SOCPC Spring CME

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SOCPC Spring CME
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Agenda

• Welcome (5 minutes)
• Didactic (30 minutes)
• Overview SOCPC
• Quality Assurance
• FAQs
• Skills (60 minutes)
• Level I ITLS Rapid Trauma Survey
• Level II IO, Lead II interpertation,
  12 Lead acquisition
• Level III Portex Airway, Needle Thoracostamy
• Scenarios (90 minutes)
• Knowledge Assessment Tool (30 minutes)
• CME Evaluation (5 minutes)

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Leading Causes of Death (US)
Institute of Medicine (USA) 2000
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Why Perform Quality Assurance (Audits)?

• Quality assurance is a Base Hospital mandate
• SOCPC is an organization that strives to improve
  not only paramedic performance but also system
  performance through the audit, investigative,
  feedback and educational processes
• All processes are linked in order to reach a
  common goal, to improve patient outcomes
• Audits may result in discovering a need for
  system change, a change in medical direction,
  individual feedback, research or group feedback
  through CME

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What is the Electronic Audit Process?

• Data obtained from ACRs is sorted and put through
  computerized algorithms based on Medical
  Directives or other standards.
• Gives the user the ability to audit 100 of all
  calls in a more timely, effective and efficient
  way.
• Each filter is based on a chief complaint or
  procedure and has multiple sub filters each ACR
  must pass through.
• The filters compare Paramedic procedures with
  directives or standards

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Electronic Audit Filters

• Currently 13 filters are in use and several more
  being developed and tested.
• Current running filters
• Ischemic Chest Pain
• Anaphylaxis
• SOB X 4 (Epi/ Ventolin for Asthma, CHF, Croup)
• Diabetic Emergencies
• Intubation X 2 (adult and paediatric)
• Cardioversion
• Pacing
• Bradycardia
• Tachycardia

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Electronic Audit Process

• Potential variances are identified for further
  review
• An auditor screens an electronic list of
  procedures (auditor may also view the image of
  the ACR)
• If required the auditor completes an audit form
  and forwards the scanned image of the original
  ACR and audit form to the Paramedic Practice
  Manager (PPM)

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Electronic Audit Process

• The PPM then reviews the ACR and may directly
  send it out to the Paramedic
• Depending on the severity of the variance the PPM
  may choose to send the documentation to the MD
• After review the MD then decides his/her course
  of action

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Reasons For Case Reviews

• Medical directive variances
• Track system trends
• Mandated reviews
  (coroners inquest, death at work)
• Post remediation reviews
• Assist stakeholders

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Type of Case Reviews

• Drug error or omission
• Documentation by type the highest reviews
  (Vital
  Signs and Times on forms)
• Equipment failure
• Dispatch
• Patches
• Medical directive
• Cancellation
• Treatment (BLS and ALS standards of practice)
• Scope of practice

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2 Best Remedies..

• Times on ACRs
• Two full set of vital signs minimum
• When a procedure is done
• When medications are given
• EPCR will help with this

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Case Review results (2007)

• Paramedic acted appropriately (19)
• Equipment removed from service for testing (2)
• Feedback required (10)
• Remediation (verbal this includes self reporting,
  written or skills review) (20)
• No action required (46)
• Operational Issue (1)
• Insufficient information (1) closed
• Unknown (2) still open
• Provisional status (0)
• Deactivation (0)
• Decertification (0)

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Self Reporting

• 31 of all case reviews performed by the BH are
  self reported incidents by paramedics.
• 99 of all self reported cases are considered
  remediated and the case is closed after the
  telephone conversation.
• Self reporting is an essential part of
  professional practice.

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Who to call?

• PCP
• Jim Summers PCP Program manager
• Office [phone]
• ACP (Level II and III)
• Dean Popov ACP Program manager
• Office [phone]
• Leave Call , Date, Name and oasis
• You can anticipate a response within 4 days

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Paramedics Working Status

• A Medics privilege to practice is dependant on
  his/her status within the Base Hospital
• The Medic may be Active, on Provisional Status,
  Deactivated or Decertified
• The Supervisor, Operations Manager and the MOHLTC
  will be notified of any status change

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Active Status

• The medic has full practicing privileges

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Provisional Status

• The Medic may use all his/her practice privileges
  but must report all calls where a delegated
  procedure was performed immediately on completion
  of the call to his/her immediate Supervisor and
  the BH
• The Medics ACR must be forwarded to the
  Supervisor within 2 working days
• The Supervisor must then forward the ACR directly
  to the BH for further review

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Deactivation

• This status prohibits the Medic from performing
  any medical delegated acts at any Level while
  working under the deactivating Base Hospital
• Deactivation is Base Hospital specific
• Not permitted to work on ambulance while
  deactivated (EHS policy)
• Medic may be deactivated to a lower certification
  level at the BHMDs discretion for a specified
  period of time
• Deactivation is rare (0.2)

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Decertification

• This status prohibits the Medic from performing
  any medical delegated acts at any Level while
  working under the deactivating Base Hospital
• Is very rare (1 in the last 10 years)
• Can result from
• Gross professional misconduct
• Falsification of documentation
• Gross negligence in patient care
• Failure to complete remediation
• Repeated deactivations

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Decertification

• Can lead to permanent loss of privileges
• Requires assembly of Ad Hoc Paramedic Practice
  review Committee, comprised of a medical
  director, a program manager and two peer
  paramedics. Each member of the committee will be
  from a different base hospital or ambulance
  service. (Advisory role only)

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FAQs????
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Do I still analyze enroute to hospital?

• There are 3 different scenarios that can occur
• Transport of a VSA patient after cardiac arrest
  protocol has been performed on scene
• Loss of pulse during transport after obtaining an
  initial ROSC
• Initial loss of pulse during transport

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1. Transport of a VSA patient after cardiac
arrest protocol has been performed on scene.

• After performing your final analysis (and
  defibrillation if necessary) in the back of the
  ambulance, turn the Zoll OFF and then ON.
• Transport and ignore voice prompts from this
  point on.
• ACPs can continue to administer medications as
  per protocol

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2. Loss of pulse during transport after obtaining
an initial ROSC

• Pull over and stop the vehicle
• Perform a 10 second pulse check
• If no palpable carotid pulse is present, press
  analyze and follow the voice prompt given by the
  AED
• After the appropriate response has been taken,
  turn the Zoll OFF and then ON

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2. Loss of pulse during transport after obtaining
an initial ROSC cont

• Ignore the voice prompts from this point on.
  Resume CPR and resume transport.
• Once transport has been resumed, complete
  transport to the hospital without stopping.
• ACPs can continue to administer medications as
  per protocol
• Stop CPR and check for carotid pulse en-route if
  the patient develops obvious signs of life.

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3. Initial loss of pulse during

transport

• If patient goes into cardiac arrest for the first
  time during transport
• Pull over and stop the vehicle
• Complete a full cardiac arrest general protocol

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Medications for traumatic arrest

• Show no benefit in the trauma setting
• If medications are given, they should only be
  administered en-route to the hospital
• DO NOT PROLONG SCENE TIME TO ADMINISTER
  MEDICATIONS

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Borders for trauma centres

• Sunnybrook (adult trauma) North
• St Michaels (adult trauma) South
• North South border
  Bloor Street in west
  up the Don Valley
  Parkway St Clair
  Avenue/ OConner in the east.
• Sick Kids ( 16 years of age) all pediatric
  trauma.

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12 Lead acquisition

• Patient is having Signs Symptoms of cardiac
  ischemia.
• Patient 40 kg.
• All ACP and CCP
• All Level II when working with an ACP or CCP

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12 lead and offload delay.

• STEMI positive ACP indicated patient
• STEMI negative patient, as per clinical
  presentation.

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Is it a STEMI or not???

• YES if the ZOLL E-series states
• ACUTE MI
• NO if the ZOLL E-series states any other
  statements including the following
• ST ELEVATION CONSIDER INFERIOR INJURY OR ACUTE
  INFARCT
• ST ELEVATION CONSIDER ANTEROLATERAL INJURY OR
  ACUTE INFARCT
• ST ELEVATION CONSIDER INFEROLATERAL INJURY OR
  ACUTE INFARCT
• MARKED T WAVE ABNORMALITY, CONSIDER ANTERIOR
  ISCHEMIA
• ANTEROSEPTAL INFARCT, POSSIBLY ACUTE
• ST ELEVATION CONSIDER ANTEROLATERAL INJURY OR
  ACUTE INFARCT
• MARKED ST ABNORMALITY, POSSIBLE INFERIOR
  SUBENDOCARDIAL INJURY

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• Questions?