nccep ems standards document - wake county nccep_ems_2011 may... · nccep ems standards document...

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NCCEP EMS Standards Document UPDATE May 25, 2010

NCCEP EMS Standards Document

NCCEP EMS Committee

This is an adaptation of prior presentation

given by Juan March, MD

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Many thanks to Joseph Zalkin, Brent Myers and Wake EMS for all of their help

OBJECTIVES

Initial subcommittee reccommendations

Audience comments

Subcommittee members will listen, take notes of these comments. Subcommittee members can respond to comments if necessary.

NCCEP EMS UPDATE

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I. Introduction (10:00-10:15)

II. Subsections of NCCEP Document

A EMS Procedures (10:15-10:30)

B. Skills and Medications (10:30-10:45)

C. EMS Equipment (10:45-11:00

D. EMS Protocols (11:00-12:00)

***Break for Lunch from 12:00- 1:00***

Agenda

***Break for Lunch from 12:00- 1:00***

E. Standards for EMD (1:00-1:15)

F. EMS Policies (1:15-1:30)

G. Qualifications for Medical Directors (1:30-1:45)

H. EMS Data Collection (1:45-2:00)

I. EMS Performance Improvement (2:00-2:15)

J. Drug List (2:15-2:30)

K. Other items (2:30-2:45)

III. Committee planning and wrap up (2:45-

3:15)

Agenda

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I. Introduction (10:00-10:15)

We need as much input as possible

Open process

We want continual feedback

II. Subsections of NCCEP Document F. EMS Procedures (1:15-1:30)

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NCCEP Protocol Revision

Procedures Subcommittee

May 25th 2011

Initial Protocol Review

Reviewers

Ossmann – 1 to 15

McGinnis – 16 to 30

Ghim – 31 to 45

Corey – 46 to 59

Tally

Keep Without Revisions – 24

Keep With Revisions – 18

Delete – 2

Still in Review - 15

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After Committee Review

Reviewers

Ossmann – 1 to 15

McGinnis – 16 to 30

Ghim – 31 to 45

Corey – 46 to 59

Tally

Keep Without Revisions – 24

Keep With Revisions – 20

Delete – 0

Still in Review - 15

Keep Without Revision – 24 Protocols

1 12 Lead ECG

3 Airway: BIAD-King

6 Airway: Cricothyrotomy-Surgical

8 Airway: FB Obstruction

13 Airway Intubation: Oral Tracheal

14 Airway: Nebulizer Inhalation Therapy

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29 Pulseless Electrical Activity

31 Childbirth

32 CNS Catheter: Epidural Catheter Maintenance

33 CNS Catheter: Ventricular Catheter Maintenance

34 Decontamination

38 Injections: Subcutaneous and Intramuscular

39 Orthostatic Blood Pressure Measurement

42 Restraints: Physical

44 Splinting


47 urinary cath

48 venous access blood draw

49 central line maintenance

50 existing caths

51 EJ

53 Femoral

55 Swan

56 wound care

57 hemostatic agent

59 Tourniquet

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Keep With Revision – 20 Protocols

2 Airway: BIAD-Combitube

How many services still use this device? Can we get Premis Data? I would also recommend that we remove or edit the section with respect to intubation with the combitube in place. If you cannot ventilate with the CT in place, you should remove the tube, open/suction the airway and ventilate with a BVM prior to reestablishment of an airway. Leaving the combitube in the OP while attempting OTI adds complication and difficulty.

4 Airway: BIAD-LMA Add: Select the appropriate tube size for the patient and Completely deflate the tube prior to insertion.

5 Airway: CPAP

Add Clinical Contraindications to include: Decreased Mental Status, Facial features or deformities that prevent an adequate mask seal, Excessive respiratory secretions. Where did the addition of an NP airway come from? - Reference

7 Airway: ET Introducer (Bougie)

Do we need to clarify? "Hold Up" may not be a universally understood term. This is a complex troubleshooting procedure and is difficult to fit it on one page.

9 Airway Intubation Confirmation - ETCO2

We should have two different procedures. One for continous waveform capnography and one for colormetric detection devices.

10 Airway Intubation Confirmation - Esophageal Bulb

Change: Squeeze the bulb to remove all air prior to securing the bulb on the tube. Also inclue a bullet on do not repeat test since a false positive test can result from instillation of air into the esophagus.

15 Airway: Respirator Operations

Pts on a transport ventilator should be monitored at all times with continous waveform capnography and pulse oximetry. Change to required from strong recommendation.


35 Defibrillation: Automated

Based on 2010 guidelines, with implanted devices, place pads preferably in AP or AL position and attempt to avoid placing directly over device

36 Defibrillation: Manual

Based on 2010 guidelines, adding a statement about patients with implanted pacers/defibrillators, paddles or pads can be in AP or AL positions and presence should not delay defibrillation. Attempt to avoid placing directly above device.

37 Gastric Tube Insertion Remove in line 4. Unconscious patient or add oral placement can be attempted after securing airway

40 Pulse Oximetry

Should we add disclaimer on line 10, Factors which may……include but are not limited to…… New 2010 guidleines report supplemental oxygen is not required if the oxyhemoglobin saturation is >= 94%, unless obvious signs of heart failure, dyspneic, or hypoxic to maintain to 94%.

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41 Reperfusion Checklist

Add age >= 18, add history of aneurysm or AV-malformation to list of structural CNS diseases. Could add to appendix H as well

43 Spinal Immobilization

Could add a statement about special equipment such as football players in full pads and helmet may remain immobilized in helmet and pads in place (multiple supporting literature on topic)

45 Stroke Screen: LA Prehospital

Under point 3. Screen the patient for…: should read NO history of a seizure disorder. Under point 5, all criteria should be a yes answer OR IF UNKNOWN, then follow the EMS System Stroke Protocol….

46 Temperature Simplify. Remove "equilibruim" phrase

52 IV LR for burns, NS for trauma or hypotension

54 Intraosseus add: "burns" to indications. Humerus insertion (easier access, faster flows, less likely to be artificial joint)

58 TASER dart removal should be done with pliers or hemostats to prevent puncture wounds to EMS personnel


11 Airway: Intubation Drug Assisted

If we keep this we should develop a very specialized training and verification program.

12 Airway: Intubation Nasotracheal Check Premis. Almost never used and likely low success rate.

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Next Steps

Discuss Revisions and Deletions (5/25/11)

Revise as needed

– Final Version Complete by 13 Jul 2011

Add CO Monitoring Protocol

Add Hypothermia Protocol

II. Subsections of NCCEP Document B. Skills and Medications (10:30-10:45)

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NCCEP Skills and Medications Recommended Changes

Change the following skills/medications from SCT-required to SCT-optional

– Venous Access – Femoral Line

– Airway – Intubation Drug Assisted (RSI) Pediatrics

– Vasopressin


Add the following skills as SCT-optional

– 15 Lead ECG

– Chest Tube – Maintenance

– Transvenous Pacing - Maintain

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Add the following skills across all levels

– Chest Compression – External Device

– Carbon Monoxide Measurement – Non-invasive

II. Subsections of NCCEP Document B. Skills and Medications (10:30-10:45)

COMMENTS

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II. Subsections of NCCEP Document EMS Equipment

II. Subsections of NCCEP Document C. Standards for EMD (10:45-11:00)

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We recommend that "Emergency Medical Dispatch ”must be a part of the system's Quality Review Committee".

The committee requested that the word "significant" be put in front of the word "change" in sentence 2:D of

the EMD standards.

"The North Carolina EMS Medical Director must approve any significant change or modification to the EMD protocols described above, other than the

configuration of the dispatch determinants."

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• Education Task Force recommendations

We were asked to review this document on May 13. The following slides address some of these recommendations

They have been edited to fit in PowerPoint

Change NC credentialing to a 2 year-cycle to mirror proprietary requirements

It seems like it will create additional work on who ever in the agency recertifies their EMD’s.

Though no longer required by the state, some agencies do scope of practice at each recert – the additional paperwork even if scope of practice is not done is not a good use of time.

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Consider allowing EMD Centers ability to recredential their personnel

There is already a mechanism in place for EMD Centers to recredential their personnel by becoming a Teaching Institute.

Since there is already a mechanism in place for this no change seems necessary.

Allow NCOEMS to accept the same requirements for Continuing Education as Priority Dispatch and APCO

The continuing education required by Priority Dispatch and APCO should be accepted by NCOEMS.

Instead of naming specific vendor EMD programs the wording should state nationally recognized programs that meet NHTSA’s EMD and ASTM requirements.

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● Allow NCOEMS to discontinue NC EMD Credentialing Classes if above Continuing Education change is adopted.

ALS service that requires a state credential? If this were possible I certainly would not be opposed to the state discontinuing the EMD credential and recognize the proprietary EMD certification.

If this is only pertaining to OEMS discontinuing the actual class, I don’t have any issue with it. I don’t know of anyone who could use this anyways as you have to first be certified in whatever EMD product you use.

NCOEMS work with NC 9-1-1 Board to identify funding opportunities to implement and sustain EMD level service.

Unsure of legality House Bill 1691, GS 62 A has a list of eligible expenses that 911 funds can be used for. EMD is not specified as an eligible expense, however there are grants available through the 911Board.

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● NCOEMS and NCCEP create a Quality Assurance/Performance Improvement (QA/PI) standard that follows nationally-recognized accreditation program.

As long as it’s compatible with all approved EMD programs and does not cause an undue financial burden on 911 centers.

As an accredited center already, I have concerns about the time it would take to go through another accreditation process.

Make EMD Data part of the EMSPIC by allowing EMD Centers to enter data directly into PREMIS.

NCOEMS should have a liaison with EMD (current/new staff person) with strong PSAP background to work with EMD centers.

NCOEMS should work with the 911 Associations to modify EMS Advisory Council membership to include EMD representation.

Make necessary changes to have EMD representation on the NC EMS Disciplinary

Committee.

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II. Subsections of NCCEP Document C. Standards for EMD (10:45-11:00)

COMMENTS

? II. Subsections of NCCEP Document D. EMS Protocols (11:00-12:00)

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Proposed protocol changes

Proposed changes

Airway – Adult – Pearls

define contra-indications to NTI (or have added to the NTI procedure protocol)

Airway failed – Adult – Pearls

reference trauma patients with regard to “change head positioning”

Abdominal Pain – Remove need for orthostatic blood pressure in the protocol (can

reference in pearls) – Re: N/V – change “if available consider” to specific medication per local

med control – Re: reference to pain protocol – change to specific medication(s) as per

local control – Pearls

Change “ectopic pregnancy” to pregnancy related Remove specific reference to appendicitis (too numerous possibilities &

covered in differentials – should be alphabetical)

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Proposed changes

Altered Mental Status

– Note for spinal immobilization IF suspected trauma

– Re: naloxone – remove reference to if respirations depressed

– Remove consider from oral glucose

– Re: consider other causes – included in differential

Proposed changes

Drowning Protocol

– If the patient is in cardiac arrest, follow the appropriate cardiac arrest guidelines.

– Initiate advanced airway management if the airway cannot be managed properly utilizing BLS airway maintenance.

– ALS providers should utilize advanced airway management with ET intubation and attach ETCO2 device, maintaining a level of 35-45 mmHg.

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Proposed changes

Respiratory Distress

– Add CPAP and magnesium in wheezing section

Drug Assisted Intubation

– Feel more medical oversight should be employed on the local end and in turn the protocol relaxed to include "appropriate paralytic" instead of just "succinylcholine", that way rocuronium or other paralytic may be given initially if succinylcholine is contraindicated

Proposed changes

Childbirth – Add section for hypertension or abnormal

vaginal bleeding -> go to Obstetrical Emergency protocol

– Change rapid transport to expedite transport with early notification

Newborn – Eliminate the word thick from meconium and

only recommend deep suctioning if the patient is non-vigorous

– Limit intubation to one attempt

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Proposed changes

Spinal Immobilization Clearance – Protocol implies "spinal clearance", I look at this

protocol as "when" to immobilize, if you note in the protocol a positive finding gets "spinal immobilization“

– Feel this protocol has been looked at from the wrong direction instead of how it should be intended

– Feel this may entail a less amount of liability

– Feel it should just be titled "Spinal Immobilization

Proposed changes

Pain Control: Adult – Pain severity: This should be left up for medic to make the determination not a

predetermined scale. All a medic will do anyway is decide if a pain is a one or a ten if they want to give meds.

– Nitrous Oxide and Acetaminophen / Ibuprofen can then be placed with the other med options instead of a section with pain less than 6

– Pearls: Vital signs should be checked every five to ten mins for drug reactions Contraindications to meds should be in the drug list with each med, not in the pearls Comment or the warning on Ibuprofen and Ketorolac should be in the contraindication on

the drug list

Pain Control: Pediatric – Pain severity: This should be left up for medic to make the determination not a

predetermined scale. All a medic will do anyway is decide if a pain is a one or a ten if they want to give meds.

– Nitrous Oxide and Acetaminophen / Ibuprofen can then be placed with the other med options instead of a section with pain less than 6.

– Pearls: Vital signs should be checked every five to ten mins for drug reactions Contraindications to meds should be in the drug list with each med, not in the pearls Comment or the warning on Ibuprofen should be in the contraindication on the drug list

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Proposed changes

Hypertension – Pearls:

Comment about Nitroglycerin use is listed in the signs and symptoms and do not need to be placed in the Pearls

Fever – Remove the age requirement for Acetaminophen

– Remove the infection control part because this is all covered under OSHA

– Remove all PEARLS but the last five

Proposed changes

PEA – Remove Atropine – ??? Epinephrine drip (is anyone doing Epi gtt) – Keep only last PEARL

SVT – Change wording to consider Adenosine/Diltiazem/Beta

Blocker. This way the medic could decide which to treat for like underline A-fib vs Sinus.

Seizure – Remove the repeat x1 in 5 mins. This will be covered in

the drug list per county – Remove most of the PEARLS we should not have to define

the different types of s

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Proposed changes

WMD-Nerve Agent Protocol – Suggest in top box/Signs & symptoms incorporate universal

SLUDGEM into box. We have most included. Highlight the SLUDGEM acronym: S - salivation (excessive drooling), L - lacrimation (tearing), U -

urination (lose control of urine), D - defecation / diarrhea, G - GI upset (cramps), E - emesis (vomiting), M - muscle (twitching, spasm, "bag of worms")

– RESPIRATION - difficulty breathing / distress (short of breath, wheezing)

– AGITATION + CNS SIGNS - confusion, agitation, seizures, coma. – Incorporate a table for treatment into a central box:

Severe respiratory distress, agitation, SLUDGEM 3 Auto-Injectors (6 mg) Monitor every 5 minutes 3 Auto-Injectors (1.8 grams)

Respiratory distress, SLUDGEM 2 Auto-Injectors (4 mg) Monitor every 10 minutes 1 Auto-Injector (600 mg)

Asymptomatic Monitor for signs/symptoms every 15 minutes None

Proposed changes

Police Custody – Pearls

Change 4th bulleted line to read: the responsibility for patient health management rests with the highest medical authority on the scene.

Change 3rd Bulleted line to read: The law enforcement officer shall accompany the patient in the ambulance if the handcuffs are to remain applied. However, if EMS personnel restrain the patient according to the procedure outlined in this policy, the law enforcement officer may elect to follow the ambulance in a patrol car to the receiving facility.

Change 6th bulleted line to read: regardless of the arrest status, the competent patient never loses the right to participate in the decision making process regarding his/her medical care

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Proposed changes

Universal Patient Care Protocol

– Add the EMSC Bear to the protocols

The EMC Bear symbolizes when Pediatric Care is warranted and Medical Control is required.

– DO NOT utilize pulse oximetry as a sole means for determining heart rate

Proposed changes

IV Protocol

– Remove protocol for IV’s because this is a procedure

– Change all protocols to read Start IV and not IV Protocol

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NO Proposed changes

Syncope – No changes

Post Resuscitation – no changes

Hyperthermia – no changes

Hypothermia – no changes

Gen

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Protocol 3 Medical Director’s Page

Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS2012

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II. Subsections of NCCEP Document D. EMS Protocols (11:00-12:00)

? COMMENTS

II. Subsections of NCCEP Document E. EMS Policies (1:00-1:15)

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1) Current policies from NCOEMS will be reviewed, edited, and published for agency use as in past iterations of the document.

2) Agencies have the option of using the policies as published or crafting their own as long as a policy is in place to address the intended topic of each individual policy.

3) New policy topics are still being evaluated.

4) Comments on existing or potential policies are still welcomed.


COMMENTS

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II. Subsections of NCCEP Document A. Qualifications for Medical Directors (10:15-10:30)


- System medical directors should have more leeway to alter protocols and/or have their own protocols

- Specialty care transport services should have a separate scope/protocols

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- Medical Director should periodically observe personnel in real or training environment

- Mandatory involvement and participation, not just a “signature provider”

Initial Subcommittee Reccomendations (additions) Attend quarterly EMS System

Performance Improvement Committee meetings and serve as chair of the committee.

Ride along with EMS and provide onsite medical direction, a minimum of 16 hours per year or respond to 8 scene responses per year (excluding their own office/practice)

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Initial Subcommittee Reccomendations

1) Completion of the North Carolina College of Emergency Physician’s Medical Director’s Course within the first year of appointment and/or complete NAEMSP on line Medical Director On Line Curriculum within the first year of practice beginning in 2012

Initial Subcommittee Reccomendations

3) It is recommended that those Medical Directors credentialed before 2012 complete the last Module of the NAEMSP Medical Director On Line Curriculum which will be North Carolina Specific, whenever it becomes available.

4) Maintain records of compliance with education and training requirements above and produce same upon request by local EMS and/or NC Office of EMS

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Reccommendations for Assistant Medical Director

4) Serve as chair of the EMS System Performance Improvement Committee meetings (if appointed by system medical director)


COMMENTS

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II. Subsections of NCCEP Document G. EMS Data Collection (1:30-1:45)

II. Subsections of NCCEP Document H. EMS Performance Improvement (1:45-2:00)

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Read the current PI Guidelines in the NCCEP Document.

Conduct a literature search to identify any new literature regarding EMS PI.

Identify areas for improvement in the current NCCEP PI document.

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The committee believes:

– PI is key to understand the success of EMS interventions

– PI measures should be more clinical

– List could be shorter

– NCCEP - PI guidelines should incorporate recommendations from local medical directors and Quality Assurance officers

The New List has been divided in four sections

– Clinical Conditions

– Clinical Procedures

– High-Risk Clinical Situations

– Operational Performance Metrics

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Altered Mental Status

Seizure

Cardiac Arrest

Congestive Heart Failure (pulmonary edema)

STEMI

Stroke

Trauma

Pain Management

Asthma / COPD

Chest Decompression Synchronized Cardioversion IO Access IV Access Orotraqueal Intubation Surgical Cricothyrotomy Blind Insertion Devices (king, LMA) Drug Assisted Intubation Obstetrical Deliveries Procedure Complications

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No Transports

High-Risk Refusals

Restraints

Medication Adverse Events

72 hour return

Deaths

Mass gatherings

Mass Casualty Incidents

Patient Care Device Failures

Dispatch Center Time Turn-out (Wheels-Rolling Time)

Response Time to Scene

Response Time to Patient

Transport Time

Scene times

Vehicle Failure

Vehicle Crashes

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Is this list enough? Do we need more? What would be useful for you as a medical

director or QA officer? Should we add more – Example: Should we

include Anaphylaxis and Syncope in the list of clinical conditions?

Should we have more operational metrics? Would it be useful to have a very

comprehensive list divided by Mandatory, Recommended and Optional?

Please let us know your comments…

Jose G. Cabanas MD

[email protected]

mailto:[email protected]

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II. Subsections of NCCEP Document I. Drug List (2:00-2:15)

Acetaminophen: pediatric dosing should be changed to 10-15 mg/kg

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Atropine: modify appropriate protocols to match current AHA ACLS guidelines

Charcoal: Limit use to ingestions known to have occurred less than 1 hour prior to EMS arrival, and to ingestions of agents known to adsorb to charcoal only. OR, consider removing charcoal from the overdose protocol completely as there is a lack of evidence to show that charcoal administration improves clinical outcome.

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Cimetidine: Remove Cimetidine from the drug list as an approved histamine-2 blocker. Cimetidine is a first generation histamine-blocker and has significant drug-drug interactions. Other H2 blockers such as Famotidine (Pepcid) have little or no effect on the cytochrome P450 enzyme system and therefore very significantly reduce the number of possible drug-drug interactions.

Furosemide: Remove Furosemide from the pulmonary edema protocol (and therefore from the drug list). It has not been shown to improve the outcomes of EMS patients with pulmonary edema. Pre-hospital providers should focus on other interventions (e.g. nitroglycerin, CPAP). In addition, it is plausible that administering a diuretic to a patient in respiratory distress NOT from pulmonary edema could be harmful.

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Prednisolone (Orapred): Add this NCMB-approved medication to the Drug List and Pediatric respiratory distress protocol as it is a commonly used oral preparation for pediatric asthma

Procainamide: Add procainamide pediatric dosing (must contact medical control?) to reconcile with protocol 45- pediatric pulseless arrest, and current PALS guidelines.

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III. Committee planning and wrap up (2:15-3:00)

COMMENTS

? III. Committee planning and wrap up

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