“Pre-hospital emergency personnel are the cornerstone of any hospital’s emergency department,” explains Jason Carter, vice president of operations and emergency services for Forsyth Medical Center (FMC), a 961-bed tertiary care hospital in Winston-Salem, N.C. “The pre-hospital care that patients receive in the field and on their way to the hospital is just as important as the care they receive once they arrive at our facility.”
Emergency medicine physician Steven Smith, M.D., reviews EKG readings for a potential heart attack patient en route to FMC.
In addition to the care that paramedics provide on site and in the ambulance, the information they gather in the field and transmit to the hospital en-route helps facilities such as FMC activate specialized care teams, prep diagnostic equipment and ready various treatment methods — all before the ambulance pulls up. And with the advancement of new technology — such as telemetry that allows physicians to view heart attack patients’ EKG readings from the ambulance — to hospital advisory councils that include EMS representation, front-line responders are playing an increasingly more important role in the evolution of improved patient care.
“It’s really difficult to overstate their contributions to patient care,” Carter says. “Without the highly skilled, trained paramedics and emergency rescue teams that work with our hospital to stabilize patients and alert us of what they’re facing, we would be at a real disadvantage when patients come through our doors.”
Teaming up to tackle stroke
Early notification by EMS ensures that patients are seen by a charge nurse, ED physician, registration and lab upon arrival at EMS Triage.
Seconds. That’s how long it takes Forsyth County emergency dispatchers to get an ambulance en route once someone calls 911 seeking medical attention for a stroke patient. And within minutes, paramedics are on site, evaluating the patient and treating any associated symptoms, such as vomiting, loss of consciousness, loss of airway control or low oxygen levels. Paramedics also try to insert IV lines if possible to speed administration of medications once the patient is admitted to the hospital. In addition, paramedics will attempt to obtain lab work, which is critical to the assessment and treatment of the patient. These routine actions can cut minutes off a patient’s treatment time at the hospital, and when it comes to stroke, time is brain.
“Part of the assessment we perform is a pre-hospital stroke screening that is very brief but gives us a baseline assessment of the patient’s condition in the field,” explains Lt. Col. Dennis Huie, Forsyth County EMS operations officer. “We also call the hospital to give them advance notice about the patient’s symptoms, any past history we were able to obtain, what measures we’ve taken and when the patient was last seen in his or her normal state, if the family was able to tell us.”
For patients arriving at FMC, this is the point at which the hospital’s charge nurse, Emergency Department (ED) physician, registration and lab will meet the patient on arrival at EMS Triage. And then, FMC’s ED pages its stroke team — the neurologist, neurointerventionalist, stroke coordinator and stroke navigator on duty — to alert them that a possible stroke patient will soon be rolling up.
The EMS crew works with the hospital team to immediately take potential patients who are stable to CT within minutes of entering the hospital.
As a result of the successful partnership of Forsyth County EMS and Forsyth Medical Center, a “Quick Look” protocol has been established at the hospital. Within minutes, the patient is quickly registered, and the EMS crew works with the team to immediately take patients who are stable over to CT (computerized tomography). This decreases the time it takes to determine whether the stroke is ischemic or hemorrhagic. Then, in consultation with the neurologist and neurointerventionalist, a treatment plan is created.
Guidelines from the Brain Attack Coalition state that stroke patients should receive a CT scan within 25 minutes of entering the hospital and have that CT scan read by a radiologist within 45 minutes of entering the hospital. Thanks to the efforts of area EMS personnel to notify the ED when a potential stroke patient is on the way, FMC has been able to exceed those guidelines in spades. During April 2010, probable stroke patients were seen by a doctor within two minutes of arrival at the ED; those who were deemed stable enough for a CT scan were taken to the CT scanner within nine minutes of entering the hospital and had their CT results read within 28 minutes of entering the hospital.
“Results like these would not be possible without the cooperation and communication that we receive from EMS personnel across the area,” says Cheré Chase, M.D., medical director of neurosciences and neurocritical care for FMC’s Stroke and Neurosciences Center. “Their ability to quickly and accurately assess a patient in the field, communicate vital information to the ED during transport and transfer the patient to the waiting hospital team gives us the best opportunity to treat and possibly reverse the devastating effects of a stroke. Their contribution in the first moments of this process is truly invaluable.”
RACing for a cure
One of the most promising advances when it comes to reducing the debilitating effects of an acute myocardial infarction is called the RACE program. A statewide initiative that has been adopted at FMC, RACE (Reperfusion of Acute MI in Carolina Emergency departments) aims to significantly reduce the time it takes for a patient with an ST-elevation myocardial infarction (STEMI) to receive cardiac catheterization once they arrive at a hospital’s Emergency Department.
At FMC, the program is working amazingly well, an achievement due in large part to the work of paramedics in the field. According to the American Heart Association, hospitals should have heart attack patients’ blocked arteries reopened within 90 minutes to have the best chance of preserving the heart muscle. At FMC, the median time for the first quarter of 2010 was 69 minutes.
“The RACE program is a critical systematic delivery of care for some of the sickest patients in the field of cardiology — those with ST-elevation myocardial infarctions,” explains Robert Preli, M.D., an interventional cardiologist with Winston-Salem Cardiology and medical director of the cardiac intensive care unit (CICU) at FMC. “It is a true example of how integrated systems translate into improved patient outcomes. Since the delivery of care for STEMI patients is such a time-critical process, the coordination of care must begin with first medical contact in the field by EMS agencies and extend into the cath lab for the best patient care.”
The program relies on emergency responders, ED staff and the cardiac catheterization team to work in concert to ensure timely notification and seamless patient transfers. For example, when paramedics know they are bringing a heart attack patient to the hospital, the ED is alerted. But instead of having to wait until the patient arrives in the ED to view their EKG, physicians at FMC can now view a patient’s heart rhythms right from the field.
“We are fortunate to have a wireless telemetry system in place with several Triad counties that allows paramedics who know or believe they are bringing in a heart attack patient to transmit the patient’s EKG results right from the ambulance to monitors in our emergency department,” explains Scott Kribbs, M.D., medical director of FMC’s emergency department. “Because we’re able to see the EKG minutes before the patient arrives, we can determine whether a patient should be monitored by a cardiologist in the ED or bypass the ED entirely and go straight to the cardiac catheterization lab for a balloon angioplasty. Getting advanced access to that EKG from paramedics before the patient arrives allows us to preemptively activate the cardiac cath team when needed and shave precious minutes off a patient’s treatment time.
Currently FMC is able to receive wireless EKG readings from paramedics in Davidson, Davie, Forsyth, Guilford, Stokes and Wilkes counties, while paramedics in Surry and Yadkin counties are expected to receive similar technology later this summer.
“EMS agencies have been critical to the success of RACE because of the concept of ‘backward integration,’” Dr. Preli adds. “This involves EMS agencies performing the role of emergency room physicians through diagnosing and treating patients with ST-elevation myocardial infarction prior to their arrival at the hospital. Without these initial steps being performed in the field by highly trained EMS agencies, the RACE program would not be able to succeed.”
Building relationships that last
FMC’s emergency department runs like a well-oiled machine, and one factor that has helped it build such successful treatment processes, especially for stroke and heart attack patients, is its relationship with local EMS departments.
Forsyth County EMS professionals Chad Winkle (left) and Todd Evans (right) transport a possible stroke patient to Forsyth Medical Center.
FMC is one of the only hospitals in the state to have a dedicated EMS liaison, Joy Brown, whose job it is to serve as a point person between ED staff and area EMS departments.
“My position provides an opportunity for EMS departments to have one go-to person to facilitate communication,” says Brown, who previously worked as a mobile ICU nurse (MICN) and served as a rescue captain with the Sauratown Fire Department for many years. “Because I’ve been a front-line responder, I have a unique understanding of the issues that paramedics and other emergency personnel face. Often paramedics transport patients and never hear what the patient’s final outcome was. I can help fill in those blanks and let them know how their care contributed to the patient’s recovery.”
Brown is also instrumental in addressing any issues that may come up regarding continuity of care, whether it’s assessing the level of care an EMS unit provided, relaying feedback on whether they were on track with their assessment and care, explaining new policies and procedures, and mediating resolutions to any concerns that EMS or ED staff may have. Having one single point of contact, Brown says, is invaluable to EMS staff because it ensures consistency and timeliness of response.
Streamlining stroke care at FMC (l-r): Scott Kribbs, M.D., emergency medicine; Cheré Chase, M.D., neurosciences and neurocritical care; Donald Heck, M.D., interventional neuroradiology; Samara Llewellyn, internal medicine; and Lt. Col. Dennis Huie, Forsyth County EMS.
FMC also places an emphasis on developing a strong relationship between the hospital and emergency medical personnel. ED staff, cardiac staff, stroke staff and FMC physicians routinely visit area EMS departments to educate front-line responders on new medical advancements or treatment protocols, and EMS representatives take part in the hospital’s interdisciplinary acute myocardial infarction and stroke teams.
“First responders have a wealth of knowledge, and we’re always looking to them to help us refine our processes and procedures so that we can provide the very best care possible,” Brown says.
To reinforce that team mentality, Brown and her team regularly highlight the achievements of the EMS personnel with which the ED staff work. Each month, one EMS team member is nominated as an EMS Star, and a brief biography is posted for physicians, nurses and staff to read. The goal, Brown says, is to make sure that everyone inside the ED knows the members of the team who works on the outside.
The hospital also holds annual EMS Week celebrations to thank EMS personnel for their contributions. And five years ago, the ED created the “Honoring Dedication to the Community Award for Excellence in EMS.” This award honors an EMS professional who shows commitment to the profession, promotes the profession, has expertise in their role and strives to share this knowledge with others.
“First responders and emergency departments are truly different members of the same team,” Carter says, “and we are proud to work with such a professional, dedicated, highly trained group of paramedics and firefighters here in the Triad. We as a facility are better because of their involvement in our operations, and I know that the patients of Forsyth and surrounding counties most definitely benefit from their expertise and knowledge. We couldn’t ask for a better partner in our efforts to deliver the most remarkable patient experience possible.”