Modifying Your EMD and EMS Response Plan for Pandemic Flu: Lessons Learned from Maryland

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Modifying Your EMD and EMS Response Planfor
Pandemic FluLessons Learned from Maryland

• By
• Richard Alcorta, MD FACEP
• State EMS Medical Director
• MIEMSS

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

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Overview

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

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Pandemic Influenza Criteria

• 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

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Preparing for Pandemic Influenza
Recommendations for Protocol Development for
9-1-1 Personnel and Public Safety Answering
Points (PSAPs)

• Facilitation of Call Screening
• Automated Data Gathering Surveillance
• Protocol Expansion/Modification
• Protocol Updates (dynamic)
• Triage/Patient classification
• Assistance with Priority Dispatch of Limited
  Emergency Medical Services (EMS) Assistance
• Tiered Responses/Altered Responses
• Dispatch Protocol Modifications
• Secondary Triage (Nursing Hotline)

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Facilitation of Call Screening

• 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.

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Recommendations for 9-1-1 Public Safety Answering
Points (PSAP)http//www.cdc.gov/swineflu/guidance
_ems.htm

• 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 (H1N1) 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.  

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Recommendations for 9-1-1 Public Safety Answering
Points (PSAP)http//www.cdc.gov/swineflu/guidance
_ems.htm

• 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.
• 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.

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

• 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.

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Principles

• 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.

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Principles

• 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.)

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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

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CDC Pandemic Severity Index
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WHO Pandemic PHASE

• No new influenza virus subtypes have been
  detected in humans
• 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

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Pandemic Severity Score

• Category 5 (gt2.0 lethality gt1,800,000 ill)
  5 points
• Category 4 4 points
• Category 3
• (0.5 to lt1.0 lethality 450,000 to lt900,000
  ill) 3 points
• Category 2 2 points
• Category 1 (lt0.1 lethality lt90,000 ill)
  1 points

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EMS/Dispatch System Demand for Services

• Critical Increase 5 points
• Severe Increase 4 points
• Moderate Increase 3 points
• Mild Increase 2 points
• Standard Operating Mode 1 points

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Reduction of EMS/Dispatch Workforce

• Absentee Rate over 40 5 points
• Absentee Rate 35-40 4 points
• Absentee Rate 25-35 3 points
• Absentee Rate 15-25 2 points
• Absentee Rate 15 or below 1 points

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Facility Capacity (Bed availability)

• Occupancy exceeds 100 5 points
• Occupancy Rate 98-100 4 points
• Occupancy Rate 95-98 3 points
• Occupancy Rate 90-95 2 points
• Occupancy Rate at 90 or below 1 points

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Dynamic System Status Score(DSSS)

• 6 -10 points DSSS CATEGORY ONE
• 11-15 points DSSS CATEGORY TWO
• 16-20 points DSSS CATEGORY THREE

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Impact Areas of DSSS

• Triage
• Treatment
• Equipment
• Transportation
• Destination

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

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

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DSSS Category One

• Determine whether to implement triage and
  treatment protocols that differentiate between
  non-infected and potentially infected patients
  based on CDC case definition.

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DSSS Category Two

• 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.

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DSSS Category Three

• Using screening algorithm to ensure only severe
  get response
• Resources assigned to those that can most benefit
  from EMS response

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Pandemic Flu Modified EMD Plan

• 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

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How does this apply to each EMS Operational
Program?

• 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

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Cornerstone

• For this exercise, the dispatchers response
  profile was based on his understanding and
  application of the DSSS Category Three.

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Pandemic Flu EMD Modified Plan
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Types of Dispatcher Resources

• First Responder
• Engine Company
• Utility
• Do they all have AEDs?
• BLS Ambulance
• ALS
• Supervisor
• Others?

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Combination of Resources

• First Response BLS
• First Response ALS
• First Response BLS ALS Chase
• First Response BLS ALS
• Above Plus Supervisor

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Current Jurisdictional EMD Profiles

• Alpha ?
• Bravo ?
• Charlie ?
• Delta ?
• Echo ?
• Omega ?

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Case Consistent Responses Profiles

• Snake Bite
• Chest pain
• Sudden Sick
• Heart Attack /Cardiac Arrest
• Choking
• Traffic Accident
• Shot in the foot
• Underwater
• Pandemic Flu

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Evaluation Tool

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

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Goal

• With todays 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.

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EMD and On-Scene

• Two Phases
• ( BOTH DRAFT PROTOCOLS)
• Modified Emergency Medical Dispatch
• On- Scene Triage

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Participants Modified EMD Plan

• Baltimore County
• Caroline County
• Charles County
• Fredrick County
• Harford County
• Montgomery County
• Prince Georges County
• Queen Anne County
• Washington County
• NOTE (Last year Dorchester and Talbot
  participated)

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Implement the Pandemic Flu Emergency Medical
Dispatch Modified Plan appropriately

• All 911/PSAP centers implemented the Pandemic Flu
  Emergency Medical Dispatch Modified Plan using
  the DSSS Category 3 column.
• 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.
• All 911/PSAPs received and managed all 50 patient
  complaint scenarios, and the determinant coding
  of the scenarios was consistent with national
  standards.

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Implement the Pandemic Flu Emergency Medical
Dispatch Modified Plan appropriately

• Corrected the education of the dispatchers and
  the briefing provided to the Call Takers during
  the exercise which was learned from last years
  exercise.
• Jurisdictions with Police units that have AED
  resources help reduce the depletion of EMS
  resources for ECHO category patients.

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Implement the Pandemic Flu Emergency Medical
Dispatch Modified Plan appropriately

• 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.

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To determine if there is any change in resource
allocation during a pandemic influenza event when
compared to standard daily resource allocation.

• 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.

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To determine if there is any change in resource
allocation during a pandemic influenza event when
compared to standard daily resource allocation.

• 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.

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• 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

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Results

• 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

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Actual Responses EMD Profiles

• Alpha No resources sent
• Bravo No resource sent or only First
  Responder/ BLS ambulance
• Charlie BLS or ALS ambulance
• Delta ALS ambulances until they ran out then
  BLS ambulance
• Echo AED units Dispatchers were very
  uncomfortable with this limited response

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Participants in On-Scene Triage

• Statewide invitation
• All Levels of EMS provider
• 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

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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
• 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

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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
• 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, 75ALS

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Managing Arrests

• 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.
• If return of pulse, initiate transport and
  rendezvous with ALS if available and can beat
  your arrival time at the ED
• No shock indicated or when shock indicated stops
  with no return of pulse, Consult Medical
  Direction to withdraw care and leave patient on
  scene.

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Treat Non- Flu Normally

• If patient has an obvious non-flu related illness
  or injury , apply appropriate Maryland Medical
  Protocol for EMS Providers then treat and
  transport appropriately

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Critical Vital Signs
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Inclusion with Normal Vital Signs

• If patient has Normal Vital Signs (Table 1) then
  go to Case Definition Signs and Symptoms for Flu
  (Table 2)
• a) If the patient has three or more Case
  Definition Signs or Symptoms for Flu transport
  patient to Alternate Care Facility
• b) 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.

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Case Definitions Signs and Symptoms for the FLU

• Difficulty breathing with exertion
• Has doctor diagnosed flu
• Cough
• Fever
• Shaking Chills
• Chest Pain (pleuritic)

• Sore throat (no difficulty breathing or
  swallowing)
• Nasal congestion
• Runny nose
• Muscle aches
• Headache

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

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

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Results

• 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

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Results

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

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On-Scene Triage Accuracy

• Comparing providers decision to the exercise
  design teams (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

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On-Scene Triage Accuracy

• 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

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Results

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

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Questions ?