Objectives Community-based Emergency Health

FRANK ARCHER Department of Community Emergency Health and Paramedic Practice Monash University
MBBS First year 25th February, 2008

1. To provide an overview and context of Community-based Emergency Health Services 2. To provide background for your emergency first aid course this semester

Overview
History Health Care System Ambulance Services EMS System Emergency Calls Response Levels Scope of Practice Clinical approach Education Research

Ambulance History
1883 - St John first aid teaching 1887 St John provided transport 1916 - Ambulance Service Formed 1961 - Ambulance Officers Training Centre

Ambulance History
1971 - Mobile Intensive Care Ambulance 1978 - Vocational Education Certificate 1988 - Statewide Defibrillation & ALS 1999 - University Degree at Monash
Available in library

Message!

Australian Health System

In Australia, health is a State responsibility Ambulance is organised at a State level Each state has a State Ambulance Authority, as a public agency Most States have an Ambulance Act All States have a government department which sets standards and monitors Ambulance performance

Ambulance services are now sophisticated community-based emergency health services, with a proud history extending over 100 years and now well integrated into the health care system

Ambulance Services
Metropolitan (MAS) and Rural (RAV) Public Agencies Committee of Management
- Appointed by Minister

Clinical Services
Medical Standards Committee Medical Directors Clinical Operations Unit
- Clinical standards, audit and research - Clinical training - Clinical support

CEO
-

Appointed by Cof M

Executive Staff : Operational, Support

Education &training

Ambulance and related services

First responders
Community emergency response teams (CERT) Workplace emergency response teams (WERT) Voluntary organisations eg St John Public gatherings eg MCG Fire Brigade Other health care providers

Non-emergency patient transport

Now regulated by Government Private patient transport providers Non-emergency Moderate acuity from GP clinic or patient home if seen by GP Inter-hospital transfers +/- escort

Emergency and Acute

Ambulance services:
Metropolitan (MAS) Rural (RAV)

Paramedics
Ambulance Paramedics at ALS level Intensive Care Paramedics (MICA) Clinical Support Officers

Specialist services:
Air ambulance Medical retrieval Disaster response

Ambulance Services
MAS
Ops Staff Sup Staff R/time (50%) R/time (90%) C/load emerg. C/load n/emerg 1200 200 8 mins 14 mins 240,000 200,000

QEMS
Multi Casuatly and Disaster Planning Advisory Committee Community Initiatives and First Aid Advisory Committee

RAV
Ops Staff Sup Staff R/time (50%) R/time (90%) C/load emerg. C/load n/emerg 840 100 8 mins 21 mins 80,000 45,000

Multi Casualty & Disaster Planning Network QAS/Medical Advisory Committee Ambulance Services

Community Initiatives & First Aid

Patient

Definitive Emergency Medical Services

Emergency Medical Services Specialist Advisory Panel

Aero-Health Services

Other health care providers

Aero Health Services Advisory Committee

Contemporary EMS model (USA)

Health care

Message!
Ambulance services can provide major support to you as doctors learn how to use it wisely, and dont abuse it.

EMS Public health Public safety

There is the opportunity for you as medical students to contribute as a volunteer with organisations such as St John.

Goal of an EMS System

Where we are

Where we want to be

How to get there

(NHTSA,1996)

To get the right response To the right patient In the right timeframe With the right decisions on initial care and destination, To obtain the best outcome for the patient In a cost-efficient manner, & To do it better next time.

EMS System Attributes

Integration of Health Services Prevention Medical Direction EMS Research Information Systems Legislation and Regulation System Finance Human Resources Public Education Public Access Communication Systems Clinical Care Education Systems Evaluation
(Agenda for the Future, 1996)

Metropolitan Ambulance Service

Emergency workload has increased about 10% per year for the last two to three years!

Why?

Trends in Health Services

Trends Impacting on Ambulance Services
Health Care Delivery Methods - Hospital care to community care, eg
De-institutionalisation Hospital in the Home Day Surgery Doctors doing less after hours work

Contemporary CBEH trends

Transition:
Transport Emergencies Acute/chronic care.

Future:
Chronic care, workforce issues, economies Who will look after the middle ground?
Health crises, but not emergencies Social support Community-based acute-on-chronic Community-based dispositions

Changing Roles in Health Providers Evidence-Based Practice Changing Health Profile of the Population, eg ageing and chronic care Prevention and Public Health Health Education and Self-determination Consumerism, Informed Patients

Shift the focus from the vehicle to the Paramedic to the generic provider

Context: Integration

Message!

Ambulance services can provide major support to you as doctors learn how to use it wisely, and dont abuse it.
Prevention Access CPR Defib ACLS Hosp.

CHAIN OF SURVIVAL

12 Calltaker Terminals

Emergency

Call 000
Membership: $60 single, $120 family

2 Emergency Dispatch Terminals 1 Non Emergency Dispatch Terminal

MAS Clinicians Message!

MAS clinical tasks: Discuss with GPs Talk to hospitals Support for EMDs Support for infield Paramedics MAS MD backup All MICA Paramedics
When you call for an ambulance as a doctor, dont just ask for MICA, but answer the call takers questions and you will get the best appropriate response available at that time Become an ambulance member it may save you heaps of money!!

Current Ambulance Service Levels

MAS Response Objective

Right response To right patient In right time frame With safety for everyone To achieve best patient outcome

Response Categories
Emergency and Urgent
Codes 1, 2, 3 Road: MICA, Ambulance, Single Officer Air Wing: Helicopter, Fixed Wing Urgent inter-hospital transfer, medical retrieval

MAS Workload: Top 10 (01)

6D1 10D3 --26A1 17A1 17B1 29B1 10C4 12A1 --Breathe prob: severe SOB (Code 1/1) Chest pain: sweat/colour (Code 1/1) Dr request <25 min (Code 2) Sick person: No priority s. (Code 3) Not dangerous fall/b. inj (Code 2) Poss dangerous b. inj/fall (Code 1/1) Traffic accident: injuries (Code 1/1) Chest pain: cardiac history (Code 1/1) Conv/post fit: is breathing (Code 2) Dr request <1 hour ( Code 3)

Patient Transport
- Codes 4, 5 - Contracted Services - Private Patient Transport Services - Non-urgent inter-hospital transfer

Message!
The ambulance service is available to help you as doctors learn how to use it wisely, someones life may depend on it!

Scope of Clinical Practice

Bachelor of Emergency Health (Paramedic) Thematic approach

Focus is on Community-based Emergency Health 1. Personal and professional development 2. Population health and illness in society 3. The Paramedic clinician 4. Community-based emergency health in integrated health and emergency systems 5. Science, knowledge and evidence

Scope of Clinical Practice

AMBULANCE PARAMEDIC:
First aid, BLS & non-emergency care, plus: A - Laryngoscope & Magill forceps, laryngeal mask B - IPPV & oxygen C - Defibrillation SAED, Fluid resuscitation Inhalation analgesia, IV Morphine Nebulised Salbutamol Chest pain: GTN (LVF), Asprin IM package: Narcan, Glucagon, Midazolam, Adrenaline Triage & time critical guidelines

Scope of Clinical Practice Ctd

MICA PARAMEDIC - Ambulance Paramedic, plus:
A - ETT, incl sedation to ETT, muscle relaxants B - Relief of tension pneumothorax C - Arrhythmia recognition, cardioversion Analgesia, IV Morphine Fluid resuscitation IV: Salbutamol, Hydrocortisone, 50% Dextrose, Atropine, Adrenaline, Lignocaine, Maxolon, Lasix, Midazolam Maintain some inter-hospital therapy in stable patients Trials: hypertonic saline, muscle relaxants

Message!
Ambulance services are now sophisticated community-based emergency health services, and provide emergency care at least at the level expected of a GP in that setting

Clinical approach
1. Is the scene safe?
Safety survey - D If not safe ACT NOW!!! Primary survey - R A B C H If dead or dying ACT NOW!!!

Scene safety

2. Is the patient alive, dead, dying?

3. If alive, how well or sick is the patient, or is the patient likely to be sick soon?
Main problem and vital signs survey - standards If sick ACT NOW!!! Secondary survey

4. What other illness or injury is present?

Patient assessment

Clinical problem solving process

Observations gather cues Assess come to a judgment Plan develop management plan Manage carry out management Evaluate reassess patients status

Message!

Develop and practice clinical thinking skills in the setting of emergency care

Department of Community Emergency Health & Paramedic Practice

Education and Training

MUCAPS is a department in this Faculty, along with medicine, nursing and a range of health sciences Vocational Education:
First aid & Workplace first aid First responder Certificate non emergency Diploma non emergency

Education and Training ctd

University - Graduate:
Grad Cert Aero medical retrieval Grad Cert Disaster medicine Grad Dip MICA Paramedic Master of Emergency Health PhD

University- undergraduate:
Diploma - Ambulance Paramedic Degree - Ambulance Paramedic

Message!

Paramedics are now included at degree level in this Faculty learn from them!!!

EMS System Attribute: EMS Research

Summary
Little evidence of improved outcome, some evidence of actual HARM from current EMS practices Evidence-based policy making with respect to the organisation of pre-hospital services cannot depend on RCTs alone. Need to improve methodology Time to move towards addressing a set of outcomes of public policy importance.

QUESTION:

WHAT DOES THE LITERATURE SAY ABOUT THE CLINICAL EFFECTIVENESS OF OUT-OFHOSPITAL EMS CARE?

Current research at MUCAPS

Trauma triage Analgesia in trauma care Simulation in trauma education Asthma care Behavioural responses in acute heath events Impact of culture on emergency care Disaster epidemiology Opportunities for you to do BMed Sc at MUCAPS after your 3rd year!!!!

Contact Details
Monash University Department of Community Emergency Health and Paramedic Practice
Peninsula Campus McMahons Road Frankston Vic 3199 Phone: (03) 9904 4638 Email: frank.archer@med.monash.edu.au Web site : http://www.med.monash.edu.au/cehpp

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