed Emergency Medications with Medical Control Contact (Adult/Peds) 21  Examples of conditions needing rare medication administration:  Hemophilia- Need Blood Factor concentrates when traumatic injured or spontaneously bleeding
  22. 22. Assisted Prescribed Emergency Medications with Medical Control Contact (Adult/Peds) 22  Emphasis:  Assist people with emergency home-use medications  The medications are prescribed and dosed for them  Need to deliver via route within scope/skill
  23. 23. Assisted Prescribed Emergency Medications with Medical Control Contact (Adult/Peds) 23  Good description of urgency and impact: “I will be in the living room, right inside the patio doors. I may be laying on the carpet or tile. I will have a ziplock bag in my arms. This bag will have the Solu-Cortef vial, current medical information and emergency contacts.” “I will need an IV started, and aggressive (push) volume replacement (dextrose 5% in normal saline solution is the best).”  This is where we described the procedure for an IO and she agreed to it.
  24. 24. Assisted Prescribed Emergency Medications with Medical Control Contact (Adult/Peds) 24  Good description of urgency and impact:  The Solu-Cortef needs to be injected into the IV, not intramuscular. “At this point of my adrenal crisis, intramuscular seems to have little to no effect, and I have a significantly more effective response to IV administration.” “The quicker I get the Solu-Cortef and fluids, the quicker I will stabilize. Delays lead to weeks or months long recovery time for me. More delays could cascade into my death.”
  25. 25. Assisted Prescribed Emergency Medications with Medical Control Contact (Adult/Peds) 25 “I will be confused, agitated, extremely fatigued, weak, crying, dehydrated and nauseous. I will have vomited already.” “My blood pressure may be high, as I will have already taken hydrocortisone orally in order to try and ward off the adrenal crisis. I may have tried to give myself a intramuscular Solu- Cortef injection, to try and buy some time.” Whether I did or not does not change the steps listed above. “I will understand very little of what is said to me, and I will remember next to nothing of the previous hours and the hours to come.”
  26. 26. Assisted Prescribed Emergency Medications with Medical Control Contact (Adult/Peds) 26  The best and only way to resolve all of this is the Solu-Cortef and fluids. “Anti-nausea medication or calming medication will have no effect, and has proven to make things worse for me.”
  27. 27. Assisted Prescribed Emergency Medications with Medical Control Contact (Adult/Peds) 27  I have attached a handout about adrenal insufficiency from a Texas EMS continuing education program.  Adrenal Insufficiency: Considerations for the Prehospital Provider; Texas EMS Magazine May/June 2013
  28. 28. Assisted Medication Protocol
  29. 29. DEA Points
  30. 30. Tips from the DEA Office 30  The latest legislation is still pending
  31. 31. Tips from the DEA Office 31  The DEA certificate is the responsibility of the Physican Medical Director  Check the counts  Check the orders  Extra orders have been processed by Service Directors  Do your own application and keep your own information  False DEA certificates have been obtained by Service Directors  No one wants to be suspicious or feel betrayed, especially in community or volunteer agencies
  32. 32. Tips from the DEA Office 32  Take care in processing controlled substances  Never have only one person handling the transactions  Ordering  Stocking  Accountability  Waste ‐ MUST be witnessed ‐ Simply squirting on the bay floor or dirt outside NOT adequate ‐ MUST render unusable and unretrievable ‐ Destroyed versus Reverse Distribution
  33. 33. My Additional Comment: Biennial Inventory 33  Narcotic Treatment Programs Best Practice Guideline PART 6  RECORDKEEPING  DEA requires that NTPs keep a record of all medication received, dispensed, administered, and destroyed. In addition, DEA requires that NTPs retain all records for two years from the date of execution….  DEA requires that NTPs conduct an initial inventory of all stocks of controlled substance medications on hand on the date that the NTP begins operations. It is also required that, at least once every two years, each NTP conduct and document a physical inventory (called a "biennial inventory") of the medication on hand. These inventories must include all forms of medication on hand (i.e., liquid, tablet, diskette, or powder) as well as the quantity and strength of each medication.  https://www.deadiversion.usdoj.gov/pubs/manuals/narcotic/part6/  My Trick or Treat is the last week of October. Choose your own.
  34. 34. Paramedic Pleads Guilty to Tampering with Morphine Supply 34 My comments  Considerations beyond pain management for harmful outcomes to patients:  Infectious Disease  Insurance fraud  DEA investigation  Loss of community trust  Loss of contracts  Loss of internal trust within the agency
  35. 35. Looking Ahead
  36. 36. Future Projects 36  EMS Example Protocol updates based on the National Model EMS Clinical Guidelines, Version 2  373-page document courtesy of NASEMSO  Evidence-Based Guidelines [Connecticut]  Minimum requirements for each scope  Update in controlled substances document to reflect new requirements based on legislation  Disposal vs Reverse Distribution guidelines
  37. 37. Future Projects 37  Medical Director exit interviews  Elite reports  Trends in medication use  Trends in chief complaint/call type  Safety check for IFTs, Emergent Transports  Advanced airway management safety check  Considerations for using AHLS guidelines/medications at the Paramedic (or as appropropriate) level  MCI/regional event considerations
  38. 38. Narcotic Diversion Case Example Paramedic Pleads Guilty to Tampering with Morphine Supply
  39. 39. Paramedic Pleads Guilty to Tampering with Morphine Supply 39  Reported by EMS World on Sept 15, 2017 [excerpts]
  40. 40. Paramedic Pleads Guilty to Tampering with Morphine Supply 40  Reported by EMS World on Sept 15, 2017 [excerpts]  A regional ambulance district is defending its security procedures after revelations that a former paramedic took painkilling drugs and gave vials of water to patients who needed pain relief.  The ambulance district issued a statement that it was "proud of the fact" that its inventory control and drug security procedures helped catch the problem.
  41. 41. Paramedic Pleads Guilty to Tampering with Morphine Supply 41  The paramedic confessed that he started tampering with drugs in March 2014, following a tonsillectomy.  The ambulance chief told investigators he first learned of a problem with the morphine supply on Jan. 30, 2015.  Special agents with the Food and Drug Administration [presumed typo: not FDA, but DEA] were notified of a possible drug tampering situation about five weeks later, on March 4, 2015.
  42. 42. Paramedic Pleads Guilty to Tampering with Morphine Supply 42  There were other signs that something was amiss.  Federal court documents show that Comstock was nearly two hours late for a training session on Feb. 21, 2015.  "The captain stated Comstock was still in his bunk sleeping"  "For 10 minutes, they knocked on his door with no answer. Eventually, Comstock responded but appeared very groggy and could not recall how long he was asleep.“
  43. 43. Paramedic Pleads Guilty to Tampering with Morphine Supply 43  The chief ordered a urine analysis, but it did not appear to test for fentanyl or morphine, according to the plea agreement.  Those were the two drugs at the center of the investigation.
  44. 44. Paramedic Pleads Guilty to Tampering with Morphine Supply 44  Bethany NTA employees told federal investigators that they had heard Comstock was suspected of drug tampering in Gallatin, Missouri, according to the plea agreement.
  45. 45. Paramedic Pleads Guilty to Tampering with Morphine Supply 45  Ultimately, Comstock pleaded guilty to three counts of tampering with fentanyl and morphine with what federal charges described as "reckless disregard for the risk that another person would be placed in danger of death or bodily injury."  There was no indication in court documents that Comstock's actions caused long-term harm to patients.  Comstock admitted that on two occasions he personally treated hip fracture patients who were supposed to receive pain relief but instead received vials of water.
  46. 46. Paramedic Pleads Guilty to Tampering with Morphine Supply 46 My comments  Considerations beyond pain management for harmful outcomes to patients:  Infectious Disease  Insurance fraud  DEA investigation  Loss of community trust  Loss of contracts  Loss of internal trust within the agency
  47. 47. Paramedic Pleads Guilty to Tampering with Morphine Supply 47  He told federal authorities he tampered with drugs on three different dates in 2015 but that he had "tampered with drugs on all the ambulances" prior to March 23 of that year.
  48. 48. Paramedic Pleads Guilty to Tampering with Morphine Supply 48  Comstock started working for the Gallatin ambulance company in 2013 and left voluntarily June 2014.  He stopped by the Gallatin office on two occasions in February of 2015. After both instances, employees noticed signs of tampering to vials of fentanyl.  Shortly after that, federal agents installed surveillance equipment at the Bethany ambulance building and placed a camera on an ambulance that was taken out of service.
  49. 49. Paramedic Pleads Guilty to Tampering with Morphine Supply 49  Surveillance equipment  Building  Ambulance that was out of service, but stocked  The very next day, Comstock was viewed entering the ambulance to access the narcotics cabinet.
  50. 50. Paramedic Pleads Guilty to Tampering with Morphine Supply 50  The director for the Community Ambulance District in Daviess County, read a prepared statement to the News-Press that was similar to NTA's statement.  Asked if the problem could have been caught sooner, he said this: "I just know we take a lot of pride in the fact that we did catch the problem. We took care of the issue when we came across it."
  51. 51. Paramedic Pleads Guilty to Tampering with Morphine Supply 51  Because of its cooperation with authorities, NTA ambulance officials don't believe the district's state and federal licensing will be in jeopardy.
  52. 52. Paramedic Pleads Guilty to Tampering with Morphine Supply 52  Officials in Bethany, in a statement, said the case illustrates scale of the opioid epidemic that kills 68,000 people a year in the United States.  "Unfortunately, the EMS community is not immune to this tragic epidemic," the ambulance district said.
  53. 53. Paramedic Pleads Guilty to Tampering with Morphine Supply 53  Summary/Discussion  How alert are you to tampering with controlled substances?  You must inform the DEA within 24 hours of suspected discrepancy or diversion  Numbers/stock versus clinical/field diversion  Discussion on waste versus tested destruction of leftover medications "Unfortunately, the EMS community is not immune to this tragic epidemic," the ambulance district said.
  54. 54. Narcotic Diversion Case Example Paramedic Pleads Guilty to Tampering with Morphine Supply

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