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Direct Medical Control Orientation Bradford H. Lee, MD, Medical Director About REMSA/Care Flight • Public Utility Model EMS Authority – No Local Tax Subsidy – 501.3C-Not for Profit • Exclusive EMS Franchise for Washoe County • All ALS Ground EMS • ILS interfacility transfers • CCT interfacility transfers for critical care patients • Regional Service Area – Northern Nevada and the Northern Sierra Nevada Range to Oregon • Helicopter Air Medical Critical Care • Largest EMS Provider in the Region What we do REMSA Operations CareFlight • 911 PSAP • Regional HEMS Dispatch • ACS Flight Management • Regional Air Medical Critical Care – Four Helicopters – Three Bases • CCT Ground Transport for Interfacility – Transfers of Critically Ill Patients • EMS RN/CCT Paramedic Crew • State of the Art Equipment • Air Methods Aviation and Maintenance • Vision Zero Safety Commitment • Integrated Hospital/Organizational – Training and CE • Independent Oversight – Medical Director, PMAC and Board • Medical Priority Dispatch • System Status Management • All ALS 911 Response/Transport • ILS Interfacility Transfers • Tactical EMS • Search and Rescue • Special Events and Operations • State of the Art Equipment • In-house Fleet Maintenance • County Emergency Management • MCI/Incident Command • Regional WMD Management • Independent Oversight Medical – Medical Director, PMAC & WCBH REMSA/Care Flight REMSA Education, Training and CQI REMSAPublicEducationandPrevention Regional EMS Undergraduate Education EMT and Advanced EMT (AEMT) Paramedic and CCT-P EMS RN AHARegionalTrainingCenter EnglishandSpanishLanguage HeartSaver CPR FirstAid BasicCardiacLifeSupport PediatricFirstAidandCPR HealthCareProvider Regional EMS Continuing Education BCLS, ACLS, EP-ACLS PALS, ITLS Nevada EMS Instructor Endorsement Community Health Paramedic Endorsement TTT Tactical Training Simulation Center AHA Training Center Quality Management and Improvement Mission: Lifeline Silver Award SafeKidsCoalition CommunityHealthEducationandPromotion CarSeatSafetyandFitting PublicEducationandPreventionGrants The REMSA Way “We care for our patients, our employees, their families and our communities” - Dean Dow, President & CEO STAR CARE • Safe • Customeraccountable • Team-based • Appropriate • Attentive to human needs • Reasonable • Respectful • Ethical Weliveourvalues EMS: Delegated Practice of Medicine NevadaStateBoard ofMedical Examiners Pre-HospitalMedical AdvisoryCommittee (PMAC) CommunityMedical Consensus StateofNevada Departmentof HealthandHuman ServicesDivisionof Health EmergencyMedical Services (BureauofLicensure andCertification) REMSA NevadaStateBoard ofNursing EMS: Delegated Practice of Medicine Direct and Indirect Medical Oversight Medical Director, Bradford H. Lee, MD Assistant Medical Director, Jeremy Gonda, MD Care Flight Executive Director, Ron Walters, MBA, CMTE Chief Nursing Officer, Diane Rolfs, MS, RN EMS providers practice under the license of the Medical Director AEMTs, Paramedics, Critical Care EMT-Ps, F-PCs EMTs, Physicians Assistants, Advanced Practice RNs (EMS-RNs) EMS RNs practice under the direction of the Chief Nursing Officer How We Care We practice medicine by protocol Protocols and Standards for Care Design and Approval REMSA/Care Flight Consensus Care Flight and Ground Clinical Committees • Field Personnel • Quality Improvement Staff • Educators • Operations/Finance/Leadership • Safety/Risk • Medical Director • Chief Nursing Officer • Director Education/Continuous Quality Improvement Community Medical Consensus Pre-Hospital Medical Advisory Committee Basic Life Support REMSA APPROVED MEDICATIONS EMT • Aspirin • Cool it® • Epi-Penâ (only if patient has their own) • Metered dose inhaler (may assist with patient’s own prescribed inhalers) • Nitroglycerin (sublingual) • OTC Medications • Oral glucose • Organic agent auto-injector (for self or partner) • Oxygen Intermediate Life Support REMSAAPPROVEDMEDICATIONS AEMT • The Advanced EMT may administer the All approved EMT medications PLUS the following, may be given per protocol and under the direct supervision of a Paramedic: above medications, to assist in ALS care, • Albuterol paramedic. • Albuterol /Ipratroprium (Duo-Neb) • Dextrose 50% • Dextrose 10% • Glucagon • Naloxone • Nitrous oxide (Nitronox) • Thiamine • Proparacaine eye drops under the direct supervision of a • The Advanced EMT may assist the ALS provider in the setting of cardiac arrest in adults with the administration of epinephrine. AEMT (not under direct supervision by a Paramedic) • The Advanced EMT not under the supervision of a paramedic (e.g. Special event, ILS transfer ambulance) may administer the following medications within protocol and if the patient presents with the listed clinical indications AFTER requesting an ALS response. • Albuterol and/or Albuterol/Ipratroprium (Duo-Neb) – for a patient with severe respiratory distress secondary to anaphylaxis or asthma. • Diphenhydramine IV or IM – for a patient with severe respiratory distress secondary to anaphylaxis. Must include cutaneous, cardiovascular, and respiratory component. • Epinephrine via an Epi-Pen® - for a patient with severe respiratory distress secondary to anaphylaxis. Must include cutaneous, cardiovascular, and respiratory component. • Dextrose 10% - for a patient with hypoglycemia with ALOC. • Naloxone – for a patient with respiratory depression secondary to suspected narcotic overdose. • Proparacaine Eye Drops – for a patient with foreign body to the eye that requires irrigation. • Nitrous Oxide – for patient with extremity trauma. • Advanced Life Support PARAMEDIC All approved EMT and AEMT medications PLUS: • Adenosine (Adenocard) • Afrin (Oxymetazoline Hydrochloride) • Racemic Epinephrine • Amiodarone • Atropine • Calcium Chloride • Diphenhydramine (Benadryl) • Dopamine • Epinephrine (including continuous infusion per Sepsis protocol and with base MD order per bradycardia protocol) • • • • • • • • • • • Fentanyl Haloperidol (Haldol) Lidocaine (Xylocaine) Magnesium sulfate Metoprolol Midazolam (Versed)Morphine Sulfate Nitroglycerin (topical) Oxytocin (Pitocin) Ondansetron (Zofran)Promethazine (Phenergan) Sodium Bicarbonate Vasopressin APPROVED MEDICATION INFUSIONS FOR SCT The Ground Paramedic may monitor, and titrate (as appropriate) the following continuous IV infusions: • Amiodarone infusion to reduce dysrhythmias • Dopamine infusion to maintain systolic BP between 80-160 mmHG • Epinephrine • Heparin IV infusion at established weight base dosage • Hydroxocolbalamin (Cyanokit) • IV antibiotics • Lidocaine (Xylocaine) • Nitroglycerin IV infusion to maintain systolic BP between 80-140 mmHG • • and/or – titrate to reduce chest pain. Potassium (40meq or less in one liter) • Total Parenteral Nutrition (TPN) • Versed infusion Care Flight and CCT CRITICAL CARE PARAMEDIC May initiate, administer, monitor, and titrate the following medications, including those approved for REMSA Paramedics only when working with a Care Flight Nurse regardless of mode of transportation. Etomidate Famotidine (Pepcid) Ketamine Nitroglycerine (IV) Labetalol (Trandate) IVP Octreotide (Sandostatin) Pantoprazole (Portonix) Rocuronimum (Zemuron) TXA (tranexamic acid) Vecuronium (Norcuron) • In addition to the REMSA ground paramedic medications, CCT paramedics functioning without a Care Flight Nurse are approved to administer the following IV drip medications from a facility on an IV pump at a fixed rate: – Diltiazem • The following medications may only be administered to patients with artificial airways at a fixed rate. Patients requiring additional pain management or sedation may be bolused with narcotic analgesia and/or versed according to the anxiety/pain protocols: – Narcotic analgesia (Fentanyl/Morphine) – Propofol – Versed Critical Care Nurse EMS RNs All REMSA Approved Medications PLUS… Any medication for which they have standing, written or verbal orders from a physician, nurse practitioner, or physician’s assistant licensed in Nevada or California. Basic Life Support Interventions and Procedures EMT-BASIC • • • • AED Pulse oximetry Traction splinting Tourniquet application Advanced EMT in addition to EMT-Basic skills • Establish intravenous access • Establish intraosseous access • Blood sugar testing • Medication administration from approved list • King Airway insertion • Defibrillation (manual mode with ALS provider / SAED mode otherwise) Advanced Life Support Interventions and Procedures Flight and CCT Paramedics: • tubes,andothertubesandmonitoringdevicesattachedtoor in addition to AEMT skills • Blood sugar testing • Blood transfusion maintenance • Capnography interpretation • MaintainFoleycatheters,chesttubesystems,NGandOG insertedintothepatient • Resetimplantedpacemakerswithamagnet • Managetransvenous pacemakers • Mechanicalventilatormanagement Defibrillation and cardioversion • Medicationadministrationfromapprovedlist • ECG rhythm and 12 lead interpretation • Needlecricothyrotomy • Establish and maintain intraosseous access • Needlethoracostomy • Establish and maintain peripheral Intravenous • NG/OGtubeinsertionandmaintenance • OralandnasalIntubation • Pulseoximetryinterpretation access, including external jugular • Infusion pump management • • King Airway insertion Surgicalcricothyrotomy • Tourniquetapplication • Laryngeal Mask Airway insertion • Tractionandothersplinting • Maintain vascular access devices • Transcutaneousandpacing • Umbilicalveincannulation Critical Care Nurse Interventions and Procedures EMS RNs All Critical Care Paramedic PLUS… • Pericardiocentesis • Chest tube placement Protocol Training and Review New REMSA/Care Flight employees undergo a rigorous prescreening process, knowledge-base and skills testing, and interviews before acceptance. REMSA/Care Flight requires a multiphase performance-based orientation and preceptorship lasting several months before granting independent field practice REMSA/Care Flight provides monthly educational programs to educate and validate competence in new protocols, equipment and procedures REMSA/Care Flight require quarterly and annual performance and skills evaluation for recertification Continuous Quality Improvement REMSA reviews monthly: Care Flight reviews monthly: All cardiac arrests All advanced airways (adult and pediatric) All administration of critical medications All deaths in the field All STEMI alerts Pediatric Patients with a GCS ≤ 14 Pediatric Versed, Epi, Narcan administration All Obstetrical Deliveries of Neonatal Resuscitations All sentinel events Critical Skills performed in the field 100% of Care Flight missions are reviewed by ACS Dispatch, Aviation, Maintenance personnel and Management Review of random sample of all care not listed for key quality indicators Statistical performance data is provided monthly to flight crews, management, education and Medical Director. Systemic or group performance trends are identified with strategies for resolution and loop closure Individual or crew care issues are identified for resolution and loop closure 100% of Care Flight clinical records are reviewed for key quality indicators using GAMUT criteria. Statistical performance data is provided monthly to flight crews, management, education and Medical Director. Systemic or group performance trends are identified with strategies for resolution and loop closure Individual or crew care issues are identified for resolution and loop closure Our Relationship Hospital Base Station State Requirement/Contract Relationship Direct (on-line) Medical Control Real-time physician contact required for consult, orders and destination issues at pre-determined trigger-points defined by community medical consensus. Medical Control Base Stations Direct Medical Control by contract for REMSA • Renown Regional Medical Center • St. Mary’s Regional Medical Center • Northern Nevada Medical Center • Renown South Meadows Medical Center By Nevada Law REMSA Paramedics/EMTs may only accept orders for care within their scope of practice from ED Base Station Physicians REMSA/Care Flight EMS RNs may accept orders for care from any appropriate physician The Protocol Manuals The REMSA and Care Flight Protocol Manuals Include: – – – – – REMSA Adult and Pediatric Protocols Procedures and Guidelines StarCare Checklist Drug Definitions and Dosages Contact Information Procedures and Guidelines REMSA approved medications and procedures Transport of Home Ventilator Patients Transfer of Patient Care Refusals of Care Hospital Destination/Diversion Civil Protective Custody Unsolicited Medical Intervention Communications Failure Procedure Do Not Resuscitate Guidelines Transport of Patients with IV Antibiotics Documentation Management of Minors Hazardous Materials Management Biological and Chemical Terrorism Trauma Criteria and Transport Considerations Interfacility Transport of Patients Not Requiring an ALS Attendant Requirements Patient Destination Patient/Family Choice Hospital catchment areas for routine patients without preference Closest Appropriate Facility e.g., Pediatrics, OB-GYN, STEMI, Stroke Trauma center requirements Patients in extremis Hospital Divert Any competent patient may override patient destination protocol with Base Station concurrence when informed of the risk/consequences of their decision Divert Override The PMAC has determined that patients with: Ø STEMI Myocardial Infarctions Ø Strokes within an 8 hour window Will be accepted by a hospital on Divert with ED physician radio consult Triggers for Base Station Contact REMSA/Care Flight has worked with our medical community to define a safe and appropriate scope of practice for our EMS practitioners Direct medical control contact is required when community medical consensus has deemed it appropriate. In general, it reflects the need by EMS personnel for physician authority, consultation with a clinically complex problem, patient advocacy or management of an unusual issue. We strive to request base station contact only when it adds value. We commit to timely and clear radio reports and specific requests for help. Thank you for your time and commitment to make EMS in our community work better. Service Inquiries We request and encourage you to contact us ASAP with comments and concerns about our care and service Ground Operations Supervisor: 775.691.4680 Care Flight Manager on Call via CF Dispatch: 775.858-5709 We are committed to evaluating and responding to your concerns Of course, we are always interested in sharing positive feedback for quality care! Contact Us REMSA/Care Flight 775.858.5700 Bradford H. Lee, MD Medical Director [email protected] Jeremy Gonda, MD Assistant Medical Director [email protected] Ron Walter, MBA, CMTE Executive Director of Care Flight [email protected] Diane Rolfs, RN, MSN Director of Education Training and CQI and Chief Nursing Officer [email protected]
