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modifying your emd and ems response plan for pandemic flu lessons learned from maryland

Modifying Your EMD and EMS Response Planfor Pandemic Flu:Lessons Learned from Maryland

By

Richard Alcorta, MD FACEP

State EMS Medical Director

MIEMSS

slide2
The following information is provided courtesy of the Maryland Institute for Emergency Medical Services Systems (MIEMSS)
overview
Overview
  • Overview of Decision points
  • NHTSA Guidance Documents
  • Dynamic System Status Score
  • Modified EMD
  • Assessing Current Practices and Profiles
  • On-Scene Protocol
pandemic influenza criteria
Pandemic Influenza Criteria
  • New influenza virus must emerge for which there is little or no human immunity;
  • It must infect humans and cause illness; and
  • It must spread easily and sustainably (continue without interruption) among humans
slide5
http://www.ems.gov/portal/site/ems/menuitem.5149822b03938f65a8de25f076ac8789/?vgnextoid=839d10d898318110VgnVCM1000002fd17898RCRDhttp://www.ems.gov/portal/site/ems/menuitem.5149822b03938f65a8de25f076ac8789/?vgnextoid=839d10d898318110VgnVCM1000002fd17898RCRD
slide6
Preparing for Pandemic Influenza: Recommendations for Protocol Development for 9-1-1 Personnel and Public Safety Answering Points (PSAPs)
  • Facilitation of Call Screening
    • Automated Data Gathering & Surveillance
    • Protocol Expansion/Modification
    • Protocol Updates (dynamic)
    • Triage/Patient classification
  • Assistance with Priority Dispatch of Limited Emergency Medical Services (EMS) Assistance
    • Tiered Responses/Altered Responses
    • Dispatch Protocol Modifications
    • Secondary Triage (Nursing Hotline)
facilitation of call screening
Facilitation of Call Screening
  • Objective: For purposes of monitoring, surveillance, treatment and the potential of contamination and quarantine, during the influenza pandemic period it will be important for the PSAP to be able to identify callers who are likely afflicted by the pandemic influenza virus and to assign the appropriate resource to help them. This resource may not be a responding EMS unit, but an alternative source of care, such as a nurse assist line or other health care call line.
slide8
Recommendations for 9-1-1 Public Safety Answering Points (PSAP)http://www.cdc.gov/swineflu/guidance_ems.htm
  • It is important for the PSAPs to question callers to ascertain if there is anyone at the incident location who is possibly afflicted by the swine-origin influenza A (H1N1) virus, to communicate the possible risk to EMS personnel prior to arrival, and to assign the appropriate EMS resources. PSAPs should review existing medical dispatch procedures and coordinate any modifications with their EMS medical director and in coordination with their local department of public health.
slide9
Recommendations for 9-1-1 Public Safety Answering Points (PSAP)http://www.cdc.gov/swineflu/guidance_ems.htm
  • Interim recommendations:   
  • PSAP call takers should screen all callers for any symptoms of acute febrile respiratory illness. Callers should be asked if they, or someone at the incident location, has had nasal congestion, cough, fever or other flu-like symptoms.
    • If the PSAP call taker suspects a caller is noting symptoms of acute febrile respiratory febrile illness, they should make sure any first responders and EMS personnel are aware of the potential for “acute febrile respiratory illness” before the responders arrive on scene.
slide10

Call to 911

Commercial

Protocols

questions

Dispatch asks

questions

Protocols

Triage questions

How

EMS

Delayed

Dispatch

EMS Unit

Type of

response

YES

Non Transport

Immediate

NO

Other Transport

EMS Assess

Pt.

Return to

Dispatch for

transport

Case Manager

(Phone Line)

Protocols

questions

Referral or

Transport

Protocols

Triage questions

Refer to

Home Care

Transport Pt.

Private

Physician

ER

Through centralized

routing

Alternate

Care Site

Home Health

(House Call)

In Pt.

Out Pt.

Waiting

Room.

Fast

Track

Acute

Care

principles
Principles
  • An appropriate response will need to be dynamic, changing swiftly according to circumstances and local resources.
  • State EMS agency, working with State Department of Health and local Public Health officers, will provide the EMS Operational Program Medical Director and 911 Center Operational Officer the authorization to activate the Pandemic Flu Modified EMD Plan.
principles12
Principles
  • The EMS Operational Program will determine their Dynamic System Status score using the four criteria.
  • The Pandemic Severity Score and the Current Hospital capacity (which can also be acquired locally) will be provided so the 911 center can modify the EMD unit(s) dispatch criteria.
principles13
Principles
  • The Pandemic Flu Modified EMD Plan is to be based on current practices and tiered response by 911 dispatch centers then modified in the event of a declared Pandemic Flu event with authorization for activation. (See criteria below chart.)
dynamic system status score
Dynamic System Status Score

A. Pandemic Severity Score

B. EMS/Dispatch System Demand for Services

C. Reduction of EMS/Dispatch Workforce

D. Facility Capacity (Bed availability)

Each is scores with a number 1 through 5

who pandemic phase
WHO Pandemic PHASE
  • No new influenza virus subtypes have been detected in humans
  • No new influenza virus subtypes have been detected in humans, However a circulating animal influenza virus subtype poses a substantial risk of human disease
  • Human infection(s) with a new subtype, but no human to human spread
  • Small cluster(s) with limited human to human transmission but spread is highly localized
  • Larger cluster(s) but human to human spread still localized, suggesting that the virus is becoming increasing better adapted to humans but may not yet be fully transmissible
  • Pandemic phase: increased and sustained transmission in general population
pandemic severity score
Pandemic Severity Score

Category 5 (>2.0% lethality & >1,800,000 ill) = 5 points

Category 4 = 4 points

Category 3

(0.5 to <1.0% lethality & 450,000 to <900,000 ill) = 3 points

Category 2 = 2 points

Category 1 (<0.1% lethality & <90,000 ill) = 1 points

ems dispatch system demand for services
EMS/Dispatch System Demand for Services

Critical Increase = 5 points

Severe Increase = 4 points

Moderate Increase = 3 points

Mild Increase = 2 points

Standard Operating Mode = 1 points

reduction of ems dispatch workforce
Reduction of EMS/Dispatch Workforce

Absentee Rate over 40% = 5 points

Absentee Rate 35-40% = 4 points

Absentee Rate 25-35% = 3 points

Absentee Rate 15-25% = 2 points

Absentee Rate 15 or below% = 1 points

facility capacity bed availability
Facility Capacity (Bed availability)

Occupancy exceeds 100% = 5 points

Occupancy Rate 98-100% = 4 points

Occupancy Rate 95-98% = 3 points

Occupancy Rate 90-95% = 2 points

Occupancy Rate at 90% or below = 1 points

dynamic system status score dsss
Dynamic System Status Score(DSSS)
  • 6 -10 points DSSS CATEGORY ONE
  • 11-15 pointsDSSS CATEGORY TWO
  • 16-20 pointsDSSS CATEGORY THREE
impact areas of dsss
Impact Areas of DSSS
  • Triage
  • Treatment
  • Equipment
  • Transportation
  • Destination
slide24

Call to 911

Commercial

Protocols

questions

Dispatch asks

questions

Protocols

Triage questions

How

EMS

Delayed

Dispatch

EMS Unit

Type of

response

YES

Non Transport

Immediate

NO

Other Transport

EMS Assess

Pt.

Return to

Dispatch for

transport

Case Manager

(Phone Line)

Protocols

questions

Referral or

Transport

Protocols

Triage questions

Refer to

Home Care

Transport Pt.

Private

Physician

ER

Through centralized

routing

Alternate

Care Site

Home Health

(House Call)

In Pt.

Out Pt.

Waiting

Room.

Fast

Track

Acute

Care

triage
Triage
  • Occur both at the 9-1-1 center and on scene
  • Authorization and Activation of DSSS level of triage and EMS triage (Critical Authorization)
dsss category one
DSSS Category One
  • Determine whether to implement triage and treatment protocols that differentiate between non-infected and potentially infected patients based on CDC case definition.
dsss category two
DSSS Category Two
  • Triage would focus on identifying and reserving immediate treatment for individuals who have a critical need for treatment and are likely to survive.
  • The goal would be to allocate resources in order to maximize the number of lives saved.
dsss category three
DSSS Category Three
  • Using screening algorithm to ensure only severe get response
  • Resources assigned to those that can most benefit from EMS response
pandemic flu modified emd plan
Pandemic Flu Modified EMD Plan
  • Left column is Classification and matches the Medical Priority Dispatch (MPD) named response profiles
  • Across the top is the Response Mode: Standard Daily Operations then the DSSS Categories: One, Two and Three
how does this apply to each ems operational program
How does this apply to each EMS Operational Program?
  • Must have a defined Standard Daily Operations
  • The DSSS Category modifies that Standard Daily Operations in a progressively increasing restriction of resource allocation
  • Each EMS Operational program would apply the DSSS chart and adjust their Classification of response profile so all Dispatchers would have clear direction
cornerstone
Cornerstone
  • For this exercise, the dispatcher’s response profile was based on his understanding and application of the DSSS Category Three.
types of dispatcher resources
Types of Dispatcher Resources
  • First Responder
    • Engine Company
    • Utility
    • Do they all have AEDs?
  • BLS Ambulance
  • ALS
  • Supervisor
  • Others?
combination of resources
Combination of Resources
  • First Response + BLS
  • First Response + ALS
  • First Response + BLS + ALS Chase
  • First Response + BLS + ALS
  • Above Plus Supervisor
current jurisdictional emd profiles
Current Jurisdictional EMD Profiles
  • Alpha = ?
  • Bravo = ?
  • Charlie = ?
  • Delta = ?
  • Echo = ?
  • Omega =?
case consistent responses profiles
Case Consistent Responses Profiles
  • Snake Bite
  • Chest pain
  • Sudden Sick
  • Heart Attack /Cardiac Arrest
  • Choking
  • Traffic Accident
  • Shot in the foot
  • Underwater
  • Pandemic Flu
evaluation tool
Evaluation Tool
  • Resources Dispatched
    • No
      • Disconnect or Refer to Health Department phone line
    • Yes
  • Type of Resource (s)
    • Start point: All units are available for exercise calls but will be consumed and not returned to service before completion of the exercise.
  • Record the Specific units sent

Units specific and Alpha through Omega)

  • Not testing hot or cold response
slide39
Goal
  • With today’s consistent standardized response, MIEMSS compared the Standard response profiles to the Pandemic Flu dispatched resources.
  • MIEMSS compared center to center for dispatch type to see if the protocol has variable interpretation.
emd and on scene
EMD and On-Scene
  • Two Phases

( BOTH DRAFT PROTOCOLS)

    • Modified Emergency Medical Dispatch
    • On- Scene Triage
participants modified emd plan
Participants Modified EMD Plan
  • Baltimore County
  • Caroline County
  • Charles County
  • Fredrick County
  • Harford County
  • Montgomery County
  • Prince George’s County
  • Queen Anne County
  • Washington County

NOTE: (Last year Dorchester and Talbot participated)

implement the pandemic flu emergency medical dispatch modified plan appropriately
Implement the Pandemic Flu Emergency Medical Dispatch Modified Plan appropriately
  • All 911/PSAP centers implemented the Pandemic Flu Emergency Medical Dispatch Modified Plan using the DSSS Category 3 column.
  • One of the 911/PSAP centers initiated standard daily dispatching of resources, then realized that they would run out of resources. They then implemented the appropriate Pandemic Flu Emergency Medical Dispatch Modified Plan.
  • All 911/PSAPs received and managed all 50 patient complaint scenarios, and the determinant coding of the scenarios was consistent with national standards.
implement the pandemic flu emergency medical dispatch modified plan appropriately44
Implement the Pandemic Flu Emergency Medical Dispatch Modified Plan appropriately
  • Corrected the education of the dispatchers and the briefing provided to the Call Takers during the exercise which was learned from last years exercise.
  • Jurisdictions with Police units that have AED resources help reduce the depletion of EMS resources for ECHO category patients.
implement the pandemic flu emergency medical dispatch modified plan appropriately45
Implement the Pandemic Flu Emergency Medical Dispatch Modified Plan appropriately
  • The 911/PSAP that used its standard daily resource allocation of resources and many of the other smaller Counties stated that they had run out of county resources by the end of the 50 complaints. It was evident that multiple counties even with a modified EMD protocol would not be able to sustain a surge of this magnitude in the face of 40% absenteeism.
  • All of the smaller and several of the larger Counties ran out of ALS response and transport resources.
slide46

To determine if there is any change in resource allocation during a pandemic influenza event when compared to standard daily resource allocation.

  • All of the Counties liberally used the referral to a nursing hotline/case manager or directed patients to an Alternate Care Facility without sending resources for the “lesser severity” patients based on the standard screening MPD protocol algorithm. The use of alternate care centers for referral and a nursing hotline/case manager clearly would reduce the burden on the 911 center.
slide47

To determine if there is any change in resource allocation during a pandemic influenza event when compared to standard daily resource allocation.

  • When comparing the three counties that had two separate Call Taking episodes, it was impressive how consistent both operators were in assigning determinate codes.
  • All 911/PSAP demonstrated consistent reduction in resource allocation per determinant code with the exception of one county who tried to maintain daily operational dispatch until they realized they were going to run out of resources to send.
slide48
Based on interviews with the Call Takers from the Dispatch centers, they felt that this type of exercise is essential for all dispatchers to go through so that they can change their frame of reference and more rigidly apply the Modified EMD protocol
results
Results
  • Each center accepted all 50 requests for EMS resources over 75 minutes
  • The 911 Centers successfully applied the Modified EMD Plan
  • Several 911 Centers ran out of resources to dispatch and could no longer send resources even with the modified response
actual responses emd profiles
Actual Responses EMD Profiles
  • Alpha = No resources sent
  • Bravo = No resource sent or only First Responder/ BLS ambulance
  • Charlie = BLS or ALS ambulance
  • Delta = ALS ambulances until they ran out then BLS ambulance
  • Echo = AED units *** Dispatchers were very uncomfortable with this limited response
participants in on scene triage
Participants in On-Scene Triage
  • Statewide invitation
  • All Levels of EMS provider
    • Front line Fire Fighters
    • First Responders
    • EMT- Basic
    • Cardiac Rescue Technician
    • Paramedic
  • Need to educate Dispatchers and EMS providers about the lethality and severity of the Case Defined Disease
screening questions of ems providers
Screening Questions of EMS Providers
  • i) Are you willing to leave a patient on scene if you believe the patient does not need transport?

Current Daily Practice YES 82% BLS, 87.5% ALS

Pandemic Flu Conditions YES 100% BLS, 100% ALS

  • ii) Are you willing to leave a patient on scene if the patient is an EMS/Do Not Resuscitate (EMS/DNR) and you know the patient is dying?

Current Daily Practice YES 88% BLS, 87.5% ALS

Pandemic Flu Conditions YES 100% BLS, 100% ALS

screening questions of ems providers53
Screening Questions of EMS Providers
  • iii) Are you willing to leave a patient on scene if the patient is not an EMS/ Do Not Resuscitate and you know the patient is dying?

Current Daily Practice YES 29% BLS, 37.5% ALS

Pandemic Flu Conditions YES 82% BLS, 75% ALS

  • iv) Are you willing to leave a patient on scene if the patient has life threatening flu and is dying at home?

Current Daily Practice YES 18% BLS, 50% ALS

Pandemic Flu Conditions YES 82% BLS, 75%ALS

managing arrests
Managing Arrests
  • If the patient is in recent cardiac arrest. CPR for 5 cycles than apply AED. Shock and continue to shock with 5 cycles CPR if indicated.
    • If return of pulse, initiate transport and rendezvous with ALS if available and can beat your arrival time at the ED
    • No shock indicated or when shock indicated stops with no return of pulse, Consult Medical Direction to withdraw care and leave patient on scene.
treat non flu normally
Treat Non- Flu Normally
  • If patient has an obvious non-flu related illness or injury , apply appropriate Maryland Medical Protocol for EMS Providers then treat and transport appropriately
inclusion with normal vital signs
Inclusion with Normal Vital Signs
  • If patient has Normal Vital Signs (Table #1) then go to Case Definition Signs and Symptoms for Flu (Table #2)

a) If the patient has three or more Case Definition Signs or Symptoms for Flu transport patient to Alternate Care Facility

b) If the patient has two or less Case Definition Signs or Symptoms for Flu (symptoms), EMS provider shall call for Medical Consult (state central resource physician) to determine if EMS provider can leave the patient on scene, self quarantine and refer to nurse /public health hotline for further assistance.

case definitions signs and symptoms for the flu
Difficulty breathing with exertion

Has doctor diagnosed flu

Cough

Fever

Shaking Chills

Chest Pain (pleuritic)

Sore throat (no difficulty breathing or swallowing)

Nasal congestion

Runny nose

Muscle aches

Headache

Case Definitions Signs and Symptoms for the FLU
slide59

Call to 911

Commercial

Protocols

questions

Dispatch asks

questions

Protocols

Triage questions

How

EMS

Delayed

Dispatch

EMS Unit

Type of

response

YES

Non Transport

Immediate

NO

Other Transport

EMS Assess

Pt.

Return to

Dispatch for

transport

Case Manager

(Phone Line)

Protocols

questions

Referral or

Transport

Protocols

Triage questions

Refer to

Home Care

Transport Pt.

Private

Physician

ER

Through centralized

routing

Alternate

Care Site

Home Health

(House Call)

In Pt.

Out Pt.

Waiting

Room.

Fast

Track

Acute.

Care

assessment
Assessment
  • Questionnaire to providers
  • Comparison of predetermined normal response and transports against those referred to alterative care
  • Behavioral observations
results61
Results
  • On-Scene Triage- Providers are very uncomfortable leaving patients on scene
  • Data was collected but there is a verbalized lack of willingness to leave someone on scene who may die due to Pandemic Flu
results62
Results
  • Education drives the actions of the EMS providers and leaving lethally ill patients on scene is currently against EMS provider decision making
on scene triage accuracy
On-Scene Triage Accuracy
  • Comparing providers decision to the exercise design team’s (physician based)
  • BLS was only 48%
  • ALS was 86%
  • Therefore the protocol needs adjustment to meet all provider needs
  • There was very little over triage to a hospital based emergency department by both the BLS and ALS providers with 1.1% BLS and 1.0% ALS
on scene triage accuracy64
On-Scene Triage Accuracy
  • Both BLS (18.7%) and ALS (17.5%) tended to inappropriately over triage patients to leave them on scene after medical consult. This is the largest group of patients that did not match the expected outcome.
  • The second largest inappropriate over triage for both BLS (17.6%) and ALS (13.5%) was to the Alternate Care Facility
results65
Results
  • Critical recommendations:
    • Standardize Alternate Care Facility Capabilities to determine what they can receive ( flu only, minor trauma, ??)
    • Nursing Hotline loop with PSAP
ad