Emergency medicine and critical care development and EMSS

1. Introduction to Emergency
Medical Service System (EMSS)
By: Bikis Liyew
(Assistant professor of EMCCN,HOD)
•Email:biksliyew16@gmail.com
• ORCID:https://orcid.org/0000-0001-7407-1870
May, 20222

2. 1. Historical background
2. Rationale of Emergency care development in Ethiopia
3. EMSS Structure
4. Pre-hospital EMS
5. Facility Emergency EMSS
6. ER workflow
7. Communication in ED.
Outlines
2

3. Case Scenario
3
 A call comes in after mid-day. You and your
partner are dispatched to a local intersection for an
incident involving a car and a bicycle collision.
 The primary patient is a 12 years old patient who is
on the ground.
 The Child is crying, showing some deformity to the
right leg.
 The woman who was driving the car is hysterical and
standing nearby.

4. Case scenario cont’d …
4
1. As emergency first-responder (EMR), what is your initial
responsibility?
2. If the patients first contact with the EMS System is
instruction with an Emergency Medical Responder
(EMR), and the second occurs when EMTs arrive, where
would be the third arrival?
3. What are major activities of pre-hospital EMS?
4. List the main rooms of Facility Emergency?

5. At the end of this session the learners will be able to:
 Define the Emergency Medical Service system (EMSS)
 Describe historical background of EMSS
 Describe challenges to EMSS in SSA
 Identify major activities and components of EMS
 Describe prehospital structures of EMS.
 Describe structures facility emergency services
 Describe communications in Emergency room
Session Objectives
5

6. Introduction and background
Of EMCC
6
The changing diseases burden

7. Definition of emergency medicine
“Emergency medicine is a field of practice based
on the knowledge and skills required for the
prevention, diagnosis and management of
acute and urgent aspects of illness and injury
affecting patients of all age groups with a full
spectrum of episodic undifferentiated physical
and behavioural disorders;

8. Introduction of EMCC…………….
• it further encompasses an understanding of
the development of prehospital and inhospital
emergency medical systems and the skills
necessary for this development.” IFEM of
Emergency Medicine

9. Emergency Medical Services System (EMSS) is:
 a network of services and resources coordinated to provide
aid and medical assistance from primary response to
definitive care,
 involving personnel trained in basic first aid to advanced
emergency care
Introduction to EMSS…
9

10. Emergency care has been developed from
 the days when the local funeral home was the ambulance
provider and, care did not begin until arrival at the hospital.
In present days, a sophisticated EMS system;
 permits patient care to begin at the scene till patent gets
definitive treatment
EMS cont’d…
10

11. EMS is part of a healthcare continuum that extends from
the time of injury/illness until rehabilitation or discharge.
Cont’d …
11
EMSS
In-Hospital Care
Out-of-Hospital Care
EMS

12. Axioms in EM
” golden hour”- in handling trauma
 “time is muscle”- in handling acute myocardial
infarction
 “time is brain” in handling stroke
Time is critical factor and people gauge their
quality of work through variables like door to IV
fluids time in shock door to balloon time , door
to thrombolytics, door to
splinting, etc
It is like running a relay. A B C

13. EM success in preventive and management
strategies in the community
• Primary prevention
• Secondary prevention
• Tertiary prevention to be applied
• ED becomes a good interface between
hospitas and families.

14. Achievements in western EDs after EM
development
Adequate space and facility has been designed
at ED.
Investigations - laboratories /imagings processed
fast.
Prehopital -dispatch ,communication and
medical ambulance system is strengthened.
ED has better communication with prehospital
system.
Trainings and staff developments are actively
planned and implemented.

15. CONT…………………………………….
Emergency department have clear guidelines to
doctors and nurses.
Infection prevention and isolation techniques are
better practiced.
ED became the engine of the whole hospitals quality
improvements.
ED staff is always ready and at high spirit to handle and
mitigate disaster.
Researches and literatures are developing and being
used to practice evidence based medicine.


16. History of emergency medicine
"Alexandria Plan“-Dr. James DeWitt Mills who, along
with other associate physicians at Alexandria Hospital,
VA established full time (24/7 ) a year round
emergency care in 1969.
Anita Dorr, RN introduced the ED ‘‘crash cart’’ in 1967
In 1970,professional development was accelerated by
the founding of the Emergency Department Nurses
Association (EDNA), later renamed the Emergency
Nurses Association (ENA).
Establishment of the Journal of Emergency Nursing
(1975)

17. Courses developed for EM nurses through time
in USA
• BLS - Basic Life Support
ACLS - Advanced Cardiac Life support
TNCC - Trauma Nurse Core Curriculum
PALS - Pediatric Advanced Life Support
and/or
ENPC - Emergency Nurses Pediatrics Course
CEN - Certified Emergency Nurse
ABLS - Advanced Burn Life Support
NRP - Neonatal Resuscitation Provider
CCRN - Critical Care Nursing

18. Other developments in USA
 the establishment of the first emergency medicine training
program at Cincinnati General Hospital, with Bruce Janiak, M.D.
The 1st EM resident in 1970.
 American colledge of emergency physicians(ACEP), the recognition
of emergency medicine training programs by the American Medical
Association AMA and the American Osteopathic Association (AOA),
and in
 1979 a historical vote by the American Board of Medical
Specialties that EM became a recognized medical specialty.
 The International Federation for Emergency Medicine(IFEM) was
founded in 1991 growing from the association of emergency
physicians in Britain, Australia, Canada and the United States.
 African federation of EM was established in NOV.2009,in cape
town.

19. EM development in Ethiopia
Federal ministry of health and Addis Ababa
health bureau efforts
 Premillinium activities-awareness creation, short
term trainings, trauma data generation .In those days
it did not bear fruits as there was no institute took
responsibility of the vision.
 Millennium
 Post millennium

20. Millinium activities
 New structure buildings were set &renovation of existing
Emergency rooms was carried out.
 Emergency rooms were filled with emergency drugs and
supplies.
 Communication system was established with three digit
telephone and direct lines and radio communications.
 Dispatch center was established at queen Zewditu memorial
hospital.
 Simulation exercise was performed in the city.
 Training of health manpower was carried out at different levels
and in the millinium week staff was on alert for any incidents.

21. Post millennium activities
Federal ministry of health has showed great
interest in emergency medicine development
and in the reform process or business process
reengineering hospital services are categorized
into three domains: the emergency care, the
regular outpatient department activities and
inpatient care. Hence, currently , emergency care
has been designed to be the nucleus of
Ethiopian hospitals services.

22. AAU,FOM efforts
Pre-2005
There were efforts of emergency medicine
developments in Ethiopia in 1990s specially in Addis
Ababa city council Health Bureau (AACCHB) and AAU
FOM but the efforts did not bear fruit because of high
turnover of staff and the efforts were not
institutionalized .the main activities performed then
were short term trainings and trauma data
development.
Post 2005 efforts and achievements

23. AAU,FOM efforts- post2005
 June 2006 at Menelik hospital ( organized by thiopian North American
Health Professionals Association (ENAHPA and AACCHB) -agreed to
strengthen emergency care and establish EM.
 AAU was given responsibility to initiate and steer training activity and to
open emergency department which would be center of excellence in the
country.
 The task force established in the faculty of medicine in the same time
from all departments.
 prepared proposal document for emergency medicine development in
the faculty presented In the Ghion Hotel workshop after 6 months. The
proposal was accepted by all stakeholders and responsibilities were
shared among. Federal ministry of health and AACCHB were given to
coordinate the expansion of emergency services and AAU FOM to
spearhead emergency medicine training .
 The first emergency services unit was established in August 7, 2008
serving adult emergencies with a capacity of 20-24 beds.

24. AAU-Trainings
Long term/intermediate programs
 The facility staff with collaboration of AACCCHB and FAEA has
trained fourty two nurses to be medical ambulance crew.
 Emergency medicine residency training
 Masters training in emergency medicine and critical care nursing
Short term trainings
 Trainings to ED nurses
 Training center modules(basic life support, trauma life support,
obstetrics support, cardiac life support, interns module, emergency
ultrasound modules , etc)
In addition the medical school task force is playing pivotal role in
advising national task force concerning emergency medicine
development, and working with sister universities to spread the
vision.

25. Residency program /medical
student
• The Emergency Medicine task force (EMTF) presented
the curriculum and it was approved by Addis Ababa
University Senate. The 3-year graduate residency
training program and the 2 year EM Critical Care
Nursing program were official launched in October
2010. The department graduated four Emergency
Medicine specialists for the first time in October 2013
• Currently, the FMOH is launching pre-hospital care
throughout the country and EMSU in all hospitals.

26. CONT………………………………………
• The medical education curriculum for
undergraduate medical students have recognized
EM as a 7-week module. when students get
didactic, skills based and clinical education in
selected EM areas. Students cover important
principles in adult EM practice, pediatric EM
area, and anesthesiology. They develop important
skills for stabilization of critically ill patients.
• The Emergency Medicine Residency Program
now has permanent status at The AAUSOM, and
will continue to

28. Gondar
• Un like Addis Ababa university .University Gondar
there were no special intensive unit to treat patients
since medical Icu were opened in 2004E.C.
• 2014 emergency organizes as unit. It gives course for
own post basic students in addition delivering first aid
common course for health science students.
• Followed MOH attention for emergency department In
2015 the renovation of emergency room and separate
room for different acuity established.

29. CONT………………………………………..
• Nov,2017 emergency and critical care nursing
recognize as department.
• July 2017 Generic emergency and critical care
curriculum developed by national level.
• Then the department of emergency and critical
care nursing took initiative to expand the MSc
training next to Addis Ababa university
• The modified national curriculum has been
developed in 2019 and the program launched in
2020.

30. Post basic program
• In an ideal setup, due to the unstable nature of these
patient populations the comprehensive/ clinical nurses
are rarely utilized in a primary care role in the
emergency care. However, as there were no specialized
nurses graduated in this field in the country,
• the care was delivered by comprehensive/ clinical nurses
having short-term trainings. In response to this
specialized emergency ,

31. • Trauma Care Ethiopia has taken the initiative to develop a
curriculum on post-basic BSc in emergency and critical
care nursing in collaboration with Addis Ababa University
on January 2011.
• As it is difficult to produce adequate number these
specialized nurses by one institution (St. Paul’s MMC), the
Federal Ministry of Health (FMOH) took the initiative to
produce a competency based integrated and modular
curriculum at bachelor degree level to train emergency and
critical care nurses as post-basic program in 2014.

32. old emergency OPD

33. Since 2015 G.C uog referral hospital emergency renovated

34. 2019 G.C MSC Curriculum
developed in UOG

35. Is EM worthwhile to
Ethiopia?
1.Changing epidemiology of illness
 “ double burden of disease”-in developing countries
 Trauma
 Ischemic heart disease and other CVS disorders and
HIV/AIDS.
 Poisoning
 metabolic illnesses
 Pregnancy and its complications.
 Neonatal and pediatric emergencies.
 Natural disasters -flooding, conflicts, Terrorism, conflicts
occur any time.

36. Is EM worthwhile?
2.Development and diplomatic issues
• Ethiopia has been registering double Digit
development in GDP in the last 5-6Yrs.
• Population has doubled in the last 30 yrs
& there is rapid urbanization (AA-
estimated to be 3-4 mill.)
• Infrastructure is developing fast-roads,
hotels, universities, dams, etc
• There is boom of investment

37. Is EM worthwhile?
3Tourism
 Ethiopia has been forecasted to be in the top ten tourist
destinations with in ten years.
 -Lucy’s legacy, migrations human ancestors from Ethiopia
 -heritages, geography, fauna and florae
4.Diplomacy
 -AA is capital of Africa and Ethiopia with many embassies
,continental and international organizations offices.
 Tremendous number of national, Continental and
international meetings take place.
 Dignitaries- country heads, parliamentarians, heads of
international organizations and others visit Ethiopia.

38. Why it become urgent issues globally?
38

39. During the Korean & Vietnam conflicts,
 injured soldiers benefited from emergency care in the field
prior to transport
1960’s the beginning of the modern EMS system
 The National Academy of Sciences Research Counsel has
advocated professional training for prehospital emergency
personnel.
Historical background of EMS…
39

40. The two important contributions made by US Federal
government and American Heart Association;
1. The National Highway Safety act
 charged the Department of Transportation with developing an EMS system
and upgrading prehospital care,
 It was a base that gradually evolved to current EMT programs
2. The American Heart Association
 began to teach CPR and BLS to the public
Cont’d…
40

41. 1.2. Emergency care in
Ethiopia
41
Rationales for Emergency care in Ethiopia and
Historical background

42. Why health emergencies become urgent issue?
Rationale for Emergency care dev’t in
Ethiopia
42

43. Pre-existing Triple burdens of emergency conditions
 Infectious ds + Obstetrics + Childhood ds emergencies
Raising Double burdens of time-sensitive emergencies;
 Trauma /injuries/ + Chronic-medical conditions
Disproportional deaths from emergency conditions are
attributed to poor prehospital and in-hospital emergency care
Rationale for Emergency care in
Ethiopia
43

44. EMSS development is a recent phenomenon in Ethiopia.
Establishment of Emergency Medicine task at AAU (in 2006)
 Collaboration with FMOH and Addis Ababa Health Bureau
FMOH reform program in 2010, for re-arrangement of
emergency service in health facilities
 emergency services become one of three hospital services
Historical development in
Ethiopia
44

45. Achievements of the 2010’s national directives
 Establishment of independent management & resource
structure for emergency service
 New ED began operating at St. Paul Hospital in 2011,
Cont’d..
45

46. In 2011, beginning of curriculum dev’t and professional
training, the first
 Post-basic BSc in ECC nursing was launched at SPMMC
 MSc in EMCCN was launched at AAU
 Currently 3 program exists in MSc program
The beginning of speciality training in EMCC at AAU,
 Recently expanded to other Ethiopian universities
Cont’d…
46

47. Several challenges to EMSS in Ethiopia
 High public demand for the care
 In adequate human resources, ambulances and equipment
 Lack of toll-free EMS number
 Lack of EMS legislation
 Lack of Awareness
 Poor culture of acute /emergency care
Cont’d …
47

48. Is EM worthwhile to Ethiopia?
1.Changing epidemiology of illness
“ double burden of disease”-in developing countries
Trauma
Ischemic heart disease and other CVS disorders and
HIV/AIDS.
Poisoning
 metabolic illnesses
Pregnancy and its complications.
Neonatal and pediatric emergencies.
Natural disasters -flooding, conflicts, Terrorism,
conflicts occur any time.

49. Is EM worthwhile?
2.Development and diplomatic issues
• Ethiopia has been registering double Digit
development in GDP in the last 5-6Yrs.
• Population has doubled in the last 30 yrs &
there is rapid urbanization (AA-estimated to
be 3-4 mill.)
• Infrastructure is developing fast-roads,
hotels,universities,dams,etc
• There is boom of investment

50. Is EM worthwhile?
3Tourism
 Ethiopia has been forecasted to be in the top ten tourist
destinations with in ten years.
 -Lucy’s legacy, migrations human ancestors from Ethiopia
 -heritages , geography , fauna and florae
4.Diplomacy
 -AA is capital of Africa and Ethiopia with many embassies
,continental and international organizations offices.
 Tremendous number of national, Continental and
international meetings take place.
 Dignitaries- country heads, parliamentarians , heads of
international organizations and others visit Ethiopia.

51. Is EM worthwhile?
• Yes it is worthwhile to invest in EMS and EM.

52. 1.3. Function & Structure of EMSS
What are the major structures of EMSS?
52

53. Emergency care systems involves the emergency care
continuum
Emergency care systems
53

54. 1. Prevention of injury and acute illness
2. Recognition of the event by bystanders
3. Activation of the EMS system,
4. Bystander care
5. Arrival of First Responders, who might be Fire/rescue
personnel (paid or volunteer), Law enforcement personnel.
6. Emergency care at the scene,
7. Transport to the receiving facility (hospital) and
8. In-hospital care
Major activities of EMSS
54

55. Components of EMSS
 1. Regulation and policy
 2. Resource management
 3. Human resources and training
 4. Transportation
 5. Facilities
 6. Communications
55
 7. Public information & education
 8. Medical oversight
 9. Trauma systems
 10. Evaluation

56. The EMS System

57. 1.4. Pre-hospital EMS
Prehospital EMS: Components, Activities
Ambulance service
57

58. Pre-hospital EMS activities
 Major activities of EMS are;
 1. Detection
 2. Reporting
 3. Response
 4. On scene care
 5. Care in Transit
58
1
2 3 4
5

59. 1. Detection:
 Bystander on the scene or victims themselves
 observe the scene, identify the dangers and report to EMS
2. Reporting:
 call for professional help & dispatch is connected with the victims.
3. Response:
 first rescuers provide First aid to the extent of their capabilities
Pre-hospital EMS activities
59

60. 4. On scene care:
 Arrival of EMS personnel and start immediate care on-scene
5. Care in Transit:
 EMS personnel depart for hospital via an ambulance for
specialized care
Pre-hospital EMS activities …
60

61. Prehospital EMS cannot function in isolation
 should be fully integrated into health care system
 EMS can be offered by numerous entities
 Municipalities, Legal enforcement, Fire department,
Hospitals and private providers
Prehospital EMS mainly relies on Ambulance service.
Providers of prehospital EMS
61

62. EMS under fire department in Larger cities
Structure of Prehospital EMS
62
Fire
Department
Fire Fighter Rescue
Ambulance
service

63. Ambulance service
 is used to transport and to render care to injured or acutely
ill patients
 operated under dispatch center & accompanied by
 are tiered ground and air ambulances
Ambulance service
63

64. It is a means of public access
Effective dispatch system requires
 Toll-free 3-digit phone system with trained dispatchers
 Collection of information by dispatcher from the callers
 Activation of the appropriate level of response (tier based)
Dispatch center and system
64

65. Pre-hos. Con…
AMBULANCE SERVICE
1. Paramedic/EMT ambulance
2. Doctor ambulance
3. Doctor helicopter /flight Dr/ Nurse
Work flow
• Dispatch center
• ambulance station
Communication system – 3 digit telephone, direct telephone, internate
manpower
• Community based 1st responder
• EMT
• Paramedic
• Nurse, doctor

66. Pre-hosp. Cont…
Equipments in the Ambulance
• i. Disposable gloves and sharps container
• ii. Airway and ventilation equipment
• iii. Basic wound care supplies
• iv. Splinting supplies
• v. Childbirth supplies
• vi. An Automated
External Defibrillator
• vii. Patient transfer
equipment

67. Dispatch facility
.Dispatch
– The dispatch facility is a center that citizens can
call to request emergency medical care.
– Most centers are part of a 9-1-1 system.
939-fire Ambulance and ------Red cross
– Dispatchers should obtain proper information
from the caller and instruct callers on how to
perform life saving techniques until you arrive.

68. Dispatch center

69. EMS Communication
Communications are important during every phase of a call .
– The dispatcher must communicate the location and type of call
to responders.
– EMRs need to communicate with patients, bystanders, family
members, dispatchers, and members of the public safety
community.
– Principles of communicating with patients in a manner that
achieves a positive relationship
– Interviewing techniques
Communication needed to:
• Call for resources
• Transfer care of the patient
• Interact within the team structure

70. Communication System
and Equipments
• The purpose of a communications
system is to relay information from one location to
another when it is impossible to communicate face to
face.
• The results of using a communication system will be
only as accurate as the information that is put into the
system
• Communications systems can be divided into two
categories:
– 1.Those that transmit voice communications
– 2.Those that transmit data

71. 1.Voice Systems
• Voice communications systems transmit the
spoken word from one location to another.
• 1. Radio systems
– Regulated by the Federal Communications
Commission (FCC)
– Frequencies are assigned according to the
function of the organization.

72. Voice Systems…
Types of radios:
1.Base station
2.Mobile radio
3.Portable radios

73. Voice Systems…
• 2.Telephone systems
– Primarily convey voice communications
– Landline phone systems: tied together through an
above-ground or below-ground hardwired system
– Cellular phones: rely on radio waves between a
cellular phone and a cellular tower to send and
receive phone messages

74. 2. Data Systems
• Data can be transmitted through :
• Radio systems or phone systems.
– Paging systems can transmit text messages or voice
communications.
– Mobile data terminals (MDTs) transmit data messages
through a radio system.
• Fax machines use phone lines or radio systems to send
written data.
• Telemetry is used by ALS providers to transmit ECGs and
other patient data to online medical control.
• E-mail is used to transmit a wide variety of messages

75. Data Systems…
• Radio systems or phone systems.
– Paging systems can transmit text messages or voice
communications.
– Mobile data terminals (MDTs) transmit data messages through a
radio system.

76. The Functions of Radio
Communications…
• 1.Dispatch
– Dispatch may be voice, text messaging, or an MDT
to alert responders to an emergency.
– It is your duty to keep your equipment ready to
receive a call when you are on duty.
– If you are unsure that all information has
been received correctly, ask the dispatcher to
repeat it.
– MDT=(Mobile data Terminal

77. 2.Response to the scene
Learn how to use your map books.
The dispatcher may give you further
information while you are en route to
the scene.
If you are delayed or encounter any
problems, notify dispatch.

78. 3.Arrival at the scene
– Perform a visual survey of the scene.
– Give the communications center a concise verbal
picture of the scene( to Dispatch center)
• Location and type of incident
• Any hazards present
• Number of patients
• Any additional assistance required

79. 4.Update responding EMS units
( to Special unit /Hospital)
– Your report should include:
• Age and sex of the patient
• Chief complaint
• Level of responsiveness
• Status of airway, breathing, and circulation
• ** Show sample video(
• 5.Transferring care to other EMS personnel
– Provide EMTs or paramedics with a “hand-off”
report.
– Use the same approach you follow during patient
assessment:

80. Transferring care (cont’d)
• Provide the age and sex of the patient.
• Describe the history of the incident.
• Describe the patient’s chief complaint.
• Describe the patient’s level of responsiveness.
• Describe how you found the patient
– Patient assessment: (cont’d)
• Report the status of the patient’s vital signs, airway,
breathing, and circulation.
• Describe the results of the physical examination.
• Report any pertinent medical conditions using the
SAMPLE format.
• Report the interventions provided and the patient’s
response to them.

81. Transferring care…
– Online medical control is generally used by EMTs
and paramedics to:
• Secure permission to perform certain skills
• Get direction regarding patient care
• Give patient care reports to the hospital
– Online medical control is generally used by EMTs
and paramedics to:
• Secure permission to perform certain skills
• Get direction regarding patient care
• Give patient care reports to the hospital

82. 6.Postrun activities
– After you have transferred care, you need to
report your status to your communications center.
– Let the communications center know how long it
will take you to get your unit ready for service and
when you will be available for another call.

83. AMBULANCE
• The term ambulance comes from a latine word
“AMBULARE’’ meaning to move or walk about,
which is a reference to early medical care where
patients were moved by lifting or wheeling
• The word originally meant a moving Hospital
• An ambulance is a vehicle that is used for treating
and transporting patients who need emergency
medical care to a hospital.

84. Different types of Ambulances:-
1. Ground Ambulances
2.Air Ambulances
3.Hospital trains, boats & ships
4. Horse and carts.

85. AMBULANCE…
• The history of ambulances began in ancient
times used to transfer by carts to transport
incurable patients by force.
• Ambulances were first used for emergency
transport in 1487 by the Spanish.
• Horse-drawn ambulances were used in major
U.S. cities in the late 1700s

86. Horse drown ambulances

87. Ambulance history in Africa

89. Our history in ambulance service

92. Ambulance color
• The Standard specifies that all ambulances will
be painted yellow, with specific color
standards, as their primary body color.[
• The color yellow was chosen primarily
because it remains visible to almost all people
in all lighting conditions, including the
majority of those with color-blindness.

93. European Ambulance Visual Identity

94. Standard Ambulances
• .

95. Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
A Type I ambulance

96. Type “A “Emergency Ambulance in
Poland

97. Ambulance parking on the scene

98. EMS IN AMBULANCE SERVICE

100. Anterior ICU in Poland

101. Back bored

102. Bledsoe et al., Essentials of Paramedic Care: Division V
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Air Medical Transport
• Air medical transport involves 2 types of air
rescue units: fixed-wing aircraft and rotorcraft.
• Missions involving air units are commonly
referred to as aeromedical evacuations, or
medevac.

103. Bledsoe et al., Essentials of Paramedic Care: Division V
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Advantages of Air Transport
• Rapid transportation
• Access to rural or remote areas
• Access to specialty units (NICU)
• Access to personnel with specialized skills
• Access to specialty supplies

104. Air ambulances
• .

106. •
• THANK YOU

107. Medical Simulation

108. EMSS cont
Monitoring and Evaluation
1. Documentation /reporting system
2. Periodic evaluation
3. Local drills /Hospital, paramedic
4. Medical rally/national, prefecture level

109. Dispatch center ….
 View of 9-1-1 dispatch center
109
 Dispatch system

110. Prehospital care providers can be
 Trained lay person or professional provider
–
Levels of pre-hospital EMS trainings are
 1.First responder: Lay person
 2.EMT Basics:
 3.EMT-Intermediates:
 4.EMT-Paramedics:
Prehospital care providers
110

111. 1.First responder:
 are typically the first trained provider to arrive on the scene.
 are trained at the most basic level first aid at scene
 police officer, firefighter, school club or volunteers
2.EMT Basics:
 are trained on basic courses to function in three areas.
 to control life treating situations, stabilizing non-life
threatening situations and use of non-medical skills such
Prehospital personnel …
111

112. 3.EMT-Intermediates:
 Are EMT-Basics who have acquired additional training to
provide more complicated care to patients.
 Provides advanced life support (ALS), including starting IVs
and giving some medications, intubation and defibrilation
Prehospital personnel …
112

113. 4.EMT-Paramedics
 the most highly trained pre-hospital care providers in the
system
 Attend extensive trainings
 Provides patient education and prevention activities
 Involved in research activities
113

114. 1.5. Facility-Based Emergency
Care Service
Hospital-based components of EMSS
114

115. Structure of EMSS
115
Basic level
Intermediate level
Advanced level
Center of excellence

116. Hospital ED is the third contact for patients with the EMSS
ED/ER is a primary care department that provides initial
treatment with a broad spectrum of emergencies.
 which could be life-threatening and requiring immediate attention.
Based on the scope of the services EDs are categorized into four
Facility-based Emergency Care
116

117. Emergency service centers are categorized into four
 1. Basic level - health center and primary hospitals
 2. Intermediate level: general hospital
 3. Advanced level: Tertiary hospital
 4. Center of excellence
Facility Emergency Care Structure
117

118. A typical ED has several different areas;
 each specialized for patients with particular severities or
types of illness.
The layout of facility emergency service: ER should
 be Leveled, labeled and clearly seen
 have waiting area visible to triage .
 have short stay beds
Facility emergency service … ED
118

119. The layout of ER: It should have
 24hrs accesses to services of: ER triage, ,laboratory,
pharmacy, radiology, Operation theater, Blood product
service, etc.
 disaster preparedness plan and trauma care service.
 ambulance parking near ER area and should waiting area,
Facility emergency service …
119

120. Triage area:,
 Areas for primary evaluation before transferring to another
area of the ED or a different department in the hospital.
 patients with life or limb-threatening conditions may bypass
triage
Resuscitation area:
 is a key area with full resuscitation materials and drugs.
Facility based service …
120

121. Observation and acute care/treatment area:
 an area for patient to be kept after resuscitation
/stabilization
 stable patients for 24hrs until transfer to respective unit
Procedure room:
 where different interventional activities are undertaken
Facility based service …
121

122. Other areas:
 stores, dispensary for emergency drugs, isolation rooms and
decontamination rooms
Standard and guidelines of ED
 There must be standard and guidelines of ED,
Cont’d …
122

123. ER Layout (at tertiary hospital)
123

124. 1.6 Other Hospital components of
Emergency Services
Emergency Room workflow
Human resources
Communication in ED
124

125. Mode of arrival
 by ambulance (ground or air) or independently
Pre-arrival notification by ambulance team
 Emergency physicians my provide medical guide to
ambulance team
Arrival to ED and triage
 Based on order of medical urgency not in order of arrival.
ED workflow
125

126. Physician in ER
 different categories depending on the hospital level
 includes EM physician, GP trained on BEC, residents
 EMCC Specialized MSC nurses assume role at lower hospitals
Emergency Nurse initiates care according to the urgency
Others HR in ED, Runners/Porters, Cleaners, Guards,
Registration Rooms and officers.
ED human resources
126

127. Where do ED should communicate:
 Dispatch center, prehospital care, other health facility & RHB
Vertical communication
 with dispatch center and ambulances, with inpatient services
such as OR, ICU and wards.
Horizontal communications
 should be in place with House staff (health professionals and non-
professionals) to facilitate patient care
Communication in ED
127

128.  Monitoring and Evaluation system for EMSS
1. Documentation /reporting system
2. Periodic evaluation
3. Local drills /Hospital & paramedic/
Monitoring and Evaluation
128

129. 129
Brainstorming
Now go back to previous Case
Scenario!

130. Case Scenario
130
 A call comes in after mid-day. You and your
partner are dispatched to a local intersection for an
incident involving a car and a bicycle collision.
 The primary patient is a 12 years old patient who is
on the ground.
 The Child is crying, showing some deformity to the
right leg.
 The woman who was driving the car is hysterical and
standing nearby.

131. 131
Q1 The initial responsibility of
the first responder (EMR) is
 At Scene; Check if the scene is safe,
 Seeing whether there are more victims in the car
 Control life treating situations,
 Controlling severe bleeding
 Stabilizing non-life-threatening situations
including dressing and bandaging wounds,
splinting injured extremities,
 Call an ambulance
 En-route care: On the way to hospital

132. 132
Q2. The third contact:
where would be the third arrival?
 The third contact would be
when the patient arrives in the
emergency department at
hospital.

133. 133
Q3. The major activities of
pre-hospital EMS?
1. Detection
2. Reporting
3. Response
4. On-scene care
5. Care in Transit

134. 134
Q4. The main rooms of Facility-
based Emergency service (ER)?
 Triage, Resuscitation, Observation
and treatment area,
 Laboratory, pharmacy,
 Procedure, OR, isolation,
decontamination.

135. Prehospital core activities are, detecting, reporting, response, on
scene care and care on exit.
Emergency components at a facility are:
 triage, resuscitation , observation and treatment area, procedure,
store, pharmacy, lab, isolation and decontamination area.
During emergency period, after being evaluated and treated,
patients are transferred according to the severity of
illness/trauma or to their nearby health facility as soon as
possible.
Summary
135

136. Good communication system with team sprite within
hospitals and pre-hospital level can improves the outcome
of critically ill patients.
Monitoring and evaluation system of EMS.
Summary…
136

137. THANKS
• .