Out With the Old, In With the New:


Exploring How Evidence-Based Medicine Can Simultaneously Improve Patient Safety and Save Money

CarolinaFireJournal - By Amar Patel MS, NREMT-P, CFC
By Amar Patel MS, NREMT-P, CFC
08/04/2013 -

Change is hard, wouldn’t you agree? We all have our regular routines, and we don’t particularly enjoy it when someone or something interrupts them. Whether it’s watching Monday night football with friends or stopping for your large coffee at Starbucks on the way to work, we like the norm. We are creatures of habit.

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“Change is the law of life, and those who look only to the past or present are certain to miss the future.”— John F. Kennedy

But as you know, we live in a constantly changing world, and that goes double for the world of first responders. Many of us have worked as firefighters, policemen and EMS professionals for years, and we’ve had to step out of our comfort zones as industry protocols and procedures have changed due to technological and medical breakthroughs. And while actually going through those changes can be difficult at the time, the increase in the number of lives saved more than makes up for any temporary inconvenience or discomfort.

One of the most recent changes in the field of EMS is the transition to caregiving with a foundation in evidence-based medicine. In layman’s terms, evidence-based medicine is the conscientious, purposeful use of the most current medical research and evidence available when making decisions about the care of individual patients. When balanced with common sense and personal knowledge based on professional experience, this type of care giving can produce uncommon — even outstanding — results.

The Leader of the Pack: Wake County EMS

One group of first responders who are blazing the trail of evidence-based medicine is the Wake County Department of Emergency Medical Services, based in Raleigh, North Carolina. I’ve had the pleasure of collaborating on numerous projects with this organization, led by Dr. Brent Myers, department head and medical director. In 2012, Dr. Myers’ team responded to nearly 85,000 requests for services, so they’ve learned a few things about using limited resources to meet the ever-growing demand for services. This challenge is expected to continue, as Wake County becomes home to more than 25,000 new residents each year.

Thinking outside the box has become one of the key factors in Wake County EMS’s success, according to Deputy Chief Joseph Zalkin, BSHS, EMT-Paramedic. “Under Dr. Myers’ leadership, we’ve begun to question even the simplest of protocols,” explains Chief Zalkin. “Early on when we modified our dispatch procedures, we studied whether it matters if we go cold (no lights, no siren) on certain types of non-life threatening calls. After collecting and evaluating our dispatch data for an extended period of time, we found that approximately 14 percent of Wake County EMS service calls could be safely dispatched as cold. That’s nearly 12,000 dispatches each year that don’t require flashing lights, blaring sirens and the need to speed through traffic and dangerous intersections. Our patients still get outstanding EMS care, and we are confident we’re saving lives due to slower, safer travel, especially during inclement weather.”

Move Over, NASCAR

If you’re a NASCAR fan, you’ll appreciate the rationale behind this next protocol change. In 2005, Wake County EMS modified the way its caregivers respond to cardiac arrest patients. They adopted the “pit crew model.”

“When you’re caring for someone who’s going through cardiac arrest, you’re dealing with airway interventions and IV’s, pulse checks, rhythm analysis, defibrillation — a multitude of interruptions that can hamper or even delay the most important thing, which is chest compressions,” says Chief Zalkin. “We’ve chosen to engineer the entire scenario, much like a pit crew engineers a pit stop in a race. Everyone’s responsibilities have been choreographed, and there is no chaos. There’s a crew member doing defib, someone controlling ventilation, etc. We take turns doing chest compressions every two minutes so there’s no team fatigue, because as you know, even 15 seconds without compressions can mean the difference between life and death.”

The team also implemented the use of therapeutic hypothermia, also known as protective hypothermia, a medical treatment that lowers a patient’s body temperature in order to help reduce the risk of the ischemic injury to tissue following a period of insufficient blood flow. Of the hypothermia-induced patients who were taken to the hospital, nearly 40 percent returned home healthy. “It’s a different way of thinking,” says Chief Zalkin. “We concentrate intensely on a problem, consult and collaborate with all major players — hospitals, physicians, etc — and apply best practices. The outcomes speak for themselves.”

Those outcomes have led to Wake County EMS being nationally recognized for their cardiac arrest save rate.

Breathing Easy: Caring for Patients with CHF

It’s no small task caring for patients with congestive heart failure (CHF). As an EMS professional, you know that a frequent (and often unpleasant) treatment protocol is performing an endotracheal intubation and providing mechanical ventilation. Unfortunately, there are potential negative consequences associated with both procedures. When portable CPAP’s became available, the Wake County EMS team weighed both the medical benefits to the patient along with the financial investment of purchasing the equipment and soon took advantage of the technology.

“Before portable CPAP’s, CHF patients would struggle to breathe, and we’d have to nasally intubate the patient, and get them to the hospital. Upon arrival, the patient would be sedated and placed on mechanical ventilation and spend days in the hospital,” Chief Zalkin explains. “The infection rate and the mortality rate were issues. It wasn’t the ideal situation.” These days, mobile CPAP’s enable caregivers to stabilize the CHF patient, eliminating the need for intubation, as well as reducing infection rates and admissions to the ICU. Wake County EMS believes the investment in new medical technology was a definite win-win for everyone involved.

Falls Patients: To Transport or Not to Transport

According to the Center for Disease Control, one in every three adults age 65 and older falls each year. As EMS professionals, we see firsthand how falls can cause moderate to severe injuries, such as hip fractures and head injuries, and can increase the risk of early death. Statistics from 2010 tell us that 2.3 million nonfatal fall injuries among older adults were treated in U.S. emergency departments, and more than 662,000 of these patients were hospitalized. The direct medical cost of these falls was $30 billion.

Numbers like these led Wake County EMS to perform a retrospective study regarding the frequency and the necessity of transports of assisted living facilities (ALFs) patients who suffer simple falls. The objective was to establish an EMS protocol that could eliminate unnecessary transports, while ensuring that ALF patients with time-sensitive conditions are transported. After reviewing the 1,700 EMS transports to emergency departments between July 2010 and June 2011, Wake County EMS found that only one-third of patients with falls in assisted living facilities actually required time-sensitive interventions (TSI) and therefore EMS transport.

But how should those ALF patients who have simple falls be treated? Wake County EMS has embarked on a three-year study in cooperation with a private medical practice, “Doctors Making House Calls” and with the knowledge of receiving medical facilities to answer that very question. “According to our new EMS protocol, primary care physicians from “Doctors Making House Calls” come directly to the assisted living facilities to care for falls patients who don’t meet the protocol requirement to transport to the ED,” says Chief Zalkin. “These patients are treated in their own living environment, which eliminates the cost of EMS transport, hospital care, and unnecessary tests and procedures. Caring for these patients in their homes also reduces their risk of infection and provides a more personalized patient/caregiver interaction. If a patient needs medical assistance in the future, there is continuity of care and a personal ongoing relationship with the physician. It will be interesting to look back a year from now to see the pros and cons of this protocol, as well as the amount of health care costs that might be saved.”

Share and Share Alike

As EMS professionals, we depend on hard facts to help us make smart caregiving decisions. We also need hard facts to determine if our organizational protocols are working. That’s where solid research and honest evaluation come into play. “At Wake County EMS, our desire is to collect information and glean the pertinent data that supports our procedures,” says Chief Zalkin. “One of the most successful ways we’re getting dispatch to discharge information is the through a bidirectional data exchange with WakeMed Health and Hospitals.”

Chief Zalkin explains that during transport, caregivers put an EMS armband on the patient. Upon arrival at the hospital, clinicians place a hospital arm band on the patient. Then the groups exchange arm band numbers. “We upload our transport information to our patient record keeping system and share it with the hospital, and the hospital does the same thing. Since 70 plus percent of Wake County EMS transports are to a WakeMed facility, those numbers provide us with great feedback about the work we’re doing.” In 2014, other hospital systems in the area will begin using the same medical record system (EPIC). Chief Zalkin is optimistic that the sharing can cross competition lines and bring better, safer health care to everyone in Wake County.

So, What Lies Ahead?

One of the hot topics Wake County EMS continues to deal with is the issue of “repeat customers” — you know, the ones who frequently use our transport system and hospitals, often for mental health or substance abuse problems. “In the past, these patients came to your emergency departments for treatment, taking up valuable patient care beds and receiving minimal interventions,” Chief Zalkin says. “However, we recently developed an evidence-based protocol that allows us to divert those patients to local mental health and substance abuse facilities that are able to provide appropriate treatments. This is just one example of our community care plan that ultimately eliminates a 14 hour ED wait for mental health placement. It’s also opens up 1000 bed hours for acute patients after one year of redirection. That’s progress.”

Henry Ford (1863-1947) once said, “If you always do what you’ve always done, you’ll always get what you’ve always gotten.” As first responders, we cannot afford to be stagnant, refusing to change or to accept evidence-based medicine as the new norm. Our teams are counting on us to lead them and to help them become better caregivers. We owe it to them — and to the patients we serve — to move forward in this ever-changing world of EMS. We may not know what’s just over the horizon, but we know we’ll be ready.

Amar Patel is the Director of the Center for Innovative Learning at WakeMed Health and Hospitals. Mr. Patel is responsible for integrating technology based educational programs to include human patient simulation, healthcare gaming, and hybrid education into regional educational programs.
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Issue 33.4 | Spring 2019

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