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