EMSA Dispatch! August, 2015

NEWSLETTER

August 2015

 

— FEATURED ARTICLE —
Director’s Message: Howard Backer, MD, MPH, FACEPDr. Howard Backer

Is EMS a Team Sport?

EMS responders are never alone on a case, yet teamwork is often lacking.  Teamwork does not mean a strict division of labor, it means using the combined skills and judgment of the team to potentiate one another’s skills. Effective teams practice and train together, but ironically, health care professionals rarely train together and often have revolving partners, making it more difficult to develop the understanding and trust required for optimal team function. Healthcare providers are traditionally trained to function as individuals in hierarchical arrangements rather than as a functional team.

Potentiating one another’s skills does not preclude specific roles—known as the “pit crew”or”assigned task model.”  Examples of assigned task models in health care include CPR and trauma teams. Each member has a specific task, but for efficient function, each team member must have familiarity with the whole process and how the roles interact. Teams require interaction and coordination of members to be in sync with your colleagues. A team shares mission requirements and collective responsibilities to accomplish a shared goal. Not surprisingly, our military has tremendous experience in developing functional teams that must operate under extreme stress, with high consequence of error. Their model is being analyzed and utilized for other types of teams in high stress and high consequence situations, including emergency medicine and crisis decision making in many other disciplines.

Use of organizational teams in medicine and in other fields leads to greater productivity, better decisions and problem solving, better services, and increased innovation. High functioning teams require communication, common goals, trust, and balance of responsibilities.  For this reason, the basic steps to having an effective team have been incorporated into the ACLS and the ATLS guidelines.

On the other hand, poor teamwork has been linked to medical errors. Teamwork is integral to a working environment that is conducive to patient safety and care. I review cases regularly where the senior health team member used poor judgment but the other team members remained silent, and the outcome was tragic.

Research across professions shows that disciplined group decision making consistently outperforms individual. This does not mean there is no role for leadership, but it does mean that a good leader solicits opinions of his/her team when time and circumstances allow. And there is no excuse for a more junior person to not speak up and offer suggestions if he or she sees wrong decisions being made.

George Patton said: “If everyone is thinking alike, then somebody isn’t thinking.”

Patient safety problems have been a concern in hospital operating rooms. Despite having a team of staff in the operating suite, there was a distinct hierarchy, and in some cases, the surgeon at the top exhibited an unapproachable attitude, resulting in limited teamwork, no overlapping responsibility for safety, and hesitancy of staff to speak up. This led to numerous medical errors with bad outcomes, from instruments left inside the patient to operating on the wrong patient or the wrong part of the body. To enhance patient safety, all staff present stop and go through a checklist together prior to anesthesia and even engage the patient when possible to confirm the right person, the right operation, and the right part prior to beginning. Patient safety is a shared team responsibility.

In EMS, one way to avoid medical errors is to foster a true team culture and to ask your team whether anyone has any other suggestions before carrying out a difficult decision.

Recent studies have focused on aircraft carrier flight operations that may be one of the most complex and dangerous operations in an extremely unstable environment with great tension between safety and reliability.  Everything we know about organizations is challenged by the fact that the crew is mostly young and largely inexperienced, and the management staff of officers turns over half of its personnel every year. The working environment must rebuild itself every 18 months.

Some of the success factors in this naval environment may be the tradition, policies and procedures, and structure, but there is a high degree of delegation and responsibility. Flexibility, overlap of skills, and monitoring of each task are other factors. Many of these elements can be applied to EMS, (see Daved Van Stralen and Thomas Mercer 2013) including the following:

  1. Do not ignore small errors, since these compound and cascade into major failure. Poor airway management is a good example of how a small error can develop into a larger failure.
  2. Be sensitive and conscious of operations; do not take shortcuts. Base medical decisions on a complete medical evaluation and then follow your medical protocols.
  3. Be reluctant to simplify. Don’t automatically and routinely go for the easiest diagnosis without considering all the information. Evaluate information carefully and use more than one point of view.
  4. Defer to available expertise. Utilize on-site knowledge and the experience of your team.

An optimally functioning team can take a long time to develop, or may never emerge if the members do not understand and embrace these concepts.

Research has shown that training in the team process can result in behavior changes with positive impact. TeamSTEPPS® is an evidence-based teamwork system based on military and civilian research aimed at optimizing patient care by improving communication and teamwork skills among health care professionals, including front-line staff. It includes a comprehensive set of ready-to-use materials and a training curriculum to successfully integrate teamwork principles into a variety of settings. Based on military experience, training for health care teams emphasizes competency in four areas:

  1. Team leadership
  2. Mutual performance monitoring
  3. Mutual support or backup behavior
  4. Communications

Check the TeamSTEPPS website for the basics and begin to discuss with your colleagues.

References and Resources

  1. Emergency Team Coordination Course. United States Army Research Institute for the Behavioral and Social Sciences. November 1995. Available here.
  2. Risser DT, et al. The potential for improved teamwork to reduce medical errors in the emergency department. Annals of Emergency Medicine 1999; 34(3):373-383. Available here.
  3. Error reduction and performance improvement in the emergency department through formal teamwork training: evaluation results of the medteams project. Health Services Research 2002; 37(6):1553-1581. Available here.
  4. Does Team Training Work? Principles for Health Care Eduardo Salas, PhD, Deborah DiazGranados, MS, Sallie J. Weaver, MS, Heidi King, MS. Academic Emergency Medicine 2008; 15:1002–1009. Available here.
  5. Clancy CM, Ornbert DN. TeamSTEPPS: Assuring optimal teamwork in clinical settings. American Journal Medical Quality 2007; 22(3): 214-7.
  6. Hunziker S, et al. Teamwork and Leadership in Cardiopulmonary Resuscitation. Journal American College Cardiology 2011; 57:2381–8. Available here.
  7. Van Stralen D, Mercer TA. EMS and High Reliability Organizing. JEMS. June 2013: 60-63. Available here.
— LATEST NEWS & EVENTS —
Health Information Exchange in Emergency Medical Services

The right information, on the right patient, at the right time, in the right place.

When the $800 billion American Recovery and Reinvestment Act (ARRA) was passed in 2009 it directed $22 billion in funding toward the development of electronic medical record keeping and information exchange. The Health Information Technology for Economic and Clinical Health (HITECH) Act within ARRA created the Office of the National Coordinator for Health Information Technology (ONC) in the U.S. Department of Health and Human Services (HHS) to administer the program with the directive to increase the standardized, secure, and interoperable movement of health information among health care providers.

Over seven years’ time this money was dispersed throughout the nation for efforts big and small, ideas innovative, creative or simply long overdue. But very little of it went to prehospital emergency medical services (EMS).

“Since its inception, HITECH funding has been almost exclusively directed toward hospitals, physicians and community health information exchange organizations,” said Dr. Howard Backer, director of the California Emergency Medical Services Authority (EMSA). “As a result, although most EMS systems and providers have been able to invest in electronic patient care reporting systems, EMS as a whole is lagging behind the rest of the healthcare system in collecting and sharing patient information.”

Now, as HITECH funding is winding down, the federal government is taking a closer look at the healthcare provider categories that haven’t been brought into HIE thus far, including EMS. Encouraged by a use case and early proposal from EMSA in 2012, ONC began to observe the necessity for incorporating EMS and disaster response into the health information exchange dialog.  First, the California Office of Health Information Integrity (CalOHII) provided $300,000 in funding to EMSA to study HIE readiness in EMS (Lumetra), put on the first HIE in EMS conference in November 2013, and fund 3 projects related to HIE readiness.  In that first HIE for EMS conference, Lee Stevens from ONC outlined the disaster and EMS use case value proposition.  This propelled further interest and resulted in a second HIE in EMS conference in November 2014.  ONC funded an initial study by Audacious Inquiry in March 2014 that recommended improvements to both disaster and EMS response.

The result of this report was the conceptualization of a disaster response medical history portal called the “Patient Unified Lookup System for Emergencies” (PULSE), which would connect the many disparate HIEs in a state or region and could be activated during and after a disaster to provide authorized users with a summary view of a relocated patient’s medical history.  It also recommended the exchange of patient health information for daily EMS use would be extremely valuable.

Following that well received report, the HHS IDEA Lab funded an innovation project to the Assistant Secretary for Preparedness and Response (ASPR) to develop the PULSE architecture and to continue discussion  of emergency medical response during disaster and incorporating emergency medical services on a daily basis.  This report was completed in February 2015.  “One of the primary lessons learned during Hurricane Katrina was that health professionals need access to patient health information to avoid medical errors, renew medication, and coordinate care,” said Kevin Horahan, ASPR senior policy analyst. “Getting a complete and accurate picture of a patient’s medical history is a challenge under normal circumstances, but it is even more difficult – and even more important – in an emergency.”

There is continued national interest as well.  In February 2014, ASPR’s Emergency Care Coordination Center (ECCC), in conjunction with ONC and the National Highway Traffic Safety Administration’s Office of EMS, convened a stakeholder meeting to discuss disaster medical response, EMS and their connection to Health Information Exchanges (HIEs).

Over the last three years, ONC and ASPR worked with EMSA and the California Association of Health Information Exchanges (CAHIE) and other stakeholders to examine these missing elements in HIE and disaster medical response.

Last spring ONC announced that they have $28 million available for projects to expand the adoption of HIE technology, tools and services and increase the integration of health information in interoperable health IT to support care processes. The pieces began to come together. EMSA applied for a grant to implement PULSE in California and in July 2015 the grant was awarded.

Over the next two years the funds will be used to develop two health information technology projects: 1) connectivity between health information organizations (HIOs) to support a disaster-focused HIE access point, and 2) technology and infrastructure to bring HIE between EMS field crews and hospital emergency departments to daily EMS operations.

This project will establish connections between four HIOs or health systems via a web portal. When a disaster happens, the web portal will be activated so authorized healthcare professionals can access patient records from outside their own health systems through their existing electronic health record system or through a secure website. Eventually healthcare providers will be able to access electronic health records from all over the state.

In addition, the grant will support the creation of technology, infrastructure and cooperative agreements to enable EMS providers on scene to exchange patient health information bi-directionally with hospitals, called PULSE+EMS. Although most patients now have an electronic health record and most emergency medical services providers use electronic patient care reporting systems, paramedics on scene don’t have access to important health information for the patient they are treating such as allergies, current health problems, medications, and the patient’s pre-directed treatment or end-of-life decisions.

To address the challenges of “real time” information needs during daily emergency operations, EMSA will help develop pilot linkages between ambulance transport providers and emergency receiving hospitals in at least two local EMS areas or regions. This will allow EMS providers to 1) search for a patient record in real time, 2) alert the hospital as to the nature of the patient coming in and receive direction, 3) file electronic patient care reports for the pre-hospital care they provided into the patient’s electronic health record, and 4) reconcile outcome data from the electronic health record back into the EMS record at the conclusion of the episode for system improvement. This framework for examining EMS health information exchange functionality is called “SAFR” which represents the SEARCH, ALERT, FILE, and RECONCILE elements.

Dan Smiley, chief deputy director of EMSA, is the project director and has been working to prepare stakeholders across the state for their role in this project, with the expectation that proposals will be solicited  in October. “In light of our ONC grant objectives, we are letting local EMS agencies, HIOs, ambulance providers, and hospitals know that we will expect a ‘coalition’ of committed partners to come forward with a plan for local implementation of the “+EMS” component as part of our upcoming funding opportunity,” Mr. Smiley said.

Much of the necessary HIE infrastructure to accomplish these projects already exists. California has more than 40 HIOs and health care system information repositories, but they are not connected. The project will require that participants work through policy considerations, interoperability issues between proprietary data systems, and cooperative agreements to make the greatest use of the health information infrastructure that now exists.

The grant will also enable the EMS Authority to provide opportunities for collaboration, education, and leadership to encourage hospitals, local EMS agencies and providers across the state to take the steps necessary to incorporate EMS into the local HIE architecture.

“It’s our hope that EMS will become a full participant in the electronic exchange of health information with regular and secure two-way exchange between EMS and other health care facilities,” said Dr. Backer. “Through increased connectivity we will improve care coordination which will help us achieve the goal of better care, smarter spending, and healthier people.”

Anyone interested in following the progress of this project is invited to visit the website, follow the project blog  or contact the EMSA HIE in EMS project coordinator, June Iljana via e-mail or at (916) 431-3723.

Education for Today. Solutions for Tomorrow

Attend this year’s EMS World Expo to discover the path your agency should take as prehospital response continues to evolve within an ever-changing healthcare continuum.

The largest EMS conference in North America provides the opportunity to network with industry experts and peers from around the world, facilitating the sharing of best practices that will redefine operational excellence for your system through the year 2020 and beyond.

Register using using promotional code “EMSA” for special discounts.

18th Annual EMS for Children Educational Forum

The EMS Authority and the EMS for Children Program invite you to attend the 18th Annual EMS for Children Education Forum, taking place on November 5th at the Double Tree Hotel in Sacramento.

This event will provide current pediatric practice guidance for EMS providers, nurses and physicians. Presentations from recognized national and state experts will focus on respiratory distress, pain management, newborn care, falls, disaster preparedness, communicable disease and cultural considerations. There will also be fun with Dr. Marianne Gausche-Hill playing “pediatric jeopardy” and Dr. Ray Johnson as the master of ceremony!

Seven hours of continuing education will be provided for EMS personnel and nurses. Join us for a fun way to obtain great education and networking opportunities!

Click here for additional details and registration information. Contact Bonnie Sinz via e-mail or at (916) 431-3649 should you need additional information.

EMSA Team Responds to River Complex Fire

Rapid Extraction management team with four EMSA Disaster Medical Services management team members

Four members of EMSA’s Disaster Medical Services management team had the privilege of embedding with the California Interagency Incident Management Team (IMT) 3 at the River Complex fire incident command post on August 11 and 12, 2015 in Willow Creek.

EMSA’s Mission Support Team functions similarly to a Type 3 IMT, and EMSA assessed the organizational structure, management and coordination of this Type 1 team led by incident commander, Mark von Tillow in order to learn lessons from this highly competent IMT. EMSA also began assessing the ability to once again provide California Medical Assistance Team (CAL-MAT) personnel to staff the medical unit under the logistics section for wildland fire missions. EMSA discontinued providing CAL-MAT personnel for this mission after re-prioritizing activities due to budget constraints several years ago. The Rapid Extraction management team practices a swift rescue on steep terrain with the use of cables.

Forty-eight cooperating agencies were represented on the River Complex fire from across California, as well as from Alaska, Florida, Idaho, Arizona, andMedical Unit Leader and Sacramento Metropolitan Fire District Captain Scott McKenney Colorado. Disaster Medical Services’ division chief, Lisa Schoenthal stated the EMSA team was impressed by the comprehensive integration of the agencies within the California IMT 3 and the high level of coordination and professionalism. A total of 755 personnel were assigned to the fire including firefighting personnel and the IMT.

The EMSA team included response personnel unit manager, Patrick Lynch, response resources unit manager, Craig Johnson and disaster medical specialist, Michael Frenn. EMSA thanks Gene Madden, safety officer for the National Incident Management Organization (NIMO) of the USDA Forest Service for coordinating the trip.

2015 EMS Awards Ceremony Quickly Approaching

This year’s EMS awards ceremony is but a few short months away, taking place on December 2nd at the iconic Marines’ Memorial Club & Hotel in San Francisco.

2015 is an important year for EMS in California as it marks the 45th anniversary of the signing of the Wedworth-Townsend Paramedic Act, which created the paramedic scope of practice, and the 35th anniversary of the signing of the Emergency Medical Services System and Prehospital Emergency Medical Care Personnel Act, which established EMSA as a department within the California Health and Human Services Agency.

The deadline to nominate an individual for an award is September 4th, so don’t wait to nominate! Our user-friendly, web-based fillable form has made the nomination process easier and more convenient than ever. Hard copy nomination forms are available here.

Visit our awards web page for additional information. Tickets to attend the event are $35 per person and will be available for purchase in the fall. Space is limited and tickets sell out very quickly for this event so do not delay if you plan to attend.

Service and Educational Achievements

EMSA’s individual achievement recognition program recognizes EMTs who have completed specified periods of service and met certain educational benchmarks. Congratulations to the following EMTs!

Service Achievement                   Educational Achievement

Chris Anderson                            Kate Bounds

Timothy Benes                             Katie Bramlette

Brian Bernay                                David Gacad

Kate Bounds                                Jeremiah Glass

Katie Bramlette                            Devon Haggie

Mike Burkey                                 Tyson Hamilton

Daniel Cariaga                             Heidi Holmes-Nagy

Denise Codding                           Jeremy Kantner

Chris Coronado                            Emily Orlando

Todd Frandsen                             Martin Pierce

David Gacad                                Kingsley Powell

Jeremiah Glass

Tyson Hamilton

William Hollingsworth

Daniel McCrain

Jason Melendy

Neal Moriarty

John Prickett

Priscilla Warke

KEEP IN TOUCH:

           

www.emsa.ca.gov

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QUESTIONS, COMMENTS, SUGGESTIONS?

Jennifer Lim

Policy, Legislative, External Affairs

(916) 431-3700

externalaffairs@emsa.ca.gov