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Modifying Your EMD and EMS Response Plan for Pandemic Flu: Lessons Learned from Maryland Modifying Your EMD and EMS Response Plan for Pandemic Flu: Lessons Learned from Maryland By Richard Alcorta, MD FACEP State EMS Medical Director MIEMSS

The following information is provided courtesy of the Maryland Institute for Emergency Medical Services The following information is provided courtesy of the Maryland Institute for Emergency Medical Services Systems (MIEMSS) MIEMSS

Overview Ø Ø Ø MIEMSS Overview of Decision points NHTSA Guidance Documents Dynamic System Overview Ø Ø Ø MIEMSS Overview of Decision points NHTSA Guidance Documents Dynamic System Status Score Modified EMD Assessing Current Practices and Profiles On-Scene Protocol

Pandemic Influenza Criteria 1. 2. 3. MIEMSS New influenza virus must emerge for which Pandemic Influenza Criteria 1. 2. 3. MIEMSS New influenza virus must emerge for which there is little or no human immunity; It must infect humans and cause illness; and It must spread easily and sustainably (continue without interruption) among humans

 http: //www. ems. gov/portal/site/ems/menuitem. 5149822 b 03938 f 65 a 8 de 25 http: //www. ems. gov/portal/site/ems/menuitem. 5149822 b 03938 f 65 a 8 de 25 f 076 ac 8789/? vgnextoid=839 d 10 d 89831811 0 Vgn. VCM 1000002 fd 17898 RCRD MIEMSS

Preparing for Pandemic Influenza: Recommendations for Protocol Development for 9 -1 -1 Personnel and Preparing for Pandemic Influenza: Recommendations for Protocol Development for 9 -1 -1 Personnel and Public Safety Answering Points (PSAPs) Ø Facilitation of Call Screening Ø Ø Ø Automated Data Gathering & Surveillance Protocol Expansion/Modification Protocol Updates (dynamic) Triage/Patient classification Assistance with Priority Dispatch of Limited Emergency Medical Services (EMS) Assistance Ø Tiered Responses/Altered Responses Ø Dispatch Protocol Modifications Ø Secondary Triage (Nursing Hotline) MIEMSS

Facilitation of Call Screening Ø MIEMSS Objective: For purposes of monitoring, surveillance, treatment and Facilitation of Call Screening Ø MIEMSS Objective: For purposes of monitoring, surveillance, treatment and the potential of contamination and quarantine, during the influenza pandemic period it will be important for the PSAP to be able to identify callers who are likely afflicted by the pandemic influenza virus and to assign the appropriate resource to help them. This resource may not be a responding EMS unit, but an alternative source of care, such as a nurse assist line or other health care call line.

Recommendations for 9 -1 -1 Public Safety Answering Points (PSAP) http: //www. cdc. gov/swineflu/guidance_ems. Recommendations for 9 -1 -1 Public Safety Answering Points (PSAP) http: //www. cdc. gov/swineflu/guidance_ems. htm Ø MIEMSS It is important for the PSAPs to question callers to ascertain if there is anyone at the incident location who is possibly afflicted by the swine-origin influenza A (H 1 N 1) virus, to communicate the possible risk to EMS personnel prior to arrival, and to assign the appropriate EMS resources. PSAPs should review existing medical dispatch procedures and coordinate any modifications with their EMS medical director and in coordination with their local department of public health.

Recommendations for 9 -1 -1 Public Safety Answering Points (PSAP) http: //www. cdc. gov/swineflu/guidance_ems. Recommendations for 9 -1 -1 Public Safety Answering Points (PSAP) http: //www. cdc. gov/swineflu/guidance_ems. htm Ø Ø Interim recommendations: PSAP call takers should screen all callers for any symptoms of acute febrile respiratory illness. Callers should be asked if they, or someone at the incident location, has had nasal congestion, cough, fever or other flu-like symptoms. Ø MIEMSS If the PSAP call taker suspects a caller is noting symptoms of acute febrile respiratory febrile illness, they should make sure any first responders and EMS personnel are aware of the potential for “acute febrile respiratory illness” before the responders arrive on scene.

Call to 911 Dispatch asks questions Dispatch EMS Unit Protocol s Triage question s Call to 911 Dispatch asks questions Dispatch EMS Unit Protocol s Triage question s YES Commercial Protocol s question s Delayed EMS How Type of response Non Transport Immediate NO Return to Dispatch for transport Home Care Case Manager (Phone Line) Refer to Protocol s question s Protocol s Triage question s Private Physician Home Health (House Call) Other Transport EMS Assess Pt. Referral or Transport Pt. ER Through centralized routing Alternate Care Site In Pt. Out Pt. Waiting Room. MIEMSS Fast Track Acute Care

Principles Ø Ø MIEMSS An appropriate response will need to be dynamic, changing swiftly Principles Ø Ø MIEMSS An appropriate response will need to be dynamic, changing swiftly according to circumstances and local resources. State EMS agency, working with State Department of Health and local Public Health officers, will provide the EMS Operational Program Medical Director and 911 Center Operational Officer the authorization to activate the Pandemic Flu Modified EMD Plan.

Principles Ø Ø MIEMSS The EMS Operational Program will determine their Dynamic System Status Principles Ø Ø MIEMSS The EMS Operational Program will determine their Dynamic System Status score using the four criteria. The Pandemic Severity Score and the Current Hospital capacity (which can also be acquired locally) will be provided so the 911 center can modify the EMD unit(s) dispatch criteria.

Principles Ø MIEMSS The Pandemic Flu Modified EMD Plan is to be based on Principles Ø MIEMSS The Pandemic Flu Modified EMD Plan is to be based on current practices and tiered response by 911 dispatch centers then modified in the event of a declared Pandemic Flu event with authorization for activation. (See criteria below chart. )

Dynamic System Status Score A. Pandemic Severity Score B. EMS/Dispatch System Demand for Services Dynamic System Status Score A. Pandemic Severity Score B. EMS/Dispatch System Demand for Services C. Reduction of EMS/Dispatch Workforce D. Facility Capacity (Bed availability) Each is scores with a number 1 through 5 MIEMSS

CDC Pandemic Severity Index MIEMSS CDC Pandemic Severity Index MIEMSS

WHO Pandemic PHASE 1. 2. 3. 4. 5. 6. MIEMSS No new influenza virus WHO Pandemic PHASE 1. 2. 3. 4. 5. 6. MIEMSS No new influenza virus subtypes have been detected in humans, However a circulating animal influenza virus subtype poses a substantial risk of human disease Human infection(s) with a new subtype, but no human to human spread Small cluster(s) with limited human to human transmission but spread is highly localized Larger cluster(s) but human to human spread still localized, suggesting that the virus is becoming increasing better adapted to humans but may not yet be fully transmissible Pandemic phase: increased and sustained transmission in general population

Pandemic Severity Score Category 5 (>2. 0% lethality & >1, 800, 000 ill) = Pandemic Severity Score Category 5 (>2. 0% lethality & >1, 800, 000 ill) = 5 points Category 4 = 4 points Category 3 (0. 5 to <1. 0% lethality & 450, 000 to <900, 000 ill) = 3 points Category 2 = 2 points Category 1 (<0. 1% lethality & <90, 000 ill) = 1 points MIEMSS

EMS/Dispatch System Demand for Services Critical Increase Severe Increase Moderate Increase Mild Increase Standard EMS/Dispatch System Demand for Services Critical Increase Severe Increase Moderate Increase Mild Increase Standard Operating Mode MIEMSS = 5 points = 4 points = 3 points = 2 points = 1 points

Reduction of EMS/Dispatch Workforce Absentee Rate over 40% Absentee Rate 35 -40% Absentee Rate Reduction of EMS/Dispatch Workforce Absentee Rate over 40% Absentee Rate 35 -40% Absentee Rate 25 -35% Absentee Rate 15 -25% Absentee Rate 15 or below% MIEMSS = 5 points = 4 points = 3 points = 2 points = 1 points

Facility Capacity (Bed availability) Occupancy exceeds 100% Occupancy Rate 98 -100% Occupancy Rate 95 Facility Capacity (Bed availability) Occupancy exceeds 100% Occupancy Rate 98 -100% Occupancy Rate 95 -98% Occupancy Rate 90 -95% Occupancy Rate at 90% or below MIEMSS = 5 points = 4 points = 3 points = 2 points = 1 points

Dynamic System Status Score (DSSS) Ø 6 -10 points DSSS CATEGORY ONE Ø 11 Dynamic System Status Score (DSSS) Ø 6 -10 points DSSS CATEGORY ONE Ø 11 -15 points DSSS CATEGORY TWO Ø 16 -20 points DSSS CATEGORY THREE MIEMSS

Impact Areas of DSSS Ø Ø Ø MIEMSS Triage Treatment Equipment Transportation Destination Impact Areas of DSSS Ø Ø Ø MIEMSS Triage Treatment Equipment Transportation Destination

Dynamic System Status Category 1 Dynamic System Status Category 2 Dynamic System Status Category Dynamic System Status Category 1 Dynamic System Status Category 2 Dynamic System Status Category 3 (Pandemic Severity Index Category 1) (Pandemic Severity Index Category 2 -3) (Pandemic Severity Index Category 4 -5) Daily use algorithms and protocols SAMPLE Protocols Determine whether to implement triage and treatment protocols that differentiate between non-infected and potentially infected patients based on CDC case definition. Triage would focus on identifying and reserving immediate treatment for individuals who have a critical need for treatment and are likely to survive. The goal would be to allocate resources in order to maximize the number of lives saved Using screening algorithm to ensure only severe get response Jurisdictional daily treatment protocols Ambulatory patients will be redirected to alternate care sites within or outside of the hospital. Treatment protocols may be modified to enable and encourage patients to receive care at home. Certain lifesaving efforts may have to be discontinued. Provision of antiviral prophylaxis if effective, feasible and quantity sufficient. Response (Standard Operating Mode) Triage (to occur both at the 9 -1 -1 center and on scene) Treatment Consider provision of antiviral prophylaxis if effective, feasible and quantity sufficient. No restrictions Equipment Prudent use of equipment Implementation of strict PPE/infection control protocols for patients meeting case definition established by CDC during the response phase of a 9 -1 -1 call. Selective criteria in place for priority use. Some scarce and valuable equipment, such as ventilators, may not be used without staff available who are trained to operate them. Strict criteria in place for equipment use. Some scarce and valuable equipment, such as ventilators, may not be used without staff available who are trained to operate them. Routine use of EMS resources Non-urgent and ambulatory victims may have to walk or self-transport to the nearest facility or hospital. Emergency medical services may transport victims to specific quarantine or isolation locations and other alternate care sites Only severe cases transported via ambulance Routine hospital based facilities Alternate care sites will be used for triage and distribution of vaccines or other prophylactic measures, as well as for quarantine, minimum care, and hospice care. Ambulatory and some nonambulatory patients may be diverted to alternate care sites (including non-medical space, such as cafeterias within hospitals, or other non-medical facilities). Emergency department access may be reserved for immediateneed patients. Transportation Destination

Call to 911 Dispatch asks questions Dispatch EMS Unit Protocol s Triage question s Call to 911 Dispatch asks questions Dispatch EMS Unit Protocol s Triage question s YES Commercial Protocol s question s Delayed EMS How Type of response Non Transport Immediate NO Return to Dispatch for transport Home Care Case Manager (Phone Line) Refer to Protocol s question s Protocol s Triage question s Private Physician Home Health (House Call) Other Transport EMS Assess Pt. Referral or Transport Pt. ER Through centralized routing Alternate Care Site In Pt. Out Pt. Waiting Room. MIEMSS Fast Track Acute Care

Triage Ø Occur both at the 9 -1 -1 center and on scene Ø Triage Ø Occur both at the 9 -1 -1 center and on scene Ø Authorization and Activation of DSSS level of triage and EMS triage (Critical Authorization) MIEMSS

DSSS Category One Ø MIEMSS Determine whether to implement triage and treatment protocols that DSSS Category One Ø MIEMSS Determine whether to implement triage and treatment protocols that differentiate between non-infected and potentially infected patients based on CDC case definition.

DSSS Category Two Ø Ø MIEMSS Triage would focus on identifying and reserving immediate DSSS Category Two Ø Ø MIEMSS Triage would focus on identifying and reserving immediate treatment for individuals who have a critical need for treatment and are likely to survive. The goal would be to allocate resources in order to maximize the number of lives saved.

DSSS Category Three Ø Ø MIEMSS Using screening algorithm to ensure only severe get DSSS Category Three Ø Ø MIEMSS Using screening algorithm to ensure only severe get response Resources assigned to those that can most benefit from EMS response

Dispatch Priority Level (match vendor or call center based dispatch protocol/tiered algorithm) Response (Standard Dispatch Priority Level (match vendor or call center based dispatch protocol/tiered algorithm) Response (Standard Operating Mode) Level 1 (A) Activation of Card 36 and ONLY for use in 6, 10, 18, and 26 DSS 1 BELOW IS BACK UP STRATEGY FOR EMD WITHOUT CARD 36 Level 2(B) Implement Declining Response /Configuration CAD Table (Moderate) + Card 36 (6, 10, 18 & 26) Level 3(C) Implement Declining Response /Configuration CAD Table (Severe) + Card 36 (6, 10, 18 & 26) DSS 2 DSS 3 Classification 1 (*Echo) Confirmed Cardiac Arrest (Not Breathing, Unresponsive per 911 call) (MPD cards- 2, 6, 9, 11, 15, 31) Closest AED Unit and Closest 1 st Responder and Closest ALS Ambulance Closest AED Unit and Closest 1 st Responder and Closest BLS Ambulance if available -Closest AED Unit and -Closest 1 st Responder if available - Closest AED Unit if available - If no unit available, no response Classification 2 (*Delta) Life Threatening Emergency/Potentially Life Threatening/Confirmed Unstable Patient(s) Closest 1 st Responder and Closest ALS Ambulance - Closest 1 st Responder and Closest ALS Ambulance if available; - BLS ambulance if ALS unit not available Closest 1 st Responder and Closest Ambulance available (ALS or BLS) -Closest 1 st Responder and -If available Closest Ambulance available (ALS or BLS) Classification 3 (*Charlie) Non-Critical/Currently Stable Patient(s) Requiring ALS Assessment Closest ALS Ambulance Closest Ambulance available (ALS or BLS) Closest Ambulance Available (ALS or BLS) - Closest 1 st Responder if available or -Closest stand-in responder unit Classification 4 (*Bravo) BLS Assessment for unknown/possibly dangerous scenes Closest 1 st Responder and Closest BLS Ambulance if available Closest 1 st Responder - Trauma Closest 1 st Responder - Medical Referral to Nurse or Health Department Advice Telephone service if available; or self-transport advice to Alternate Care Site Classification 5 (*Alpha) BLS Treatment BLS Ambulance Alternate Care Referral Classification 6 (*Omega) Non Ambulance Care Alternate care such as Poison Control Center; Police/Fire service call, etc Alternate care such as Poison Control Center; Police/Fire service call, etc

Pandemic Flu Modified EMD Plan Ø Ø MIEMSS Left column is Classification and matches Pandemic Flu Modified EMD Plan Ø Ø MIEMSS Left column is Classification and matches the Medical Priority Dispatch (MPD) named response profiles Across the top is the Response Mode: Standard Daily Operations then the DSSS Categories: One, Two and Three

How does this apply to each EMS Operational Program? Ø Ø Ø MIEMSS Must How does this apply to each EMS Operational Program? Ø Ø Ø MIEMSS Must have a defined Standard Daily Operations The DSSS Category modifies that Standard Daily Operations in a progressively increasing restriction of resource allocation Each EMS Operational program would apply the DSSS chart and adjust their Classification of response profile so all Dispatchers would have clear direction

Cornerstone Ø MIEMSS For this exercise, the dispatcher’s response profile was based on his Cornerstone Ø MIEMSS For this exercise, the dispatcher’s response profile was based on his understanding and application of the DSSS Category Three.

Pandemic Flu EMD Modified Plan MIEMSS Pandemic Flu EMD Modified Plan MIEMSS

Types of Dispatcher Resources Ø First Responder Ø Ø Ø Ø MIEMSS Engine Company Types of Dispatcher Resources Ø First Responder Ø Ø Ø Ø MIEMSS Engine Company Utility Do they all have AEDs? BLS Ambulance ALS Supervisor Others?

Combination of Resources Ø Ø Ø MIEMSS First Response + BLS First Response + Combination of Resources Ø Ø Ø MIEMSS First Response + BLS First Response + ALS First Response + BLS + ALS Chase First Response + BLS + ALS Above Plus Supervisor

Current Jurisdictional EMD Profiles Ø Alpha = ? Bravo = ? Charlie = ? Current Jurisdictional EMD Profiles Ø Alpha = ? Bravo = ? Charlie = ? Delta = ? Echo = ? Ø Omega =? Ø Ø MIEMSS

Case Consistent Responses Profiles Ø Ø Ø Ø Ø MIEMSS Snake Bite Chest pain Case Consistent Responses Profiles Ø Ø Ø Ø Ø MIEMSS Snake Bite Chest pain Sudden Sick Heart Attack /Cardiac Arrest Choking Traffic Accident Shot in the foot Underwater Pandemic Flu

Evaluation Tool Ø Resources Dispatched Ø No Ø Disconnect or Refer to Health Department Evaluation Tool Ø Resources Dispatched Ø No Ø Disconnect or Refer to Health Department phone line Ø Yes Ø Type of Resource (s) Ø Start point: All units are available for exercise calls but will be consumed and not returned to service before completion of the exercise. Ø Record the Specific units sent Units specific and Alpha through Omega) Ø MIEMSS Not testing hot or cold response

Goal Ø Ø MIEMSS With today’s consistent standardized response, MIEMSS compared the Standard response Goal Ø Ø MIEMSS With today’s consistent standardized response, MIEMSS compared the Standard response profiles to the Pandemic Flu dispatched resources. MIEMSS compared center to center for dispatch type to see if the protocol has variable interpretation.

EMD and On-Scene Ø Two Phases ( BOTH DRAFT PROTOCOLS) Ø Modified Emergency Medical EMD and On-Scene Ø Two Phases ( BOTH DRAFT PROTOCOLS) Ø Modified Emergency Medical Dispatch Ø On- Scene Triage MIEMSS

Dispatch Priority Level (match vendor or call center based dispatch protocol/tiered algorithm) Response (Standard Dispatch Priority Level (match vendor or call center based dispatch protocol/tiered algorithm) Response (Standard Operating Mode) Dynamic System Status Category 1 Dynamic System Status Category 2 Dynamic System Status Category 3 Classification 1 (*Echo) Confirmed Cardiac Arrest (Not Breathing, Unresponsive per 911 call) (MPD cards- 2, 6, 9, 11, 15, 31) Closest AED Unit and Closest 1 st Responder and Closest ALS Ambulance Closest AED Unit and Closest 1 st Responder and Closest BLS Ambulance if available -Closest AED Unit and -Closest 1 st Responder if available - Closest AED Unit if available - If no unit available, no response Classification 2 (*Delta) Life Threatening Emergency/Potentially Life Threatening/Confirmed Unstable Patient(s) Closest 1 st Responder and Closest ALS Ambulance - Closest 1 st Responder and Closest ALS Ambulance if available; - BLS ambulance if ALS unit not available Closest 1 st Responder and Closest Ambulance available (ALS or BLS) -Closest 1 st Responder and -If available Closest Ambulance available (ALS or BLS) Classification 3 (*Charlie) Non-Critical/Currently Stable Patient(s) Requiring ALS Assessment Closest ALS Ambulance Closest Ambulance available (ALS or BLS) Closest Ambulance Available (ALS or BLS) - Closest 1 st Responder if available or -Closest stand-in responder unit Classification 4 (*Bravo) BLS Assessment for unknown/possibly dangerous scenes Closest 1 st Responder and Closest BLS Ambulance if available Closest 1 st Responder - Trauma Closest 1 st Responder - Medical Referral to Nurse or Health Department Advice Telephone service if available; or self-transport advice to Alternate Care Site Classification 5 (*Alpha) BLS Treatment BLS Ambulance Alternate Care Referral Classification 6 (*Omega) Non Ambulance Care Alternate care such as Poison Control Center; Police/Fire service call, etc

Participants Modified EMD Plan Ø Ø Ø Ø Ø Baltimore County Caroline County Charles Participants Modified EMD Plan Ø Ø Ø Ø Ø Baltimore County Caroline County Charles County Fredrick County Harford County Montgomery County Prince George’s County Queen Anne County Washington County NOTE: (Last year Dorchester and Talbot participated) MIEMSS

Implement the Pandemic Flu Emergency Medical Dispatch Modified Plan appropriately 1. All 911/PSAP centers Implement the Pandemic Flu Emergency Medical Dispatch Modified Plan appropriately 1. All 911/PSAP centers implemented the Pandemic Flu Emergency Medical Dispatch Modified Plan using the DSSS Category 3 column. 2. One of the 911/PSAP centers initiated standard daily dispatching of resources, then realized that they would run out of resources. They then implemented the appropriate Pandemic Flu Emergency Medical Dispatch Modified Plan. 3. All 911/PSAPs received and managed all 50 patient complaint scenarios, and the determinant coding of the scenarios was consistent with national standards. MIEMSS

Implement the Pandemic Flu Emergency Medical Dispatch Modified Plan appropriately 4. Corrected the education Implement the Pandemic Flu Emergency Medical Dispatch Modified Plan appropriately 4. Corrected the education of the dispatchers and the briefing provided to the Call Takers during the exercise which was learned from last years exercise. 5. Jurisdictions with Police units that have AED resources help reduce the depletion of EMS resources for ECHO category patients. MIEMSS

Implement the Pandemic Flu Emergency Medical Dispatch Modified Plan appropriately 6. 7. MIEMSS The Implement the Pandemic Flu Emergency Medical Dispatch Modified Plan appropriately 6. 7. MIEMSS The 911/PSAP that used its standard daily resource allocation of resources and many of the other smaller Counties stated that they had run out of county resources by the end of the 50 complaints. It was evident that multiple counties even with a modified EMD protocol would not be able to sustain a surge of this magnitude in the face of 40% absenteeism. All of the smaller and several of the larger Counties ran out of ALS response and transport resources.

To determine if there is any change in resource allocation during a pandemic influenza To determine if there is any change in resource allocation during a pandemic influenza event when compared to standard daily resource allocation. Ø MIEMSS All of the Counties liberally used the referral to a nursing hotline/case manager or directed patients to an Alternate Care Facility without sending resources for the “lesser severity” patients based on the standard screening MPD protocol algorithm. The use of alternate care centers for referral and a nursing hotline/case manager clearly would reduce the burden on the 911 center.

To determine if there is any change in resource allocation during a pandemic influenza To determine if there is any change in resource allocation during a pandemic influenza event when compared to standard daily resource allocation. Ø Ø MIEMSS When comparing the three counties that had two separate Call Taking episodes, it was impressive how consistent both operators were in assigning determinate codes. All 911/PSAP demonstrated consistent reduction in resource allocation per determinant code with the exception of one county who tried to maintain daily operational dispatch until they realized they were going to run out of resources to send.

Ø MIEMSS Based on interviews with the Call Takers from the Dispatch centers, they Ø MIEMSS Based on interviews with the Call Takers from the Dispatch centers, they felt that this type of exercise is essential for all dispatchers to go through so that they can change their frame of reference and more rigidly apply the Modified EMD protocol

Results Ø Ø Ø MIEMSS Each center accepted all 50 requests for EMS resources Results Ø Ø Ø MIEMSS Each center accepted all 50 requests for EMS resources over 75 minutes The 911 Centers successfully applied the Modified EMD Plan Several 911 Centers ran out of resources to dispatch and could no longer send resources even with the modified response

Actual Responses EMD Profiles Ø Alpha = No resources sent Bravo = No resource Actual Responses EMD Profiles Ø Alpha = No resources sent Bravo = No resource sent or only First Responder/ BLS ambulance Ø Charlie = BLS or ALS ambulance Ø Delta = ALS ambulances until they ran out then BLS ambulance Ø Echo = AED units *** Dispatchers were very uncomfortable with this limited response Ø MIEMSS

Participants in On-Scene Triage Ø Ø Statewide invitation All Levels of EMS provider Ø Participants in On-Scene Triage Ø Ø Statewide invitation All Levels of EMS provider Ø Ø Ø MIEMSS Front line Fire Fighters First Responders EMT- Basic Cardiac Rescue Technician Paramedic Need to educate Dispatchers and EMS providers about the lethality and severity of the Case Defined Disease

Screening Questions of EMS Providers i) Are you willing to leave a patient on Screening Questions of EMS Providers i) Are you willing to leave a patient on scene if you believe the patient does not need transport? Current Daily Practice YES 82% BLS, 87. 5% ALS Pandemic Flu Conditions YES 100% BLS, 100% ALS Ø ii) Are you willing to leave a patient on scene if the patient is an EMS/Do Not Resuscitate (EMS/DNR) and you know the patient is dying? Current Daily Practice YES 88% BLS, 87. 5% ALS Pandemic Flu Conditions YES 100% BLS, 100% ALS Ø MIEMSS

Screening Questions of EMS Providers iii) Are you willing to leave a patient on Screening Questions of EMS Providers iii) Are you willing to leave a patient on scene if the patient is not an EMS/ Do Not Resuscitate and you know the patient is dying? Current Daily Practice YES 29% BLS, 37. 5% ALS Pandemic Flu Conditions YES 82% BLS, 75% ALS Ø iv) Are you willing to leave a patient on scene if the patient has life threatening flu and is dying at home? Current Daily Practice YES 18% BLS, 50% ALS Pandemic Flu Conditions YES 82% BLS, 75%ALS Ø MIEMSS

Managing Arrests Ø If the patient is in recent cardiac arrest. CPR for 5 Managing Arrests Ø If the patient is in recent cardiac arrest. CPR for 5 cycles than apply AED. Shock and continue to shock with 5 cycles CPR if indicated. 1. If return of pulse, initiate transport and rendezvous with ALS if available and can beat your arrival time at the ED 2. No shock indicated or when shock indicated stops with no return of pulse, Consult Medical Direction to withdraw care and leave patient on scene. MIEMSS

Treat Non- Flu Normally Ø MIEMSS If patient has an obvious non-flu related illness Treat Non- Flu Normally Ø MIEMSS If patient has an obvious non-flu related illness or injury , apply appropriate Maryland Medical Protocol for EMS Providers then treat and transport appropriately

Critical Vital Signs Transport to ED Consider Alternate Care Pulse Equal or Greater than Critical Vital Signs Transport to ED Consider Alternate Care Pulse Equal or Greater than 130 Less than 130 Respiratory rate Equal or Greater than 30 Less than 30 Blood Pressure Systolic Less than 90 Equal or Greater than 91 Pulse Oximeter Less than 92 on room air Equal or Greater than 93 Temperature No fever Fever AVPU Pain or Unresponsive Alert or Verbal Lung sounds MIEMSS Normal Vital Signs Rales/ Wheezing Clear

Inclusion with Normal Vital Signs Ø If patient has Normal Vital Signs (Table #1) Inclusion with Normal Vital Signs Ø If patient has Normal Vital Signs (Table #1) then go to Case Definition Signs and Symptoms for Flu (Table #2) a) b) MIEMSS If the patient has three or more Case Definition Signs or Symptoms for Flu transport patient to Alternate Care Facility If the patient has two or less Case Definition Signs or Symptoms for Flu (symptoms), EMS provider shall call for Medical Consult (state central resource physician) to determine if EMS provider can leave the patient on scene, self quarantine and refer to nurse /public health hotline for further assistance.

Case Definitions Signs and Symptoms for the FLU 1. 2. 3. 4. 5. 6. Case Definitions Signs and Symptoms for the FLU 1. 2. 3. 4. 5. 6. MIEMSS Difficulty breathing with exertion Has doctor diagnosed flu Cough Fever Shaking Chills Chest Pain (pleuritic) 7. 8. 9. 10. 11. Sore throat (no difficulty breathing or swallowing) Nasal congestion Runny nose Muscle aches Headache

Call to 911 Dispatch asks questions Dispatch EMS Unit Protocol s Triage question s Call to 911 Dispatch asks questions Dispatch EMS Unit Protocol s Triage question s YES Commercial Protocol s question s Delayed EMS How Type of response Non Transport Immediate NO Return to Dispatch for transport Home Care Case Manager (Phone Line) Refer to Protocol s question s Protocol s Triage question s Private Physician Home Health (House Call) Other Transport EMS Assess Pt. Referral or Transport Pt. ER Through centralized routing Alternate Care Site In Pt. Out Pt. Waiting Room. MIEMSS Fast Track Acute. Care

Assessment Ø Ø Ø MIEMSS Questionnaire to providers Comparison of predetermined normal response and Assessment Ø Ø Ø MIEMSS Questionnaire to providers Comparison of predetermined normal response and transports against those referred to alterative care Behavioral observations

Results Ø Ø MIEMSS On-Scene Triage- Providers are very uncomfortable leaving patients on scene Results Ø Ø MIEMSS On-Scene Triage- Providers are very uncomfortable leaving patients on scene Data was collected but there is a verbalized lack of willingness to leave someone on scene who may die due to Pandemic Flu

Results Ø MIEMSS Education drives the actions of the EMS providers and leaving lethally Results Ø MIEMSS Education drives the actions of the EMS providers and leaving lethally ill patients on scene is currently against EMS provider decision making

On-Scene Triage Accuracy Ø Ø Ø MIEMSS Comparing providers decision to the exercise design On-Scene Triage Accuracy Ø Ø Ø MIEMSS Comparing providers decision to the exercise design team’s (physician based) BLS was only 48% ALS was 86% Therefore the protocol needs adjustment to meet all provider needs There was very little over triage to a hospital based emergency department by both the BLS and ALS providers with 1. 1% BLS and 1. 0% ALS

On-Scene Triage Accuracy Ø Ø MIEMSS Both BLS (18. 7%) and ALS (17. 5%) On-Scene Triage Accuracy Ø Ø MIEMSS Both BLS (18. 7%) and ALS (17. 5%) tended to inappropriately over triage patients to leave them on scene after medical consult. This is the largest group of patients that did not match the expected outcome. The second largest inappropriate over triage for both BLS (17. 6%) and ALS (13. 5%) was to the Alternate Care Facility

Results Ø Critical recommendations: Ø Standardize Alternate Care Facility Capabilities to determine what they Results Ø Critical recommendations: Ø Standardize Alternate Care Facility Capabilities to determine what they can receive ( flu only, minor trauma, ? ? ) Ø Nursing Hotline loop with PSAP MIEMSS

Questions ? MIEMSS Questions ? MIEMSS