From here to there: navigating the geography of time.

Thomas Judge, CCTP

Norm Dinerman, MD, FACEP,

Sandra Benton, MSN, CCRN

Kim McGraw, RN, CCTP

Kevin Burkholder, CCTP

Geography: pre-hospital considerations

Location of event: time zero to:

closest cardiac system hospital

equidistant: cardiac system hospital or cardiac intervention center?

cardiac intervention center direct—bypass closest hospital

Essential information: BLS or ALS service? Time of response– time/mileage to closest

hospital vs. time/mileage to cardiac intervention center

Determine:•Glasgow Coma Scale

•Systolic Blood Pressure•Respiratory Rate

Determine:•Glasgow Coma Scale

•Systolic Blood Pressure•Respiratory Rate

Calculate:Revised Trauma Score (RTS)

orPediatric Trauma Score (PTS)

Calculate:Revised Trauma Score (RTS)

orPediatric Trauma Score (PTS)

Is RTS <11 or PTS <8?

Determine: if any of the following exist:Paralysis;Amputation proximal to wrist or ankle;Penetrating injury to chest, abdomen, head or neck;Two or more proximal long bone fractures;Unstable pelvic fracture;Open or depressed skull fracture;Burn associated with trauma

Determine: if there is associated fatality in same

vehicle compartment

Determine: if there is associated fatality in same

vehicle compartment

YES

YES

YES

NO

NO

NO

I. OLMC confirms RTS/PTS

II. OLMC considers patient transport to Trauma Center, using following guidelines:

a) If transport time by ground or air to Trauma Center is less than 30 minutes, patient should go to Trauma Center directly;

b) If transport time to Trauma Center is greater than 30 minutes, determine the difference in transport time between the Trauma Center and the most accessible hospital:

1) If difference is less than 10 minutes, consider transport to Trauma Center;

2) If difference is greater than 10 minutes, consider transport to most accessible hospital;

III. If, upon arrival in the ED,

a) Facility is not a Trauma Center, and;

b) Patient continues to satisfy criteria of Assessments One and Two, and;

c) Patient can be stabilized for further transport, then receiving ED clinician should provide only life-saving procedures (avoiding unnecessary diagnostics) prior to transport to Trauma Center unless he/she judges clinical situation to not warrant such transfer.

I. OLMC confirms RTS/PTS

II. OLMC considers patient transport to Trauma Center, using following guidelines:

a) If transport time by ground or air to Trauma Center is less than 30 minutes, patient should go to Trauma Center directly;

b) If transport time to Trauma Center is greater than 30 minutes, determine the difference in transport time between the Trauma Center and the most accessible hospital:

1) If difference is less than 10 minutes, consider transport to Trauma Center;

2) If difference is greater than 10 minutes, consider transport to most accessible hospital;

III. If, upon arrival in the ED,

a) Facility is not a Trauma Center, and;

b) Patient continues to satisfy criteria of Assessments One and Two, and;

c) Patient can be stabilized for further transport, then receiving ED clinician should provide only life-saving procedures (avoiding unnecessary diagnostics) prior to transport to Trauma Center unless he/she judges clinical situation to not warrant such transfer.

TRANSPORT TO TRAUMA SYSTEM PARTICIPATING HOSPITAL

If pre-hospital providers are unable to definitively manage the airway, maintain breathing or support circulation, begin transport to most accessible hospital and simultaneously request ALS intercept or tiered response.

MAINE EMS TRAUMA TRIAGE PROTOCOL

Time Modeling Study for MMC Helipad:Assumptions for air vs. ground decision support models

• Grid model:

• EMS arrival + 2 minutes = time zero

• Ground: time zero +17 minutes + drive time to trauma center

• Air: time zero + 10 minutes launch + flight time to scene + 10 minute scene time + flight time to trauma center

•LOM called by ambulance at scene--2 min. decision time--total 19 min. on scene time

•10 min. LOM alert and launch

•Flight time to scene

•10 min. LOM intervention/packaging time

•Flight time from scene to MMC,CMMC, EMMC

Scenario B;

Helipad at MMC

Decision Support

Time Modeling

Scenario C;

Helipad at MMC and 10

minute “Jump” on

LOM through early

mobilization at time of

EMS dispatch

Decision Support Time

Modeling

•LOM called at dispatch--save 10 min. alert and launch time

•Total 19 min. on scene time

•Flight time to scene

•10 min. LOM intervention/packaging time

•Flight time from scene to MMC, CMMC, EMMC

NECA ALGORITHM((For hospitals outside the Bangor areaFor hospitals outside the Bangor area))

Algorithm for Fibrinolytic Eligible PatientsAlgorithm for Fibrinolytic Eligible Patients

♥ Thrombolytic therapy (TNK or Retevase)♥ ASA (chew 4 baby aspirin)♥ Heparin (2)

♥ Beta-Blocker (3)

♥ NTG IV boluses PRN (4,5)

Call NECA 947-4940Transfer Emergently to EMMCConsider LifeFlight helicopter

1-888-0421-4228

Call NECA 1 hour after starting lytic therapy if patient still has persistent

chest pain with ST-elevation

Transfer Emergently to EMMC

Consider LifeFlight helicopter

1-888-421-4228

♥ Thrombolytic therapy (TNK or Retevase)♥ ASA (chew 4 baby aspirin)♥ Heparin bolus & infusion ♥ Beta-Blocker (3)

♥ IV NTG infusion (5)

HIGH RISKHaving any one of these criteria:

Anterior MI

Age 75 years and older

CHF / Pulm Edema

Hypotension or Shock

LOW RISKHaving none of the high risk criteria

Geography: system hospital considerations

High Risk Rapid transfer to intervention center

Failed lysis / rescue

Other issues– transfer (LVAD, IABP, AICD, Pedi, etc.)

Essential information Time Goal– Standardized Order Set / Preparation

Transportation Plan (stability y/n ?)

Time of transfer– time/mileage to closest to cardiac intervention center

Enroute– expected complications / deteriorates

Geography: manage time and system

Parallel process at time of EMS first info

Destination decision

Transfer needed?

Skills needed? Capability of EMS Agency-scope of

practice / equipment, RN needed

Transfer service activated— Time to Respond

Initial Stabilization / Intervention /

Preparation

Transfer

Limitations: weather, service availability

Rumford Community Hospital N=8

• ED 75%• ICU 25%• Over BST Benchmark 13%• Triage to Request

– (4) 40 minutes

Rumford Community Hospital N=8

Averages CMMC MMC

BST 18 15

Tone to Rcvg 72 95

Bedside to Rcvg

37 63

Ground Times

48 108

Geography: unresolved questions

• Do all lysis patients get transferred– when?

• What are consensus time goals for decision

trees?

• Definition of stability? Scope of practice

needed.

• Scope of practice across spectrum

• Measurement predictive high performance