Is there more EMS can be doing to help patients survive cardiac arrest beyond getting them to the hospital faster? What progress is being made in Washington, D.C., to revamp fire and EMS services after a scathing 2006 report?
These were among the topics discussed at the 2010 Pinnacle EMS Leadership Forum held in San Diego from July 27–30. The conference brought together more than 300 of the nation’s top experts in fire and EMS to discuss how best to address the challenges confronting the profession.
Improving EMS in the nation’s capital
From making sure all firefighters and paramedics are cross-trained as all-hazards responders to overhauling the department’s supervisory structure, the District of Columbia Fire and Emergency Medical Services Department has made dramatic changes since a notorious 2006 incident in which a journalist was beaten to death, reports assistant fire chief Rafael Sa’adah.
On Jan. 6, 2006, retired New York Times reporter David Rosenbaum was robbed, beaten and left lying on the street. A report by the District’s inspector general uncovered a string of grievous errors in the care provided to Rosenbaum at the scene, in the ambulance and at Howard University Hospital, where he died three days later. Among the errors: EMS workers assumed that Rosenbaum was a drunk who had fallen, while hospital ED workers let him languish on a gurney, oblivious to his head injury. The mistakes “suggest an impaired work ethic that must be addressed before it becomes pervasive. Apathy, indifference, and complacency … undermined the effective, efficient, and high quality delivery of emergency services expected from those entrusted with providing care to those who are ill and injured,” the 69-page report reads.
Rosenbaum’s family sued. But instead of seeking monetary compensation, the family agreed to forgo the lawsuit if the city reformed EMS and formed a task force made up of representatives from city government, fire, EMS, the Rosenbaum family and outside EMS experts.
Since then, leaders in EMS and fire, along with Mayor Adrian Fenty, have made overhauling the department a top priority. Of 50 action items recommended by the task force in 2007, 39 have been completed, while the other 11 are a work in progress. “There’s nobody who can’t learn from our experience, no matter what sort of service they operate,” Sa’adah says.
The major goals of the task force’s recommendations included: fully integrating fire and EMS into an all-hazards agency with a single command structure; reforming the structure of the department to strengthen the EMS mission; improving patient care through enhanced training, evaluation and quality assurance; improving responsiveness and crew readiness by revising deployment procedures; reducing the misuse of EMS and delays in patient transfers; and strengthening the Department of Health’s oversight of EMS.
Specific initiatives included:
- Integrating fire and EMS and cross-training all employees as all-hazards responders. This included transitioning civilian, single-role EMS providers into sworn uniformed members, giving them the same pay and benefits offered to dual-role firefighter/EMTs and firefighter/paramedics, and requiring firefighters to be trained as EMTs. (Even Fire Chief Dennis Rubin was not exempt. He underwent EMS training and became National Registry-certified.) Today, only 12 percent of the workforce is not all-hazards-trained.
- Requiring all responders to be National Registry-certified. Accomplishing this has required a substantial investment in education, training, testing and remedial courses, Sa’adah says. Today, about 83 percent are certified.
- Increasing the use of electronic patient health records to better track performance and patient outcomes.
- Reducing misuse of EMS and delays in patient transfers through a public education campaign about the proper use of 911 and establishing a mobile outreach program to target chronic EMS users.
- Establishing an employee recognition program for those who have shown outstanding EMS performance.
- Conducting anonymous employee surveys to gauge attitudes, opinions and concerns.
- Keeping the public updated on initiatives through detailed, frequent progress reports on the D.C. Fire and EMS website.
The efforts are earning the department the respect of others within EMS. “This is one of the best examples I’ve seen of a catastrophe become very public, and an infrastructure changing to hopefully not allow that to happen again,” says Ed Racht, M.D., chief medical officer for American Medical Response. “Hats off to you for doing the hard thing—and the right thing.”
To view the D.C. Fire and EMS progress report, click here.
Rethinking resuscitation
This November, the American Heart Association (AHA) will release its updated guidelines for CPR and emergency cardiovascular care. Between now and then, EMS supervisors should consider the difficulties of 2005—the last time the AHA updated the recommended protocols—and take steps to prepare, says Blair Bigham, an Ornge flight medic and prehospital investigator at Rescu, the resuscitation science program at the University of Toronto and St. Michael’s Hospital in Toronto.
The 2005 update called for significant changes in the way first responders performed resuscitation. Instead of 15 compressions followed by two breaths, the 2005 guidelines called for 30 compressions followed by two breaths. Other changes included waiting two minutes instead of one minute between defibrillator shocks; doing away with three-in-a-row “stacked shocks”; and instead of shocking the heart immediately upon arrival on scene, holding off and beginning CPR first. The rationale, of course, was that getting blood to the heart via compressions before delivering the shocks—so-called “priming the pump”—would make defibrillation more likely to succeed.
“We had paramedics doing things a certain way for 10 years or more, they had it down pat, then we were telling them to totally re-choreograph what they were doing,” Bigham says.
But implementation of the 2005 guidelines was rife with problems, leaving many responders either ill-trained or confused, Bigham says. A survey of dozens of EMS providers found that it took, on average, 416 days—well over a year—to complete training and implementation of the guidelines.
Why did it take so long? Some 38 percent cited training barriers, including lack of updated printed training materials; difficulty scheduling trainers; and cost of scheduling training and hiring trainers. About 38 percent cited equipment issues, such as not being able to get software updates in a timely manner or having defibrillators that could not be updated and instead had to be purchased new. Some 18 percent cited slow decision-making. That included having medical directors who weren’t sure if they wanted to make the changes; waiting for fire departments to get on board; and waiting for state regulators to OK the new procedures before EMS could begin teaching them.
The implementation problems led, at least briefly, to a disturbing trend. While the hope was that the changes would immediately result in an improvement in survival rates, shortly after the guidelines were issued in 2005, research shows there was actually a slight uptick in deaths from sudden cardiac arrest, Bigham says.
Eventually, as the guidelines were more widely accepted and responders became comfortable with the changes, the new protocols began to have their intended effect, which was improving survival rates through improved, evidence-based technique. Survival rates for sudden cardiac arrest doubled, rising from 4 percent in the U.S. and Canada to 8 percent. But during the transition in late 2005/early 2006, an estimated 18,000 people could have been saved if training and implementation of the protocols had gone better, Bigham says.
The 2010 update is not expected to have as many changes as the 2005 guidelines, Bigham says, although it’s possible there will be even less emphasis on ventilation than is currently recommended. “We need to go home and think about the problems we had with implementing the 2005 guidelines and get prepared,” he adds.
To prepare, Bigham recommends that EMS providers:
- Make sure your organization has implemented the 2005 guidelines and EMTs/paramedics are performing according to the protocols. “Just because you’ve taught them doesn’t mean they’re actually using them,” he says.
- Track your agency’s CPR to hospital discharge rates so you know how well you’re performing.
- Give responders feedback on their performance, including measuring the quality of the CPR they’re providing. Ask yourself difficult questions about how smoothly implementation went at your organization in 2005, and get staff energized and ready to learn any updates later this year.
Bigham also called on EMS providers to pay more attention to how they treat cardiac arrest patients after resuscitation. Many cardiac arrest patients who are resuscitated in the field will go on to die in the hospital. He says responders should make sure they are doing all they can before dropping off patients at the hospital to stabilize them and avoid having them go into arrest again while en route or at the hospital.
Those steps include using capnography equipment and manometers; paying attention to both diastolic and systolic pressure; improving ventilation techniques; giving dopamine when appropriate; possibly beginning therapeutic hypothermia in the field; and taking the patient to a resuscitation center or a hospital that specializes in treating patients with heart problems. “Quality of care is more important than speed,” Bigham says.
Food for thought
There are an estimated 30,000 to 60,000 words in the English language and 750,000 body language cues, says Ed Racht, M.D., chief medical officer for American Medical Response. Yet only 25 percent of what’s heard is remembered, and 70 percent of mistakes are attributable to misunderstandings. “Make sure you are aware of how you’re being perceived,” Racht says. Jenifer Goodwin is Best Practices’ associate editor.
