Download anatomy of a medical call - San Francisco Fire Department

ANATOMY
OF A
MEDICAL CALL
or
“How we do…what we do!”
San Francisco Fire Commission
Thursday July 28, 2005
What we’ll talk about
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The Language of EMS
Summary Statistics
Rules of the Game
A Typical Incident
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Intake (the call to 911)
Operations (what happens on scene)
The back-end
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Quality Improvement / Risk Management
Billing and Revenue / Medical Records
The Other Players
The Language of EMS
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ALS = Advanced Life Support
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BLS = Basic Life Support
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EMT level of care
Code 3 = Potentially life threatening event
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Paramedic level of care
Lights and sirens
Code 2 = Potentially non-life threatening event
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Respond with the flow of normal traffic
More Info
EMT-local certification
 Minimum 120 hours of training
 Non-invasive maneuvers
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Bleeding control, basic airways, CPR, w/hold CPR
1100 + in our Department
PARAMEDIC-California State license
 Minimum of 1400 hours of training
 Invasive maneuvers
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IVs, drugs, advanced airways, pronouncement
270 in our Department
San Francisco Fire Department
Summary Statistics
FY 2004 – 2005

102,000 Total incidents
 70,773
Primary medical complaint
 47,234
Code 3 responses
 20,720 Code 2 responses
 48,126 transports (68 %)
Summary Stats
FY 2004 – 2005
 48,126 transports
SFGH – “The Mission / The Mish”
Pacific Medical Center – RKD Campus
St. Francis Hospital
VA Hospital
Pacific Medical Center – Pacific Campus
Chinese Hospital
St. Luke's Hospital
Kaiser – South San Francisco
UCSF
Seton Hospital
Kaiser – San Francisco
Pacific Medical Center – California
Campus
St. Mary’s Hospital
*McMillan Stabilization Center
38 % of our transports go to San Francisco General Hospital
Rule of the Game
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OUR AVAILABLE RESOURCES
First Responders
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42 Engine Companies
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19 Truck Companies (EMT staffed)
2 Heavy Rescue Squads (EMT staffed)
Transport units
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24 ALS Paramedic staffed
18 BLS EMT staffed
19 ambulances (1 PM / 1 EMT)
Dual H1 ambulances (2 PMs) (Tue – Fri: 6am – 2am)
4 Paramedic Captains (RCs)
Rules of the Game
At Dispatch
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Cannot turn down any requests
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Code 3 requires 2 paramedics
Call taking and dispatch is done at the ECD –by
civilian PSDs
Call evaluation / triage– done with a nationally
recognized system – MPDS (“Clawson system”)
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Software integrated into CAD
Rules of the Game
In the Field
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Response time goals (90th percentiles):
Code 3’s
1st unit in 4:30
 1st ALS in 7:00
 Ambulance in 10:00
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Code 2’s
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Ambulance in 20:00
Rules of the Game
Patient Disposition
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Transport to appropriate ER
Transport to McMillan Stabilization Center – 39 Fell St.
Patient refusal
Other
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MAP
Medical Examiner
Police
POV
Rules of the Game
Emergency Departments
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Trauma Center - SFGH
Specialty Centers
Burns
 Re-implantation
 Pediatric Critical Care
 In custody – SFGH
 OB
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One Twist: Hospitals can close to ambulances – “diversion”
Rules of the Game
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Transport
Hospital notification – not so sick
 Base Hospital contact – MD consult
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Patient Refusal
Consult w/Base Hospital
 Agreement of 2 paramedics
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Death in the Field
A Typical Incident
INTAKE AT 9-1-1
A Call to 911
The Emergency Communications Department
1011 Turk Street
Where the Dispatch Comes From
A Call to 911
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ECD receives 4,300-4,600 calls per day
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1.6 million phone calls per year
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Emergency calls (3200-3400)
Non-emergency calls (800-1200)
85% Police
15% Fire
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8 to 20 Call takers on duty
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Call pick-up
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Answered @ 9 secs*
Interrogation
Between 1.5 - 3 minutes*
*2003
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MPDS
Medical Priority Dispatch System
“The Clawson System”
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Inter-nationally recognized
Standard of Care
Used world-wide
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London, Sydney, Los Angeles, San Francisco
ProQA software
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700 + call type codes
Echo, Delta, Charlie
 Bravo, Alpha, (Omega)
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STEP 1:
Call Entry
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Determine the
Chief Complaint
STEP 2:
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Ask Key
Questions
STEP 3:
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Confirm
appropriate
call type
STEP 4: Dispatch from CAD
Our Call
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Chief Complaint
Difficulty Breathing
 6E1 (6 –ECHO-1)
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Recommended Dispatch
Closest Engine
 ALS Engine (if 1st closest is BLS)
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For second paramedic
Paramedic Captain
 Ambulance (1 PM / 1 EMT)
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STEP 5:
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Give caller
pre-arrival
instructions
(PADs)
if indicated
A Typical Incident
OPERATIONS:
“What happens on scene”
The Dispatch
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Engine 32 – BLS Engine
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Engine 11 – ALS Engine
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Closest ALS resource
Rescue Paramedic Captain 3
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Closest First Responder
Quartered at Station 11
Medic 12
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Closest available ambulance
Getting
“out the door”
Finding the
patient
Getting to the
patient’s side
Initial Assessment
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Scene Survey
C-Spine
 Airway
 Breathing
 Circulation
 Determining
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the Chief
Complaint
Initial BLS Treatment
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Vital Signs
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Pulse
B/P
Respirations
Oxygen
ALS Assessment & Treatment
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IV access
Medications if
indicated
Albuterol
MS
Lasix
The Transport Decision
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Treat and Transport
v.
Scoop and Run
Patient condition dictates treatment
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Patient assessment is
ongoing throughout
incident
Patient conditions and
treatment can and often
do change
Invasive and Advanced Interventions
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Advanced Lifesaving
Airway Techniques
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Naso-tracheal intubation
Transport Code
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Code 3: for
the truly ill
(8-10%)
Code 2: for
most patients
En route to the ER
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Code 3 to Closest
appropriate
hospital
Critical Patient
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SFGH
Base Hospital
Contact
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Verbal report
from PM to MD
At the Emergency Room
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Transition care to ER staff
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Verbal report that includes:
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Complete and turnover PCR
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Patient condition
Treatment
History / meds
Anything else important
Patient Care Report
Clean and ready ambulance
Head back to quarters
A Typical Incident
FOLLOW THROUGH:
Continuous Quality Improvement
Risk Management
&
Billing and Revenue
Medical Records
Continuous Quality Improvement
CQI
Ongoing Performance Assessment
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Performance Measures
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Clinical Projects (mandated)
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Response Times
Clinical Performance
Regulatory Compliance
Cardiac Arrest
Advanced Airway
Evaluation
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Assess effectiveness of education and training by field
performance
Risk Management
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Identify Potential Risks
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Not Just a Financial Consideration
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Patient Safety
Worker Safety
Public Safety
Legal Considerations
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Collaborate with the City Attorney’s Office
Risk Management
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Perform Investigations
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Sentinel Events
Exception Reports / Near Miss
Complaints
Root Cause Analysis of Significant Events
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System Problems
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Policy / Protocol
Education / Training
Practice
Individual
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Performance Improvement Plan
Intersection of Risk Management with Education and Training
Billing & Revenue
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EMS Billing Function is Outsourced
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Advanced Data Processing Inc. (ADPI)
* Contract expires 12/05 – competitive bid process ongoing
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FY 2004-2005
$ 32.5 Million Billed
 $ 15.9 Million Collected (Net*)
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49% remittance
Medical Records
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HIPAA Compliance
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FF/PM Rhab Baughn
Medical Records Section
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1415 Evans
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Joe Mareschi and Robert Rowbottom
Some Other Players
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Health Commission
Director of Public Health
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EMSA
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Hospital Council
Private Ambulance Services
Smaller Organizations
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Dr. John Brown / Mike Petrie / Nick Nudell
Base Hospital
Private Hospitals
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Dr. Mitch Katz
Senior Action Network / Neighborhood Associations
Emergency Physicians Association
What we do best
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Shortness of Breath
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Asthma
COPD
Altered Levels
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Insulin Shock
Heroin Overdose
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Cardiac Emergencies
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Slow and fast rhythms
Sudden cardiac arrest
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Trauma
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Auto v Pedestrian
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SF #1 in US
Psychiatric Emergencies
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Dementia
Crisis
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SF #1 Auto/Ped deaths
217 / 219
Homeless Emergencies
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Hypothermia
Seizures
MOST program
“WE HELP PEOPLE WHO NEED OUR HELP”
That’s All Folks!
Thank you for your attention!