OMD - CE

Paul Hinchey MD, MBA, FACEPJose Cabanas MD, MPH, FACEP

The Plan

Update on important new EMS literature

Therapeutic hypothermia

EMS 12-lead ECG Discuss medication related events Understand the extent of medication errors and

their impact on patient care Discuss common strategies to prevent medical

errors Update on clinical performance improvement

activities

Science Update

What is optimal target temperature for

PCAC Therapeutic Hypothermia? Total 939 patients in randomized controlled

trial 36 International ICUs across Europe Study endpoint: mortality/neuro outcome 80% VF/VT; 20% Non VF/VT

NEJM (2013)

32-33 vs. 35-36 TH

Unwitnessed asystole cases not included

24% intravascular; 76% surface cooling

28 hours of total cooling

NEJM (2013)

Study Outcomes

36 3310

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52 535452

SurvivalPoor Neuro

NEJM (2013)

Study Outcomes

Conclusion

In unconscious survivors of OHCA of

presumed cardiac cause, TH at a targeted

temperature of 33°C did not confer a benefit

as compared with a targeted temperature of

36°C. Preventing Hyperthermia appears crucial. No changes in our current process for PCAC

Does Prehospital TH have benefits? Randomized clinical trial1,359 patients Seattle King County Medic 1 583 with VF; 776 non-VF Almost all patients cooled on ED arrival

JAMA (2013)

EMS cooling: up to 2L of 4C° LR Mean core temp decrease by 1.20 C° to ED EMS patients took 1 hr less to get to 34°C Study endpoints: mortality and neuro status EMS pts: 7-10mg pavulon + 1-2 mg valium

JAMA (2013)

Survival

No EMS TH EMS TH10

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7064 63

1619

VFNon-VF

Neurological Status

No difference in Neuro Outomes

Important Results

• EMS TH higher cases of pulmonary edema. (p<.001)

• Remember Control group did NOT receive paralytics.

Conclusion

Prehospital TH reduced core temperature and reduced the time to reach a temperature of 34°C.

No improvement in survival or neurological status.

This is one study, no change in our system at this time.

How often are STEMI patients initial

ECG non-diagnostic?Do repeat ECGs have real value in

routine evaluation of CP patients? 41,560 STEMI patients in ACTION

Registry (2007-2010)

Results

For patients with an initial non-diagnostic

ECG (11%) , 72.4% (N= 3,305) had an ECG

diagnostic for STEMI within 90 minutes. No significant differences in the

administration of guidelines-recommended

treatments for STEMI.

Wait…..There’s more!

Do repeat 12-lead ECGs make a

difference?

Do repeat prehospital ECGs make

any difference in STEMI diagnosis?

Canadian Study

Prehosp Emerg Care 2012; 16:109-114

Retrospective Analysis of 325 consecutive prehospital STEMI’s

EKG on-scene, repeat en-route and pre ED entry 275 STEMI’s in First EKG (84.6%) 30 STEMI’s in second EKG (93.8%) 20 STEMI’s in third EKG (100%)

Prehosp Emerg Care 2012; 16:109-114

Take Home

1/10 STEMI cases not apparent in first 12-

lead ECG. ACS cases evolve – repeat 12-leads! Prehospital ECG’s save approx. 20-30

minutes in reperfusion time.

Patient Safety

Medical Errors

1999 Institute of

Medicine (IOM) report: 3-4% of hospital patients

are harmed by the health

care system 7% of hospital patients

are exposed to a serious

medication error 50,000 – 100,000 deaths/

yr from medical mistakes

Serious Safety Event Event that reaches the patient & results in (death, life-threatening consequences, or serious physical or psychological injury

Precursor Safety Event

Event that reaches the patient & results in minimal to no harm

Near Miss “Good Catch” An event that almost happened, but error caught by a detection barrier

PrecursorSafetyEvent

SeriousSafetyEvent

Near Miss Safety Event

“Good Catch”

Patient Safety Event

©2010 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED.

Courtesy Dr. Edmond – SETON HRO

“Swiss cheese” model of accident causation

Some holes dueto active failures

Other holes due tolatent conditions

Successive layers of defences, barriers and safeguards

Hazards

Losses

System defences

Can you think about a particular patient safety event in our system?

Can you think of specific examples?

Wrong medication Wrong dose / route Unrecognized clinical deterioration Wrong procedure Tunnel vision / decision-making Treatment delay

What Kinds of Errors do Human Make?

3. Auto-Pilot

3 errors/1,000 acts25% of

healthcare errors

2.By the Rules

1 error/100 acts60% of

healthcare errors

1.Figuring it Out

30-60 errors/100 acts15% of

healthcare errors

Knowledge-based Rule-based Skill-based

Medication Related Events are common in prehospital care…

Medication Error

“Any preventable event that may cause or lead to inappropriate

medication use or patient harm while the medication is in the control of the health care professional, patient, or

consumer”

National Coordinating Committee-Medication Error Reporting and Prevention (NCC MERP); accessed at http://www.nccmerp.org/aboutMedErrors.html; Jan. 2012.

Medication Errors

Figure 2. Commonly studied medication errors as causes of adverse drug events (ADEs): percent of ADEs for each cause: Reducing and Preventing Adverse Drug Events To Decrease Hospital Costs. March 2001. Agency for Healthcare Research and Quality, Rockville, MD

Out-of-hospital environment

Emergency situationNo written orderNo external crosscheckNo electronic decision supportHigh‐risk medicationsDrug shortage issues and

constant substitutions

EMTPs completed pediatric patient

simulation scenarios Failure to use Broselow tape: 50% Incorrect use of Broselow tape: 47% Incorrect dosing:

Epinephrine: 68-73%

Diazepam: 47%;

Midazolam 60%

ATCEMS Medication Related Events

2012 20130

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ATCEMS Medication Related Events

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20122013

Fentanyl administration

We continue to see confusion with dosage calculation

1mcg/kg first dose (max 100mcg) 25mcg every 10 minutes if needed – max total

300mcg Goal is to reduce confusion Protocol committee looking at other

potential COG changes

Prevention of Medication Errors

Most providers have memorized the five

rights of medication administration Right patient, Right route, Right dose, Right

time and Right medication. These 5 “Rights” focus mostly on

individual performance. System-wide issues may impact the ability

for providers to perform the 5 “Rights”

Medication Safety Strategies

Standardization in medication administration

procedure Use of memory aids and checklists Risk-reduction strategies to minimize

opportunities for error Medication storage and packaging

Redundancies and independent backups Team-work crosscheck

Medication Errors

Performance improvement team actively

working in identifying additional ways to

eliminate medication related events in our

system More information to come with 2015 COG

update.

PI Updates

STEMI UpdateCardiac Arrest UpdateClinical Performance IndicatorsClinical Audits (Surveillance)

Reminder

PI Updates

Performance Improvement Activities

Performance Improvement Activities

17,730 PCR’s reviewed (2013) 560+ calls DMO Line

211 clinical events

45% self report rate Medical Director meetings

CY 2012 = 22

CY 2013 = 33

EMS Calls Reviewed (2013)

PCR’s Reviewed: (n=13,495) Trauma Activations (n=181) Stroke Activations (n=415) STEMI Activation/Feedback (n=271) ACS (n=2260) Altered Mental Status (n=5550) Seizure (n=3513) Stroke (n=635) Cardiac Arrest (n=670)

Clinical Audits (2013)

NTI (n=5) OTI (n=22) Surgical Airway (n=1) Diltiazem (n=42) Versed (n=605) Fentanyl (n=3,000)

Tourniquet (n=13) Pelvic Binder (n=3) Needle

Decompression (n=13) CPAP (n=305) Pacing (n=24) Cardioversion (n=5)

July-Dec 2013

High Risk Low Frequency Events (n=4,025)

Clinical Events Reviewed

Level 1 Level 2 Level 3 Near Miss Self Reports

2012 41 105 62 1 92

2013 53 134 23 1 93

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DMO Activity

Coun

t

STEMI

How important is to save

time if

the D2B time will beat the

90 minute goal?

43, 801 STEMI PCI patients

Median D2B of 83 min (IQR 6-109

min)

Examined D2B time vs. Mortality

2005-2006; 600 US Centers

Consecutive Patients

No Transfers

No Pre PCI thrombolytic treatments

Analysis repeated excluding patients

in shock

Analysis repeated using only D2B <

6 hours

Key Take Home Message for STEMI:

•Limit Scene Time•Identify STEMI early•Activating the PCI team makes a difference

We need to work harder…

Minimize on scene interventions Shorten time-to-First 12-lead Minimize total Scene Time

Remember prehospital STEMI Bundle▪ ASA, 12-lead (activation), PCI Center (< 90

balloon)

▪ NNT = 15 Harm avoided: Stroke, 2nd MI or Death

Cardiac Arrest

Cardiac Arrest Data, Analysis & CPR Quality

84,625 in hospital arrests 2000-2009 79.3% AS or PEA 20.7% VF or VT Survival to D/C 13% to 22.3%

In-Hospital Cardiac Arrest

Asystole and PEA survival about 13-

14% 40% significant, 17% severe

disability VF / VT survival 40% 25% Significant, 8% Severe Disability

New Engl J Med 2012; 367:1917-20

AHA Consensus Statement addressing four key areas: Metrics of CPR Performance Monitoring and feedback Team-level logistics issues Emphasis on CQI for resuscitation

Components of High Performance CPR

Chest compression fraction (CCF),

Chest compression rate

Chest compression depth

Chest recoil (residual leaning)

Ventilation.

Minimize Interruptions

Goal is to maximize the amount of time chest compressions generate blood flow

CCF is the proportion of time that chest compressions are performed during a cardiac arrest

Data on out-of-hospital cardiac arrest indicate that lower CCF is associated with decreased ROSC and survival

Chest

2013 Non-VF patients from ROC Network

64% Asystole, 28% PEA Median Compression Rate: 110/min ROSC 24.2% 2% Survival to D/C Increasing CCF = ROSC Target a CCF of 80%

Our EMS System Compression Fraction

89%

Compression Fraction

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2013 CPR Compression Fraction (Median)

Manual W/ Mechanical

Compression Fraction

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2013 CPR Compression Fraction (Average)

Manual W/ Mechanical

Our System’s Cardiac Arrest Survival Rates

Current CARES Sites

As of January 2014

The clinical measures presented above have been approved by the EMS System Medical Director

* *Indicates incomplete quarter

National

CARES 10.1%

The clinical measures presented above have been approved by the EMS System Medical Director

* *Indicates incomplete quarter

National

CARES 30.8%

Performance improvement updates

Clinical Performance Indicators

Trauma Scene Time

16:39

09:42

Stroke Scene Time

15:32

10:57

STEMI Scene Time

19:02

11:52

Delays STEMI Scene Time

19 minutes on-scene, 10 minutes to first 12 lead.     

NTG OS 23 minutes, 15 minutes to 12 lead, 19 minutes on-scene, 9 minutes to obtain12 lead 19 minutes, 5 minutes to 12 lead.

3 NTG on the scene prior to transport 15:35 on-scene, 10 minutes to 1st 12 lead 16 minutes on the scene, 6 minutes to the first 12 lead.

IV initiated prior to leaving the scene

Aspirin in ACS

96%

BGL in Altered Mental Status

94%

BGL in Seizure

94%

BGL in Stroke

96%

AHA Mission lifeline EMS System

Recognition Measures

D2B of ≤ 90 minutes now reads “an ideal of FMC -to-

device time. STEMI System goal of ≤ 90 minutes”

(1B)

FMC of 120 minutes or less is new target for patients

who arrive at a non-PCI center (1B)

D2B now officially transitioning to “E2B”

Mission Lifeline EMS RecognitionFMC to Device < 90 Minutes

88%

Mission Lifeline EMS Recognition

92%

Questions??

Paul.hinchey@austintexas.gov Jose.cabanas@austintexas.gov