Office of the Medical Director - -- Emergency Medical Services

Office of the Medical Director

2007Annual Report

January 1, 2007 – December 31, 2007

Office of the Medical Director1111 Classen Drive

Oklahoma City, OK 73103405-297-7173

1417 N. Lansing AvenueTulsa, OK 74106

918-596-3054

Table of Contents

I. Letter from Office of the Medical Director ................................................................................... 1

II. Medical Control Board Members ................................................................................................. 3

III. Organizational Chart .................................................................................................................... 5

IV. Regulated Service Area .................................................................................................................. 6

V. Office of the Medical Director Staff .............................................................................................. 9

VI. Dr. Sacra’s Curriculum Vitae ....................................................................................................... 11

VII. Medical Director’s Report ........................................................................................................... 19

Medical Control Board Budget, FY 2008 ..................................................................... 21

Recertification of First Responders, Year 2007 .............................................................. 24

Prehospital Testing Results for the Orientation Academies, Year 2007 .......................... 25

Recertification Testing of Prehospital Operational Standards for Paramedics by Agency, Year 2007 ................................................................................. 26

VIII. Heart and Stroke Task Force ....................................................................................................... 27

IX. Homeland Security

Metropolitan Medical Response System ....................................................................... 30

Medical Reserve Corps ................................................................................................. 31

X. Prehospital Operational Standards – Revisions and Additions .................................................... 33

XI. Cardiac Arrest Registry ............................................................................................................... 34

XII. First Response Advanced Life Support (ALS) .............................................................................. 49

XIII. Air Medical Report ..................................................................................................................... 51

XIV. Community-Wide Public Health/Safety Net .............................................................................. 56

XV. Clinical Quality Improvement Executive Reports

EMSA .......................................................................................................................... 66

Oklahoma City Fire Department .................................................................................. 73

Tulsa Fire Department .................................................................................................. 85

XVI. State of the System and Future Direction ................................................................................... 98

Office of the Medical Director – 2007 Annual Report

[ 1 ]

Dear Mayors and City Councilors:

I am pleased to provide this report on the status of your Emergency Medical Services system. The system continues to be studied and visited by EMS professionals from across the country and the world because of its reputation within the industry for medical quality and cost efficiency. This report gives you a glimpse of what transpired during 2007 with a few highlights summarized below.

While ambulance diversion is a major problem for EMS systems throughout the United States, the proactive approach used here has served our citizens well. Except for brief periods during the ice storm and the peak of the influenza season, we were able to minimize the number of patients diverted from one hospital to another. We have taken what we learned from the increases during those peak periods to develop a new proposal which is being considered for implementation during 2008. The proposed new protocol will allow patients who are stable, not in need of immediate emergency interventions and established (those patients with a previous relationship with a particular hospital or physician) to be delivered to a hospital even when it is on divert status for unassigned patients. Our experience has taught us that displacement of assigned patients is a dissatisfier for patients, hospitals and physicians. We will continue to stay on top of this important issue which has tremendous impact on patient care and the efficiency of your EMS system.

Another important development during the year was a more in depth and engaged strategic planning effort. In the fall of 2007, a small working taskforce made up of key decision makers began studying the 14 guiding principles of the Strategic Blueprint for EMS. With the leaders from the Office of the Medical Director, the Oklahoma Institute for Disaster and Emergency Medicine, the Fire Departments from Tulsa and Oklahoma City, the Emergency Medical Services Authority and representatives from the City of Oklahoma City and the City of Tulsa, we are considering system changes and ways to implement those changes for the benefit of those we serve. As you may recall, there were many who supported a more thoughtful and deliberate approach to system changes outside of the rushed and sometimes emotionally charged “window of opportunity”. I am very encouraged by this process and the involvement of our key stakeholders and hope to conclude this phase of the process during 2008.

The ice storm which hit Oklahoma City and Tulsa in December showcased our fine pre-hospital system. The prolonged period of response, particularly in Tulsa, illustrated not only the caliber of our medics but the worth of a system with redundancy and behind the scenes added value. System redundancy became critical as the standard of care was changed to allow Fire Fighters to discontinue their roles as First Responders to concentrate on fires, dangerous debris and downed lines. EMSA medics stepped up to fill the dual roles of First Response and Transport even as demand continued at peak levels for an extended period of time. The system served our citizens well. While the system worked seamlessly and transparently throughout the intense period, the coordination and communication provided by the Metropolitan Medical Response System and the Medical Emergency Response Center was invaluable and little recognized. These added value features are essential during disasters and other periods of system overload.


[ 2 ]

The relationship with the EMS system and the Oklahoma Institute for Disaster and Emergency Medicine continues to evolve with the off-line medical direction for your EMS system on course to move into the University of Oklahoma based Institute beginning in July 2008 and finalized by July 2009.

As in past years, I cannot tell you how proud I am to provide medical direction for nearly 2,800 fine medics providing both First Response and Transport. It is because of the dedication of these committed individuals that we are able to provide pre-hospital care at levels which other cities wish to emulate. Thank you for the opportunity to work for you and with this system. I encourage you to review this report with particular attention on the State of the System and Future Direction section. As always, I am available at any time to answer questions about your pre-hospital system. Please do not hesitate to contact me.

Sincerely,

John C. Sacra, M.D., FACEPMedical Director


[ 3 ]

Medical Control Board Members

The Medical Control Board provides medical consensus from the local medical community. These physicians offer valuable insight and counsel to EMSA, First Response Agencies and the Medical Director by helping establish the Standard of Care. The Medical Control Board is comprised of four Emergency Department Directors from each Division and one physician from another specialty. The Emergency Physician Foundations of the Eastern and Western Divisions elect four members each to the Medical Control Board to serve staggered four-year terms. The ninth member of the Medical Control Board, a specialist other than Emergency Medicine, is selected from the Western Division and serves a four-year term. The Medical Control Board meets every other month. The following is a brief biography of the current members of the Medical Control Board.

Dale C. Askins, D.O.Dr. Askins graduated from Kirksville College of Osteopathic Medicine in 1979. He is Board Certified in Emergency Medicine. He is currently on staff at Integris Southwest Medical Center, OU Medical Center – Presbyterian Tower, Edmond Medical Center, St. An-thony Hospital, Comanche County Memorial Hospital, Norman Regional Hospital, Claremore Regional Hospital, Integris Canadian Valley Regional Hospital, Unity Health Center, Community Hospital and Bone & Joint Hospital. He is President/Chief Operating Manager of Morningstar Emergency Physicians. Dr. Askins was member of the Medical Control Board August, 1994 to May 2007.

Brent Barnes, M.D.Dr. Barnes is a native Oklahoman and graduated from the University of Oklahoma Medical School in 1993. He completed his residency in Emergency Medicine at the University of Oklahoma Health Sciences Center in 1997. In February 2005 Dr. Barnes was appointed Chief of Emergency Medicine at the OU Medical Center and serves as Medical Director at the OU Medical Center for the Presbyterian Tower. Dr. Barnes became a member of the Medical Control Board in September, 2004.

William H. Bickell, M.D.Dr. Bickell received a Bachelor of Science degree in 1976 from Rockhurst College. He received his Doctor of Medicine in 1980 from Georgetown

University School of Medicine. Dr. Bickell did his internship and residency at Brooke Army Medical Center in Fort Sam Houston, Texas. He is currently the Medical Director for the Trauma Emergency Center and the Director of Trauma Research for Saint Francis Hospital and Warren Clinic, Inc. in Tulsa. Dr. Bickell has been a member of the Medical Control Board since December 1998 and served as the Chairman from January, 2002 through January, 2003.

Doug Coffman, D.O.Dr. Coffman graduated from Baylor University in 1988 and from the University of North Texas Health Science Center in 1994. Dr. Coffman completed his residency and internship in Emergency Medicine at the Emergency Medicine Hillcrest Health Center in 1998. He is Board Certified in Emergency Medicine. He is currently the Medical Director for the Emergency Department at St. Anthony Hospital. Dr. Coffman has been a member of the Medical Control Board since November, 2004.

Jeffrey D. Dixon, M.D.Dr. Dixon is a native Oklahoman. He received his Bachelor of Science degree from Washington & Lee University in Lexington, Virginia in 1985. He received his M.D. from Washington University School of Medicine in St. Louis in 1989. He did his residency in Emergency Medicine at the University of Oklahoma Health Sciences Center from 1989-1993. Dr. Dixon is currently the Medical Director and Section Chief for Emergency Medicine at Hillcrest Medical Center in Tulsa. He has been a member of the Medical Control Board since November, 1999 and was elected Chairman in September, 2004.

Charles F. Engles, M.D.Dr. Engles is a native Oklahoman, graduating from the University of Oklahoma Medical School in 1979. He completed a flexible internship at Gorgas Hospital in the Panama Canal Zone and a Neurosurgical residency at O.U. He has been in private practice of Neurosurgery since 1985. He was a Clinical Professor of Neurosurgery at the Medical School and currently has a private office at the Mercy NeuroScience Institute in Oklahoma City. Dr. Engles has been a member of the Medical Control Board since May, 1992.


[ 4 ]

Charles A. Farmer, M.D.Dr. Farmer graduated from Arkansas Polytechnic Col-lege in 1967. He received his Medical Degree from the University of Arkansas School of Medicine in 1971. He completed a mixed Medicine/Surgery residency at St. John Medical Center in March 1972. From 1972-1975 Dr. Farmer served in the Navy as a Flight Surgeon and during 1975-1976 he completed one year of residency in Surgery at Tulsa Medical Education Foundation, University of Oklahoma. He has been the Director of the Emergency Department at St. John Medical Center since January 1977, and the Chairman of the Depart-ment of Emergency Medicine since January 1977. Dr. Farmer has been a member of the Medical Control Board since its inception in May, 1990.

John C. Nalagan, M.DDr. Nalagan did his undergraduate at the University of Oklahoma and graduate work at the OU Health Science Center. He graduated from the OU College of Medicine in 1996 and completed his Emergency Medicine residency at the University of Oklahoma Health Sciences Center in 2000. Dr. Nalagan has worked in the Emergency Departments at Integris Baptist Medical Center and OU Medical Center in Oklahoma City for eight years. He is the Medical Director for Medi Flight of Oklahoma. He was elected to the Medical Control Board in June 2007.

Jeff Reames, M.D.Dr. Reames is a native Oklahoman. He did his undergraduate and graduate work at the University of Oklahoma. He graduated from medical school in 1989 and completed his Emergency Medicine residency at the University of Oklahoma Health Sciences Center in 1993. Dr. Reames has worked in the Emergency Department at Integris Baptist Medical Center in Oklahoma City for eight years. He was elected to the Medical Control Board in January, 2001 and has served as Vice-Chairman since November, 2004.

Stan R. Stacy, D.O.Dr. Stacy is a native Oklahoman. He received a Bachelor of Science degree from the University of Oklahoma in 1986. He received his Doctor of Osteopathy from Oklahoma State University College of Osteopathic Medicine in 1991. Dr. Stacy completed his Emergency Medicine residency at Tulsa Regional Medical Center in 1995. Dr. Stacy was appointed Chief of Staff for SouthCrest Hospital in Tulsa from 2002 through 2005. He is currently the Director of Emergency Services at SouthCrest Hospital. He has been a member of the Medical Control Board since January, 2000.


[ 5 ]

Organizational Chart

Public Utility Model

Governmental Entity

EMSABoard of Trustees

EMSA

OperationsContractor

First ResponseProviders

On-LineMedical Control

Medical ControlBoard

Office of theMedical Director

Western ChapterEmergency Physicians

Foundation

Eastern ChapterEmergency Physicians

Foundation


[ 6 ]

The Regulated Service Area, (RSA) which includes the greater metropolitan areas of Tulsa and Oklahoma City, encompasses 1030 square miles with a resident population of 1.1 million people. The EMSA Ambulance Service provides Advanced Life Support (ALS) ambulance coverage to Tulsa and Oklahoma City and surrounding suburbs. The 9-1-1 centers of Tulsa and Oklahoma City combine to handle 153,045 medical calls annually, resulting in transport of patients to 20 designated hospitals. There are three components of the on-line EMS system:

(1) Fire Department First Response (most fire departments within the RSA are Automatic External Defibrillator [AED] capable), Oklahoma City and Tulsa Fire Departments are currently providing limited ALS/First Response,

(2) Emergency Medical Services Authority (EMSA) ALS Transport Agency,

(3) On-Line Medical Control.

The RSA is currently a two-tiered system comprising of approximately 400 paramedics, 2400 EMT- intermediates, EMT-B/Defibrillators, EMT-Basics, FR/Defibrillators, Law enforcement and on-site security staff FR/defibrillators, and approximately 100 On-Line Medical Control Physicians.

The Medical Control Board (MCB) is the medical over-sight authority. Dr. John Sacra is the full time medical director for the MCB providing medical direction for the following metropolitan entities:

EMSA Advanced Life Support Ambulance Service° Providing approximately 127 12-hour ambulance

tours (Eastern and Western Divisions)° Providing approximately 6 24-hour ambulance

tours (Western Division)° Providing approximately 3 16-hour ambulance

tours (Western Division)° Providing approximately 1 9-1/2-hour ambulance

tour (Western Division)° All ambulances are Advanced Life Support

capable

Tulsa Fire Department° 30 Fire Stations

° 7 stations are Advanced Life Support ° 23 stations are First Responder or EMT-Basic and

AED capable

Oklahoma City Fire Department° 35 Fire Stations° 22 stations are Advanced Life Support° 13 stations are First Responder or EMT-Basic and

AED capable

Edmond Fire Department° 5 Fire Stations° 3 stations are Advanced Life Support° 2 stations are First Responder or EMT-Basic and

AED capable

Bethany Fire Department° 1 station/AED capable

Mustang Fire Department° 1 station/AED capable

Nichols Hills Fire Department° 1 station/AED capable

Piedmont Fire Department° 2 stations/AED capable

The Village Fire Department° 1 station/AED capable

Warr Acres Fire Department° 1 station/AED capable

Yukon Fire Department° 2 stations/AED capable

Will Rogers Airport Fire Department° 1 station/AED capable° Sponsored and deployed Public Access

Defibrillation within the airport terminal

Sand Springs Fire Department° 2 stations/AED capable and ILS staffed

Bixby Fire Department° 2 stations/AED capable

Regulated Service Area DescriptionEastern and Western Division


[ 7 ]

Jenks Fire Department° 2 station/AED capable

Keystone Lake Fire and Rescue° 1 station/AED capable

Turley Fire and Rescue° 1 station/AED capable

Berryhill Fire Department° 1 station/AED capable

Oak Cliff Volunteer Fire Department° 1 station/AED capable

Rock Volunteer Fire Department° 1 station/AED capable

Condea Vista Company Emergency Response° On-site first response services/AED capable

Sunoco Refinery° 1 station/AED capable

Oklahoma Air National Guard/Bombing Memorial Park Service

° On-site first response services for the Bombing Memorial/AED capable

Tulsa County Sheriff Department° Law enforcement first response in the

unincorporated areas of Tulsa County/AED capable

Oklahoma City Community College° On-site first response services for the campus at

OCCC/AED capable

Federal Reserve Bank° On-site first response services/AED capable

• Tulsa and Oklahoma City Fire Departments operate special units including water rescue, hazardous material, etc. All fire departments provide rescue services.

• The Medical Control Board employs Dr. Sacra and staff of the Office of the Medical Director, which includes 3 full-time employees.

• The EMS system includes a combination of urban and rural areas. The largest city is Oklahoma City, which has a population of approximate 650,000.

• There are 16 cities with signed EMS Interlocal Cooperation Agreements.

• Air-ambulance programs provide prehospital scene response according to protocol established by the Office of the Medical Director.

The EMS System serves the Cities of: 1. Tulsa, OK 2. Oklahoma City, OK 3. Edmond, OK 4. Bethany, OK 5. Mustang, OK 6. Nichols Hills, OK 7. Piedmont, OK 8. The Village, OK 9. Warr Acres, OK 10. Yukon, OK 11. Lake Aluma, OK 12. Sand Springs, OK 13. Jenks, OK 14. Bixby, OK 15. Arcadia, OK 16. Valley Brook, OK

Description of Off-Line Medical Direction:Off-Line direction is provided by the Medical Director, which includes retrospective chart review, cardiac arrest registry, written and practical testing of all EMS personnel and On-Line Medical Control Physicians. The Medical Control Board provides administrative and medical oversight. The Medical Director and his staff develop protocols and quality improvement activities. Ad hoc consultants in emergency medicine, pediatrics, cardiology, neurology, trauma, toxicology, disaster medi-cine, and injury control assist in the development of protocols.


[ 8 ]

Description of On-Line Medical Direction:The hospitals in Tulsa and Oklahoma City provide On-Line medical direction to ambulances bringing patients to their facilities. The physicians providing On-Line medical direction are required to be knowledge-able in the system’s protocols and update themselves when annual revisions occur. On-Line communication is largely UHF, VHF, and cellular phone activity. On-Line Medical Control physicians are actively involved in the QI process for this system.


[ 9 ]

John C. Sacra, M.D.Medical DirectorDr. Sacra is a past President of the American Trauma Society, and a member of the National Trauma Committee of the American College of Emergency Physicians. Locally Dr. Sacra serves on the Oklahoma County Medical Society’s Emergency Medical Care Committee, the Tulsa County Medical Society’s Council on Community Relations, the Oklahoma State Trauma Advisory Council and the Medical Direction Subcommittee for the EMS Division of the Oklahoma State Health Department. He chairs the Medical Audit Committee for the OSDH Trauma Division.

In 2006 Dr. Sacra received the American College of Emergency Physician’s Outstanding Contribution in EMS Award and The Beverly Doyle EMS Leadership Award presented by the Oklahoma Emergency Medical Technician’s Association.

Since September 11, 2001, Dr. Sacra has been appointed to several state and national task forces on terrorism.

Dr. Sacra has been the Medical Director since January 1, 1998. His duties and responsibilities are outlined in the EMS Interlocal Cooperation Agreement and are as follows:

(1) Be Board certified in emergency medicine, family practice, internal medicine, or surgery, or at least, have current certification in Advanced Cardiac Life Support (ACLS) and Advanced Trauma Life Support (ATLS).

(2) Be familiar with the design and operation of pre-hospital emergency medical service systems, and thoroughly knowledgeable of the capabilities of the different levels of licensed personnel and of the established protocols.

(3) Have experience in the emergency department management of the acutely ill or injured patient(s), in the urban setting. In the rural setting, the physician shall routinely and actively participate in the care for acutely ill or injured patient(s).

(4) Be knowledgeable and actively involved in quality assurance and the educational activities of the emergency medical technician, by either direct involvement or appropriate designation and surveillance of his responsible designee.

(5) Live in a community for which the licensed ambulance service(s) and/or first response agency(ies) have primary service area coverage, or have staff

Office of the Medical DirectorPosition DescriptionsThe Office of the Medical Director currently has four full time employees; the Medical Director, Director of Clinical Affairs, Director of Clinical Affairs/Eastern and Western Divisions, and an Administrative Assistant. The Office of the Medical Director provides a System Standard of Care to include:

I. Input Standards includes but is not limited to personnel certification requirements, in-service training requirements, equipment specifications, on-board inventory requirements, and other requirements which the system must fulfill before receipt of a request for service;

II. Performance Standards includes but is not limited to priority dispatching protocols and pre-arrival instructions, medical protocols, standing orders, protocols governing authority for on-scene control of patient care, and other performance specifications describing how the system should behave upon receipt of a request for service; and,

III. Outcome Standards includes but is not limited to target survival rates for certain narrowly defined presenting problems or presumptive diagnoses, such as witnessed cardiac arrests involving patients whose medical histories meet defined criteria. Outcome standards define the results the system intends to achieve by meeting its input and performance standards.


[ 10 ]

privileges at a hospital where a significant part of the ambulance patients are transported for medical care. A physician may be the Medical Director for more than one licensed ambulance service and/or first responder agency.

(6) Provide a written statement, to the Department, which includes consent to be the Medical Director, address, an Oklahoma Bureau of Narcotics and Dangerous Drugs (OBNDD) number, and be actively involved in pre-hospital care.

(7) Develop medical protocols for patient care including EMT-Basic/First Responder, Intermediate, EMT Advanced/Cardiac and EMT Paramedic life support protocols and submit to the Health Department for approval, before utilization. Protocols shall include medications to be utilized, treatment modalities for patient care procedures, and appropriate security procedures for controlled and dangerous drugs. For EMT Defibrillation, the Medical Director(s) must agree in writing to adhere to State protocols, which must be submitted to the Health Department for approval, before utilization.

(8) Supervise a quality assurance (QA) program. The QA program, or policy, shall be submitted with treatment protocols, for approval by the Department. Quality assurance documentation may be requested by the Department.

(9) Participate in the statewide emergency medical service system.

Anthony J. “TJ” Reginald, EMT-PDirector of Clinical Research and DevelopmentEastern and Western DivisionsThe Office of the Medical Director has employed Mr. Reginald since April 1990. The Director of Clinical Research and Development is a highly responsible administrative position focused on Clinical Quality Improvement activities, clinical research, protocol development and evaluation of all new Standard of Care changes.

David Howerton, EMT-PDirector of Clinical AffairsEastern and Western DivisionsThe Office of the Medical Director has employed Mr. Howerton since January 2003. The Deputy Director of Clinical Affairs is a highly responsible administrative position focused on the overall management of ongoing quality improvement programs, including but not limited to retrospective medical auditing, prospective educational program development, personnel and equipment certification, and enhancement of First Responder Programs. This position also requires contact with provider agencies and participation in local committees and task forces to facilitate cooperation between EMS agencies in the Regulated Service Area.

Alicyn A. SmithAdministrative AssistantEastern and Western DivisionsThe Office of the Medical Director has employed Mrs. Smith since June 1990. This position provides administrative, clerical and organizational support to the Medical Director, the Medical Control Board and the Emergency Physicians Foundations of the Eastern and Western Divisions. This position also requires contact with provider agencies to facilitate cooperation between EMS agencies in the Regulated Service Area.


[ 11 ]

John C. Sacra, M.D.

BIRTHDATE February 8, 1944 Pauls Valley, Oklahoma

EDUCATION Pauls Valley High School 1959-1962 United States Military Academy 1962-1964 University of Oklahoma 1964-1966 College of Medicine 1966-1970 University of Oklahoma

Internship 1970-1971 St. John Medical Center Tulsa, Oklahoma

Internal Medicine Residency 1971-1972 Tulsa Medical Education Foundation

Chief Resident 1978-1979 Internal Medicine Medical College of Georgia

MILITARY United States Army 1962-1964 SERVICE Honorable Discharge

HONORS AND Alpha Omega Alpha Honor Society 1970 PROFESSIONAL University of Oklahoma OFFICES College of Medicine

Secretary-Treasurer, Georgia Chapter 1976-1977 American College of Emergency Physicians

Member, Board of Directors 1976-1979 Georgia Chapter American College of Emergency Physicians

Examinee, Validation Exam 1977 Emergency Medicine Certification Exam

National Counselor 1977-1979 Representing the State of Georgia American College of Emergency Physicians

Member, Board of Directors 1979-1984 Oklahoma Chapter American College of Emergency Physicians

Curriculum Vitae


[ 12 ]

HONORS AND Member, Toxicology Committee 1979-1980 PROFESSIONAL American College of Emergency Physicians OFFICES (continued) Member, Trauma Committee 1980-1985 American College of Emergency Physicians

Chairman, Trauma Committee 1981-1984 American College of Emergency Physicians

Fellow 1982 American College of Emergency Physicians

Member 1982-1991 Technical Medical Direction Committee Oklahoma State Department of Health

Member, Physicians’ Advisory Board 1982-1983 City of Tulsa

Editorial Board 1984-1988 Urgent Care Update

Member, Board of Directors 1985-2004 American Trauma Society

Member, Board of Trustees 1987-1993 Emergency Medical Services Authority

Member, Board of Directors 1988-Present Oklahoma Chapter American College of Emergency Physicians

Chairman, Physicians’ Advisory Board 1988-1990 City of Tulsa

Chairman, Institutional Ethics Committee 1988-1997 Saint Francis Hospital

Member, Executive Committee 1990-2004 American Trauma Society

Co-Chairman, Trauma Committee 1990-1991 American College of Emergency Physicians

Chairman, Trauma Committee 1991-1993 American College of Emergency Physicians


[ 13 ]

HONORS AND Member 1991-1992 PROFESSIONAL Emergency Medical Services Advisory Council OFFICES Oklahoma State Department of Health (continued) Chairman, Medical Subcommittee 1991-1992 Emergency Medical Services Advisory Council Oklahoma State Department of Health

Chairman 1992-1994 Emergency Medical Services Advisory Council Oklahoma State Department of Health Member, Medical Control Board 1993-1998 Emergency Medical Services Authority

Member 1994-Present State Trauma Advisory Council Oklahoma State Department of Health

Chairman 1996-1998 Trauma Advisory Council Oklahoma State Department of Health

Governor’s Trauma System Task Force 1996-2000 State of Oklahoma Secretary, Board of Directors 1997-1998 American Trauma Society

Member, EMS Committee 1998-2004 American College of Emergency Physicians

Vice President, Board of Directors 1998-2000 American Trauma Society

President, Oklahoma Chapter 1998-2000 American College of Emergency Physicians

Member 1999-2005 Emergency Medical Service Advisory Council Oklahoma State Department of Health

President 2000-2002 American Trauma Society

Member 2001-Present Emergency Medical Care Committee Oklahoma County Medical Society


[ 14 ]

HONORS AND Member 2001-2004 PROFESSIONAL Council on Community Relations OFFICES Tulsa County Medical Society (continued) Member 2001-2004 Task Force, Emergency Medicine Department and Residency Training Program University of Oklahoma College of Medicine

Chairman 2001-2005 Emergency Medical Alliance of Tulsa

Chairman 2001-2005 Emergency Medical Alliance of Oklahoma City

Member 2001-Present Task Force for Bioterrorism Oklahoma State Medical Society

Member-National Advisory Council 2000-2006 National Study on Costs and Outcomes of Trauma Care

Member-National Advisory Council 2000-Present Trauma Information and Exchange Program

Member 2001-2005 Terrorism Response Ad Hoc Committee National Association of EMS Physicians

Member 2002-Present Mayor’s Homeland Security Task Force City of Tulsa

Member 2003-Present Governor’s Committee on Homeland Security Funding

Clinical Associate Professor of 2004-Present Family Medicine University of Oklahoma College of Medicine

Member 2005-Present Medical Direction Subcommittee Oklahoma Emergency Response Systems Development Advisory Council


[ 15 ]

HONORS AND Curtis P Artz Award 2005 PROFESSIONAL Highest Honor Bestowed by the OFFICES American Trauma Society for (continued) Contributions to Trauma Care

American College of Emergency Physicians 2006 Oustanding Contributions in EMS Award

SOCIETY American College of Emergency Physicians MEMBERSHIP Tulsa County Medical Society Oklahoma State Medical Society American Medical Association

PROFESSIONAL Medical Director 1972-1974 EXPERIENCE Department of Emergency Medicine St. John Medical Center Tulsa, Oklahoma

Associate Director of Medical Education 1972-1974 St. John Medical Center Tulsa, Oklahoma

Emergency Department Physician 1974-1978 Associate Director University Hospital Emergency Services Augusta, Georgia Assistant Professor of Surgery 1974-1979 Medical College of Georgia Regional EMS Medical Director 1977- 1998 Region VI, State of Georgia

Assistant Professor of Medicine 1978-1979 Medical College of Georgia

Medical Director 1979-1997 Trauma Emergency Center Saint Francis Hospital Tulsa, Oklahoma

Medical Director 1979-1997 Tulsa Life Flight Saint Francis Hospital Tulsa, Oklahoma


[ 16 ]

PROFESSIONAL Medical Director 1983-1991 EXPERIENCE Physical Performance Center (continued) Wellness Program Cardiac Rehabilitation Saint Francis Hospital Tulsa, Oklahoma

Medical Director 1980-1982 Emergency Medical Services Authority City of Tulsa

Clinical Associate Professor 1993-2003 University of Oklahoma College of Medicine, Tulsa

Instructor 1978-Present Advanced Cardiac Life Support

Affiliate Faculty 1978-1995 Advanced Cardiac Life Support Regional Faculty 1998-Present Advanced Cardiac Life Support

Instructor 1980-Present Advanced Trauma Life Support

Medical Director 1998-Present Medical Control Board Emergency Medical Services Authority

Clinical Associate Professor 2003-2006 Department of Internal Medicine Division Head of Emergency Medicine University of Oklahoma College of Medicine, Tulsa

Chairman 2006-Present Department of Emergency Medicine University of Oklahoma College of Medicine, Tulsa

MEDICAL Oklahoma State-9512 1971-Present LICENSE Georgia State-16667 1974-1980 SPECIALTY Diplomat, 1979 STATUS American Board of Internal Medicine Diplomat, 1980 American Board of Emergency Medicine


[ 17 ]

MEDICAL Recertification 1992 LICENSE American Board of Emergency Medicine 2001 SPECIALTY STATUS (continued)

CONTINUING American Medical Association Current MEDICAL Physicians Recognition Award EDUCATION American College of Emergency Physicians Current Certificate of Continuing Medical Education

CONSULTING State of New Mexico 1981-1984 Trauma Designation Consultant University of New Mexico 1981 Review of Emergency Department

EMS Foundation 1983 Fort Wayne, Indiana Review of Prehospital EMS

State of Pennsylvania 1986-2004 Trauma Systems Foundation Consultant

State of Oregon 1988-2000 Trauma Designation Consultant Coordinating Emergency Physician for 1990 President George Bush’s Visit to Oklahoma State of Florida 1992-1998 Trauma Designation Consultant

State of Mississippi 1992 State Emergency Medical Services Evaluation

State of Alaska 1994 and 1999 State Emergency Medical Services Evaluation

National Faculty 1994-1996 Development of Trauma Systems National Highway Traffic Safety Administration

Consultant 2003-Present Oklahoma State Department of Health for Emergency Medical Services and Trauma


[ 18 ]

PUBLICATIONS “Emergency Care of the Hemophiliac Patient”, Annals of Emergency Medicine, 9:476-479, September, 1980, Guthrie, T.H., Jr., and Sacra, J.C.

Liaison from American College of Emergency Physicians to Committee on Trauma of the American College of Surgeons for the Update of: “Hospital and Prehospital Resources for Optimal Care of the Injured Patient,” 1983.

“Community Hospital Level II Trauma Center Outcome”, Journal of Trauma, 32: 3, 1992, Drs. Thompson, C.T., Bickell, Wm. H., Siemens, Roger A., Sacra, John C., Saint Francis Hospital.

“Model Trauma Care System Plan,” U.S. Department of Health and Human Services, September 30, 1992.

“Trauma Systems”, Principles of EMS Systems, Second Edition, Chapter 3: 25-50, 1994, ACEP, Sacra, John C., M.D., Martinez, Ricardo, M.D.

“National Inventory of Hospital Trauma Centers,” Journal of the American Medical Association, Vol. 289, No. 12: 1515, March 26, 2003, Ellen J. MacKenzie, Ph.D.; David B. Hoyt, M.D.; John C. Sacra, M.D.; Gregory J. Jurkovich, M.D.; Anthony R. Carlini, M.S.; Sandra D. Teitelbaum, M.L.S.; Harry Teter, Jr. L.L.B.

“Trauma Systems”, Principles of EMS Systems, Third Edition, Chapter 4:40-57, 2005, ACEP, Sacra, John C., M.D.


[ 19 ]

This section of the Annual Report briefly describes some of the activities of the Office of the Medical Director during the CY 2007. Subsequent sections will describe in more detail some of these activities.

Clinical PerformanceA 100% case review occurred of all patient encounters for 2007 (55,693 in the Western Division and 54,089 in the Eastern Division). A portion of the Patient Care Records (PCRs) are selected for manual review by the electronic patient care report based on an apparent protocol deviation. These PCR’s are reviewed manually to determine if the deviation was clinically indicated. The Office of the Medical Director is currently monitoring the successful and failed intubation rates, Code 1 trauma delivery, trauma scene times and non-transported patients.

Medical Control Board BudgetThe Medical Control Board submitted its proposed budget for FY 2008 to the City Councils of Oklahoma City and Tulsa. The budget was approved by the Medical Control Board on May 9, 2007, the Oklahoma City City Council on June 5, 2007, and the Tulsa City Council on May 31, 2007. The total budget was $485,488. This reflected a slight decrease from the previous year’s budget.

In addition to the $485,488 budget, a separate budget was approved by the Oklahoma City City Council. This budget was to provide for costs incurred for ALS training in the Fire Department of Oklahoma City. The amount approved for FY 2008 was $43,778.38, which represented a decrease from the previous year’s budget. This money will be used as needed by the Office of the Medical Director to provide medical oversight and training for firefighter paramedics.

Also approved by the Tulsa City Council was a separate budget for additional costs incurred by the Office of the Medical Director to employ a full time staff member rather than the part time position in the Eastern Division. The budget approved by Tulsa City Council for the Eastern Division for FY 2008 was $13,995, which reflected a decrease from the previous year’s budget.

Medical Control Board Action ItemsThe regularly scheduled meetings for the Medical Control Board were March, May, July, September and November of 2007, the January meeting was canceled due to inclement weather.

March 2007No Action Items

May 2007Approval of Revisions to Protocol I.4: Categorization of Hospitals and Destination ProceduresApproval of Revisions to EMD ASA ProtocolApproval of Medical Control Board FY 2008 BudgetApproval of CY 2006 Office of the Medical Director Annual Report

July 2007Approval of Strategic Planning Letter to Mayors and City Councils of Tulsa and Oklahoma CityApproval of Revisions to Protocol III.18: Neona-tal Resuscitation

SepteMber 2007Approval of Revisions to Protocol I.3: Controlled SubstancesApproval of Revisions to Protocol II.33: BurnsApproval of Revisions to Protocol I.4: Categorization of HospitalsApproval of Medical Control Board 2008 Schedule of MeetingsApproval of Revisions to ALS Inspection FormApproval of Revisions to the First Responder Inspection Form

NoveMber 2007Approval of Revisions to Protocol I.4: Categorization of Hospitals and Destination Procedures

Medical Director’s Annual Report – January 2007 – December 2007


[ 20 ]

Approval of Revisions to Protocol III.18: Neonatal ResuscitationApproval of Revisions to Protocol III.38: Use of Meconium Aspirator

InspectionsDuring CY 2007, 118 ambulances and 2 ALS Engines were inspected by the Office of the Medical Director. All deficiencies found during the ambulance and ALS Engine inspections were reported to the appropriate agency and corrections were made.

First Responder UpdateThe personnel from the Office of the Medical Director continue to meet every other month with the First Responder Agencies in both Divisions. Representatives from the fire departments in EMSA’s Regulated Service area attend these meetings. The volunteer fire department personnel are also invited to attend.

In the Western Division, the Office of the Medical Director has worked to establish and maintain 22 ALS Engine Companys with the Oklahoma City Fire Department and 3 ALS Engine Companys with the Edmond Fire Department. In the Eastern Division, the Office of the Medical Director has worked with the Tulsa Fire Department to establish and maintain 7 ALS Engine Companys.

Personnel CertificationThe Office of the Medical Director is continually responsible for the certification and recertification of approximately 400 paramedics, 2400 EMT- Intermediates, EMT-Basics, First Responders, and 100 On-Line Medical Control Physicians.

The Office of the Medical Director has created and maintained a database to include all Paramedics, EMT-Basics, Firefighter/Paramedics and First Responders’ test results. The purchase of a Scantron machine that corrects all tests and gives several options on tracking the results has proved to be an invaluable tool. Having the process automated has allowed us to provide feedback to the test taker on the individual test question(s) they have missed, with additional information about the subject matter of the question(s).

Orientation AcademyParamedics entering the system as recent graduates or experienced paramedics new to the Emergency Medical Services Authority must meet rigorous requirements to become certified. New system paramedics are granted provisional certification and must function under another certified paramedic during the evaluation period. The standard provisional period is six months.

The Office of the Medical Director completed a total of 7 orientation academies. Each academy is an intense four-week course covering the Prehospital Operational Standards. The medics must complete the full academy successfully to be released to function independently as a medic in the EMSA system. Both EMSA and Firefighter paramedics attend the academies. Upon completion of the academy, each paramedic is given a 150 questions written examination, and practical examinations in trauma and advanced cardiac megacode.

Divert ReportThe Office of the Medical Director reports monthly on the number of patients who were diverted. These reports are distributed to the hospital administrators, nurse managers, EMSA Board of Trustees, and members of the Emergency Physicians Foundations in the Eastern and Western Divisions. Hospital diverts are a nation-wide problem which have been causing major problems in the treatment of patients. Our system is one of the few in the nation which has avoided major problems with hospital diversion due to a good working relationship with each emergency department and their physicians.

Clinical Quality Improvement ReportThe Office of the Medical Director has been instrumental in the development of a comprehensive clinical quality improvement mechanism. The addition of the MEDUSA System allows 100% tracking of all patient care forms and will allow the Office of the Medical Director a mechanism to track all medical procedures being done in the field. The CQI report identifies problem areas to be addressed with field personnel. This report tracks the percentage of trauma cases returned Code One to the emergency departments versus the number of those cases that meet “trauma alert” criteria in order to monitor rates of over/under-triage. Airway management skills and the success rate for IV’s and intubations are also monitored monthly.


[ 21 ]

FY 2008 Budget Income: Quality Assurance Fund $485,488

Expenses:

1. Salaries 323,665 2. Payroll Taxes 17,082 3. Employee Insurance and Benefits 29,114 4. Retirement 38,927 5. Books and Periodicals 2,400 6. Professional Liability Insurance 16,550 7. Dues and Memberships 3,000 8. Business, Travel, Meals and Meetings 11,000 9. Postage and Courier Service 1,250 10. Legal Fees 1,000 11. Supplies 8,000 12. Telephone 6,500 13. Professional Services and Training 1,500 14. Computer Upgrades/Equipment 9,500 15. Statistical Support for Clinical Research 4,000 16. Vehicle Allowance 12,000

Total Expences: $485,488

Approved by the Medical Control Board 5/9/07Approved by the Oklahoma City Council 6/5/07Approved by the Tulsa Council 5/31/07

Medical Control BoardFY 2008 Budget


[ 22 ]

Quality Assurance Fund of the Medical Control BoardBudget for Incremental Cost of ALS First Response – Western Division/OCFD

Year Ending June 30, 2008

FY 2008 Revenues: Reimbursement from Oklahoma City $43,778.38

Expenses:

Salaries 31,699.55 Payroll Taxes 2,852.42 Retirement 3,505.07 Insurance Benefits 5,721.34 Total Expences: $43,778.38

Approved by the Medical Control Board 5/9/07Approved by the Oklahoma City, City Council 6/5/07

Medical Control Board


[ 23 ]

Quality Assurance Fund of the Medical Control BoardBudget for Incremental Cost of ALS First Response – Eastern Division

Year Ending June 30, 2008

FY 2008 Revenues: Reimbursement from Tulsa $13,956.56 Expenses:

Salaries 10,105.10 Payroll Taxes 909.29 Retirement 1,117.34 Insurance Benefits 1,823.83 Total Expences: $13,955.56

Approved by the Medical Control Board 5/9/07Approved by the Tulsa City Council 5/31/07

Medical Control Board


[ 24 ]

Agency Candidates Average Test Passed Passed Passed Tested Score 1st Attempt 2nd Attempt 3rd Attempt

Bixby Fire Dept 18 85 18 N/A N/A

Edmond Fire Dept 27 95 27 N/A N/A

Mustang Fire Dept 6 86 6 N/A N/A

Oklahoma City Fire Dept 352 90 352 N/A N/A

Tulsa Fire Dept 254 88 239 8 N/A

Recertification of Fire Department/First Responders, Year 2007


[ 25 ]

Agency Candidates Average Test Passed Passed Passed Tested Score 1st Attempt 2nd Attempt 3rd Attempt

EMSA/Paramedic 68 85 62 4 2

EMSA/EMT 85 82 58 20 7

OCFD FF Recruit 15 87 15 N/A N/A

TFD Paramedic Recruit 7 89 7 N/A N/A

Testing Results for Orientation and Recruit Academies, 2007


[ 26 ]

Ag

ency

Ca

ndid

ates

Av

erag

e Te

st

Pass

ed

Pass

ed

Pass

ed

Faile

d to

pas

s

Te

sted

Sc

ore

1st A

ttem

pt

2nd

Atte

mpt

3r

d At

tem

pt

on 3

rd A

ttem

pt

EF

D P

aram

edic

15

88

15

N

/A

N/A

N

/A

EM

SA B

asic

EM

T’s

69

84

51

13

5 N

/A

EM

SA P

aram

edic

s 10

7 88

10

4 3

N/A

N

/A

O

CFD

Par

amed

ics

80

92

79

1 N

/A

N/A

T

FD P

aram

edic

s 16

89

15

1

N/A

N

/A

Recertification of EMT-Basics and Paramedics Year 2007Pre-hospital Operational Standards Results


[ 27 ]

Heart and Stroke Task Force

Oklahoma State Stroke System Advisory Committee (OSSAC)Marking his seventh year of service, Mr. T.J. Reginald, Director of Clinical Research and Development for the Office of the Medical Director continued to serve as Chairman of the Operation Stroke EMS Sub-Committee established by the American Heart Association.

Program OverviewOklahoma State Stroke Systems Advisory Committee (OSSSAC), formally known as Operation Stroke, is devised into 4 sub- committees: Medical, EMS, Rehab and Recovery, and Community Education. OSSSAC is an initiative of the American Heart Association working to reduce the devastating effects of stroke by:

• Increasing the percentage of people who know the warning signs of stroke;

• Increasing awareness of stroke as medical emergency; • Increasing the number of people who seek medical

care rapidly;• Assuring the best emergency medical response system

is available to treat and transport patients to medical care;

• Organizing the best in medical technology, diagnosis, treatment, care and rehabilitation to treat stroke patients, save lives, reduce disability and;

• Improve the quality of life for survivors.

Current SituationThere are two major categories of stroke, or “brain attack.” The majority of stroke patients fall victim to as ischemic stroke in which blood flow to the brain is disrupted by blood-vessel blockage. One approved method of treatment, although not universally accepted by the medical community, is Tissue Plasminogen Activator, or tPA, a drug that can dissolve the blood clots that commonly cause these blockages and restore blood flow to the brain. Prompt treatment with tPA can potentially minimize or prevent long-term neurological disability from stroke, such as impaired speech and loss of muscle control. But it is not without significant complications such as bleeding in the brain and must be administered within three hours of the onset of symptoms. After this time, tPA treatment is no longer effective for most patients and the risk of bleeding in the brain increases even more. The remaining 10 – 15 percent of strokes are classified as hemorrhagic strokes

in which a blood vessel in the brain bursts. In these cases, tPA should not be given to patients because the drug escalates the bleeding and worsens the condition.

Less than 5 percent of stroke patients currently receive tPA treatment for the following reasons:

• Most patients wait, on average 22 hours to get help• It has been reported that nationally, only 26 percent

of the general public can name one or more of the warning signs of stroke

• Medical professionals are reluctant to use tPA because of its risk and because it has not been used extensively.

New treatment methods for stroke are currently under investigation and since stroke is a time-sensitive condi-tion the value of organizing resources to ensure prompt treatment will be invaluable in the future.

accoMpliShMeNtS of 2007In the Eastern and Western Division Eight hospitals are maintaining Stroke Teams.

Stroke teaM• Members of the Stroke Team have a strong common

interest in treatment of acute stroke. The team comprises 2 parts: (1) the code team members, who respond to a code pager and deliver urgent treatment and (2) a task force that works daily to facilitate patient access to treatment.

• Usually, the code team consists of a neurologist or, in some cases, an ED physician, and a nurse. The task force, which is frequently larger, may include members from many disciplines—neurology, emergency medicine, radiology, and physical medicine and rehabilitation. Development of the team often requires early input from the hospital’s administration to enhance problem solving and integration between services

• To achieve maximal efficiency, the team must integrate itself with all services involved in the care of patients with acute stroke, which include the local community, emergency medical services (EMS), the emergency department (ED), computed tomography (CT) scanning, and pharmacy. The team educates the public and care providers about stroke warning signs and availability of stroke treatments, evaluates and streamlines services,


[ 28 ]

provides stroke treatment rapidly, and continuously monitors the efficacy of its work.

1st Annual statewide Stroke Conference: Extending Evidence Base Stroke Care to Rural Oklahoma

• This conference offered 8 hrs of CME and CEU. The conference was hosted by INTEGRIS Stroke Center: OSSSAC Medical Co Chair. Dr. Charles Morgan.

Advance Stroke Life Support (ASLS) CourseOffered by OU Medical Center. This class taught pre-hospital providers management techniques for the acute stroke patient. The 8 hr CME covered the Cinncinnati Prehospital Stroke Scale (CPSS) in conjunction with the Miami Emergency Neurologic Deficit exam (MEND) and focused the critical role the paramedic plays in the rapid evaluation and rapid transportation of a stroke patient to an appropriate medical facility; over 50 EMTs and paramedics attended, EMSA, OCFD, EFD, were all represented. The course was hosted by. OSSAC Medical Co- Chair. Dr. David Gordon.

Public EducationThe Community Education Sub-Committee focused the dissemination of Act FAST (Face, Arm, Speech, Time) message which also stressed the importance of calling 911 immediately at the first sign of a possible stroke. To date, over 2000 toolkits, available in both English and Spanish, distributed to community members, nurse educators, teachers, members of faith based organizations and many members of the Oklahoma State Legislature. Many media interviews took place and news releases appeared in print media statewide. Public interest in the Act FAST campaign has been over-whelming as well as gratifying. Already, one incident of a stroke being recognized in a restaurant by an individual who viewed the Act FAST video one day earlier has been reported.

Medical and EMS Sub – Committees of OSSSACIn March, 2007 the Oklahoma State Health Department in conjunction with the Medical and EMS Sub- Com-mittees of the Oklahoma State Stroke System Advisory Committee sent a survey out to all hospitals in the state to assess the hospitals stroke care capabilities. About 75 % of the hospitals responded to the survey and a

total of 16 hospitals have requested the assistance of OSS-SAC to help with the establishment of stroke protocols.

The Medical and Emergency Medical Services Sub-Committees combined into one committee to modify the existing Oklahoma Trauma Legislation to include rules governing stroke care. The proposed rule change should establish a state based stratification for hospitals reflecting their level of stroke care capacity. The rule change will also allow EMS personnel to bypass hospitals without stroke treatment capacity when transporting a suspected stroke patient. The rule change is expected to be in effect by June 2008.

EMS SYSTEM• In some cases transport systems have been slow to

change how they transport stroke patients to acute care facilities. This has not been the situation in our EMS System. Paramedics are a critical part of the stroke care because they are the first to recognize the stroke patient. While urgent transport is the goal because “Time is Brain”, more importantly, paramedics have been trained to transport the patient who meets the screening criteria for acute stroke to a hospital with Stroke Team capabilities. It is better to divert stroke patients to a more distant hospital for prompt evaluation and treatment, if appropriate, as opposed to being taken to the closest less appropriate hospital. The bypass idea remains a sensitive subject. We would much rather see every hospital able to treat stroke effectively. However, it was discovered during our survey that some hospitals were unable to organize an effective stroke-treatment protocol.

Proposed Projects for 2008• Establish and maintain a Stroke Registry as an

observational study examining treatments and outcomes

• Stroke Legislation to cover such topics like stroke task forces; stroke awareness days or months; stroke education; stroke plans; treatment centers

• Establish Oklahoma Stroke Partnership which is a coalition of stroke experts who collaborate to recommend and implement key strategies to reduce the burden of stroke in Oklahoma.

• The mission is to raise awareness of stroke, promote stroke prevention, and improve systems of stroke care throughout Oklahoma.


[ 29 ]

• The Oklahoma Stroke Partnership implements activities, projects, and programs which are spear-headed by three task groups on the following topic areas:

• Public Education • Continuous Quality Improvement • Epidemiology and Surveillance

• Advanced Stroke Life Support Courses for Hospital and Prehospital Providers, July 21st, 22nd, 2008, Enid Oklahoma.

• It is recommended that EMS personnel continue to initially perform the basic 3-step Cincinnati Pre-Hospital Stroke Scale (CPSS) and if time is available en route, it is recommended that EMS personnel perform the expanded Miami Emergency Neurologic Deficit (MEND) Exam that incorporates the Cincinnati Scale and components of the NIH Stroke Scale.

• Establishment and Designation Criteria for Stroke Centers

• Stroke Centers are centers specifically designated for the development of new approaches to diag-nose and treat stroke.

• Stroke Centers bring together physicians from multiple specialties including neurology, neuro-surgery, neuroradiology, internal medicine, and emergency medicine to provide comprehensive evaluation and management of patients with cerebrovascular diseases.

Long Term Objectives• Raise awareness and reduce disability and death from

stroke by 25% by 2010


[ 30 ]

Homeland Security

METROPOLITAN MEDICAL RESPONSE SYSTEMThe Medical Director continues to be active in the Metropolitan Medical Response System and is working with the Oklahoma State Department of Health in managing their CDC/HRSA Grants. Dr. Sacra sits on the CDC/HRSA Senior Advisory Council and they continue to meet quarterly. This Council is currently distributing funds throughout the state to better prepare the hospital and EMS communities to deal with disasters and acts of terrorism.

The development of an integrated and capable medical response system continued in 2007 through key partnerships with the Oklahoma State Department of Health, Oklahoma Office of Homeland Security, and the Oklahoma City and Tulsa City/County Health Departments. In Oklahoma City and Tulsa, Over $2 million dollars was received in 2007 to continue this system development through regional planning, communication system improvement, training and education, and medical volunteer coordination.

Regional planning is an on-going activity in the Oklahoma City and Tulsa areas. The concept of the Metropolitan Medical Response System has been expanded to Lawton and Southwestern Oklahoma with active regional planning addressing some of the chal-lenges faced in rural Oklahoma. Current issues include medical surge (caring for an overwhelming number of patients), pandemic flu planning, and hospital integration with the traditional response community.

Communications within the medical community is critical and efforts continued to improve the capabilities of the Medical Emergency Response Centers in Oklahoma City, Tulsa, and Lawton. The Oklahoma City Medical Emergency Response Center expanded and moved into the new Oklahoma City Regional Emergency Operations Center in 2007. The Western Division also is implementing and 800 MHz radio system to allow seamless communications with the Eastern Division and neighboring jurisdictions.

These system development and planning efforts were put to the test during two disasters in 2007. The first disaster, in January 2007, resulted from a significant ice and hail storm that affected most of Oklahoma,

and created severe hardships form extended power loss in Northeastern and Southeastern Oklahoma. The MMRS, in conjunction with OSDH provided response assistance in two key areas: Shelter operations in Northeast Oklahoma and support to McAlester Regional Hospital in Southeast Oklahoma. Medical Reserve Corps personnel, coordinated jointly between EMSA and the Tulsa City County Health Department, provided emergency medical staffing assistance to both regions. Oklahoma City and Tulsa were spared the power loss, but experienced significant EMS call volume increases and response challenges from icy roads.

The second incident, another ice storm, took full aim on both Oklahoma City and Tulsa in December 2007. Both cities were struck by a storm that created mas-sive limb destruction and widespread, long-term power outages. The incident required full MMRS activation and an active role for the Medical Director’s Office in response operations. Both the Tulsa and Oklahoma City Medical Emergency Response Centers were activated and staffed on a 24 hour basis to coordinate with each City’s EOC and address medical system issues such as hospital and EMS volume, patients at home with power-dependent medical devices, shelter populations, and an explosion in carbon monoxide poisoning incidents. Large shelters requiring medical support were established in both cities. The Medical Director’s Office provided both staffing and clinical oversight for these shelter operations. The Medical Reserve Corps provided over 700 hours or volunteer medical assistance in both Oklahoma City and Tulsa. The Medical Director authorized an innovative approach to the carbon mon-oxide patient volume by establishing specialized units in both cities to provide multiple patient transport capability and free up EMS units for other patients created by the incident.

The Medical Director continues to work in both Divisions to ensure Homeland Security and coordinate EMS and medical system response into community planning and funding. This is seen as an important role for the Office of the Medical Director. During 2007, the Medical Director continued to serve on both the Oklahoma State CDC/HRSA Joint Advisory Committee and the City of Tulsa’s Mayor’s Homeland Security Task Force.


[ 31 ]

Serving on Tulsa Mayor Kathy Taylor’s Homeland Security Task Force, Dr. Sacra continues to work with other Task Force members to consider issues related to the safety of Tulsa area citizens from disasters or acts of terrorism. The Task Force meets monthly and includes wide representation from both the city and county in the areas of law enforcement, fire, emergency medical services, MMRS, public works, public health, telecommunications, the airport authority, and others. Members of the group regularly provide updates on security issues relative to their respective areas and regional training opportunities are shared.

The Task Force follows pending Federal legislation as well as State and Federal grant opportunities and works cooperatively to prioritize the needs of the city and county for grant applications. An important by-product of the Task Force is the collegial relationships established across departmental and city/county lines. The Task Force has worked closely together in exercise scenarios including multiple exercises testing the capabilities of the community’s response system and identifying opportunities for improvements. Additionally, the Task Force is involved in developing a National Incident Management System, Incident Management Team. This team is designed to be a canned major incident management program that focuses on a unified approach to all significant issues. The group’s ability to communicate and work together ensured success both in formal training, exercise drills and in times of disaster.

The Medical Director continues to work with OU Health Sciences Center to develop the Oklahoma Institute for Disaster and Emergency Medicine to provide educational programs to train and educate physicians, nurses, paramedics and other “First Responders”. This program has the potential of being one of the finest regional training centers in the nation in dealing with terrorism and disaster response. During 2007 the Schustermann Center in Tulsa obtained certification as a Regional Training Center for the disaster medical training program called Basic Disaster Life Support (BDLS). The Institute should obtain Advanced Disaster Life Support status in early 2008. Several BDLS courses were held in 2007 with dozens of BDLS students receiving their certifications. Eight BLDS Courses and four ADLS classes are

planned for Oklahoma City and Tulsa in the first half of 2008

The Medical Director’s Office continues to be actively involved with the growth of the Oklahoma Medical Reserve Corps (MRC). The MRC began in Tulsa in 2003 to recruit, train, and deploy medical volunteers for a response to a disaster or public health emergency. The program has grown statewide with over 4,000 volunteers currently in the database. The value and importance of having a pre-credentialed was clearly demonstrated during the ice storms in January and December 2007.

The Medical Directors Office continues efforts in regional planning, equipment acquisition, trauma system development, communication improvement, and education delivery will help ensure a rapid and effective response to any future medical disaster or public health emergency. The MMRS program, and its various preparedness components, has demonstrated the value of a system-wide approach to medical and public health disaster response. This system includes key partners in public health and the first response agencies that are dedicated to addressing the medical and public health needs of the community during a time of crisis.

MEDICAL RESERVE CORPSThe Oklahoma Medical Reserve Corps (OKMRC) provides medical and public health professionals as well as dedicated citizens an organized system for volunteer-ing during a large-scale emergency such as a pandemic, chemical spill or act of terrorism. In addition, OKMRC volunteers work to improve the overall health and well-being of their communities by engaging in public health initiatives throughout the year. The OKMRC is comprised of over 4,000 volunteers, supporting local communities across the state of Oklahoma.

OKMRC receives annual contractual funding from the Oklahoma State Department of Health and is housed in the Emergency Medical Services Authority (EMSA) under the legal body of the EMSA Trust. The Oklahoma Medical Reserve Corps has one full-time Administrator, one part-time Education Coordinator, and three local Coordinators housed in Tulsa, Creek and Oklahoma county health departments.


[ 32 ]

The OKMRC has an active and diverse group of partners including: Oklahoma State Department of Health, Tulsa City–County Health Department, Oklahoma City-County Health Department, additional local County Health Departments, Oklahoma Office of Homeland Security, American Red Cross, Baptist General Convention, United Way, Salvation Army, OK-1 Disaster Medical Assistance Team (DMAT), local and state Emergency Management, and others who make up the Statewide Steering Committee. This committee meets quarterly to provide leadership and direction for the OKMRC program.

Administrative milestones accomplished in 2007 include: the design and production of a new OKMRC volunteer identification system, the in-house ability to process Oklahoma State Bureau of Investigations Background Checks, the purchase and implementation of a Rapid Notify advanced calling system and the development of OKMRC Policies and Procedures. Also during 2007, the Tulsa Medical Reserve Corps began the initial phase of an MRC Public Engagement Campaign. This project included research and focus groups on local volunteer participation, community engagement standards and implementation suggestions. As a result phase two, which will include a 20-second television commercial, is set to launch in April 2008.The OKMRC has also served as a resource for educational and training opportunities for volunteers across the state. During 2007, the OKMRC training committee developed a statewide training matrix modeled from guidelines established by the National Medical Reserve Corps program. This matrix covers core competencies for individual volunteers and is based upon the needs of Oklahoma communities. The curriculum template is a multi-tiered structure with different levels of training: Tier I identifies four basic trainings which are appropriate for all volunteers and are required to be completed within the first year of joining the MRC. Tier II identifies training which is desirable for all volunteers but not required and Tier III is agency-or deployment-specific training which each community can tailor to their unique needs. Tier IV includes disaster preparedness education which may be professional discipline specific. In 2007, Oklahoma experienced three federally declared disasters. OKMRC volunteers provided much needed assistance, at the request of response agencies across the state, during those disasters:

When ice storms crippled much of Eastern Oklahoma in January 2007, the OKMRC was activated. The Oklahoma City MRC coordinated response efforts for the McAlester Hospital deployment. An MRC call center was set up at EMSA Headquarters to field calls and provide information to volunteers willing to assist. Over the course of six days, 10 MRC nurses supple-mented hospital staffing needs at the Regional Health Center and assisted clinical staff with operational duties. The Tulsa MRC coordinated response efforts in Mayes County and set up a call center located in the Tulsa Health Department. Volunteers were deployed to provide medical assessments and assistance in nine shel-ters located in and around Mayes County.

In July 2007, torrential rainfall descended on the north-eastern Oklahoma town of Miami. The OKMRC State Animal Response Team (SART) was deployed three times to address the special needs of the more than 200 displaced animals. The OKMRC SART team supplied medication, building materials, extra cages, cleaning products and veterinarian assistance to area animal shelters and clinics.

December 2007 ice storms caused the largest power outage the state of Oklahoma had ever seen. The OKMRC utilized its newly purchased Rapid Notify calling system to alert volunteers in the Tulsa and Oklahoma City area of an MRC activation. Call Centers were established in both Oklahoma City and Tulsa to coordinate, schedule and track OKMRC volunteers. In Tulsa, 30 MRC volunteers assisted public health in providing medical support for three large shelters over a six-day operation. OKMRC volunteers also supported shelters opened in Sapulpa, Bristow and Drumright. In Oklahoma City, more than 60 OKMRC volunteers worked in unison with other response agencies to provide medical assistance in s helters for a 10-day period.

Oklahoma Medical Reserve Corps volunteers, despite being victims themselves, gave when their community needed them most. As individual citizens, they are car-ing, capable and ready. As a unified organization the OKMRC is committed to building strong, healthy and prepared communities.


[ 33 ]

Prehospital Operational StandardsCY 2007 Revisions and Additions

Protocol I.3 Controlled SubstancesThe Medical Control Board approved revisions to ensure compliance with current DEA regulations.

Protocol I.4: Categorization of Hospitals and Destination ProceduresRevisions were made to the destination of Priority 2 Adult Trauma patients in the Eastern Division to include OSUMC.

The Medical Control Board approved all Priority 2 pediatric trauma patients in the Western Division be transported to Oklahoma Medical Center/Presbyterian Tower. Protocol II.33: BurnsThe Medical Control Board approved the revisions to Protocol II.33 to reflect the American College of Surgeons recommended changes as identifiers for patients transported to burn centers to read “partial and full thickness”.

Protocol III.18: Neonatal ResuscitationThe Medical Control Board approved changes to the verbiage to include “Re-intubation followed by suctioning no longer than 3-5 seconds. If baby is severely depressed with heart rate < 60 b/m, positive pressure ventilation may be needed through a second endotracheal tube after suctioning is performed”. The verbiage was changed to reflect correct usage of the Meconium Aspirator.

Protocol III.38: Use of Meconium Aspirator The Medical Control Board approved to add the Meconium Aspirator to the arsenal of equipment used by the paramedics. This device will allow paramedics to attach the suction unit tubing to the intubation tube for ease of removing meconium from the newborn.


[ 34 ]

Cardiac Arrest Registry

The outcome for cardiac arrest is dependent on critical interventions such as, early defibrillation, effective chest compressions, assisted ventilation, and advanced cardiac life support. To improve clinical outcomes for cardiac arrest, a thorough evaluation of the contribution of all of interventions is critical. We are fortunate that our evaluation has not been hindered by the lack of accurate data on treatment and the outcome of care, in part, because of the uniformity in defining and reporting our results. Hypothetical survival curves suggest that the ability to resuscitate is a function of time, type, and sequence of therapy. Our survival rates seem to be im-proving mostly because CPR is started early, i.e., bystander CPR, initiated by dispatcher-assisted CPR instruction, which we speculate permits definitive procedures including defibrillation, medications, and intubation, to be more effective.

What has improved our situation in comparison to so many other EMS systems is the strict adherence of uniform reporting for adult and pediatric resuscitation and education system-wide so the individual provider has a greater understanding and appreciation of the essential elements of resuscitation.

The Uniform collection and tracking of data facilitate continuous quality improvement within our EMS system and the communities we serve.

Due to on-going changes in resuscitation medicine, we continue to revise our templates which include practical operational definitions. Constant revisions to our own practice of resuscitation should lead to better and more accurate reporting of cardiac arrests, a greater understanding as to the elements of resuscitation, and, most important, a continual progression to improve the outcome from cardiac arrest by better understanding resuscitation attempts in both adults and children. Cardiac ArrestThe emergency management of this devastating event remains one of the core purposes of any EMS system. The cornerstone to providing optimal care to these patients is timely and effective interventions from the entire community (“Chain of Survival”). From the bystander or family member calling for help, to the provision of bystander CPR and use of Automated External Defibrillator (AED) until the arrival of

paramedics, all links must come together to achieve the highest possible survival for sudden cardiac arrest. More people can survive sudden cardiac arrest if a sequence of events occurs as rapidly as possible. This sequence is 1) recognition of early warning so there is a greater potential for beneficial results; 2) activation of the emergency medical systems; 3) basic cardiopulmonary resuscitation; 4) defibrillation; 5) intubation; 6) intravenous administration of medications.

Data CollectionThe collection and analysis of data abstracted from prehospital run reports is the current method used for evaluating prehospital cardiac arrests in our system. To ensure the quality of cardiac arrest data, the same information must be documented on each report and then recorded accurately on the abstract form. Uniform reporting of statistics, also known as the Utstein Style, is the model we use in reporting information from resuscitations in order to ensure consistency, uniform definitions of individual clinical items, and outcomes.

Trained personnel from the Office of the Medical Director collect cardiac arrest data from EMS run sheets and/or electronic databases. This information once collected is organized into an abstracted data collection form and entered into a customized computer software system.

From this information we can calculate numerous different outcomes since multiple combinations of denominators and numerators are possible. Most of our outcomes are reported as rates or percentages, for example, the rate of successful admissions per resuscitations attempted. We report the persons discharged alive divided by the number of persons with witnessed cardiac arrest in ventricular fibrillation of cardiac etiology. This single calculation is the most practical for comparing our system to others.

Through the use of uniform terminology, data collection and common reporting approaches, we can focus our efforts on the problem of cardiac arrest and which factors improve survival and reduce mortality. As a result of continual studies and observations, we will be able to determine the therapeutic effects of certain medications, different system organizational approaches such as system wide first response advanced life support,


[ 35 ]

innovative interventions such as public access defibrillation, and more widespread public education about early recognition of cardiac pain and cardiac arrest.

By studying the many aspects of the practice of resuscitation, including the outcome of the patient, we continue to drive the system to achieve optimal perfor-mance in the area of cardiac arrest. The citizens of the greater Tulsa and Oklahoma City area can be proud of their EMS system and the professionals that work within the system.

In the Western Division January 1, 2007 to December 31, 2007Of the 591 cardiac arrests for which resuscitation was attempted, 380 (64%) met entry criteria as primary cardiac events [An arrest is presumed to be of cardiac etiology unless it is known or likely to have been caused by trauma, submersion, drug overdose, asphyxia, exsanguination, or any other non-cardiac cause as best determined by rescuers, hospital diagnosis, or Medical Examiner ruling]. None of the 380 cases lack hospital follow-up. 343 of the 380 cases represented non-EMS witnessed events. The overall survival rate for all cardiac arrest was 11%. 197 patients (57%, 197 / 343, non-EMS-witnessed events) were found in asystole (flat line ECG tracing). From this group, 20 patients were admitted to the hospital after a return of spontaneous circulation with 4 patients living to discharge. 34 patients (10%, 34 / 343, non-EMS-witnessed events) patients were found in pulseless electrical activity. From this group 8 patients were admitted to the hospital after a return of spontaneous circulation with 2 patients living to discharge. 112 patients (33%, 112 / 343, non-EMS-witnessed) were found in ventricular fibrillation. From this group, 53 patients were admitted to the hospital after return of spontaneous circulation with 30 patients surviving to discharge. Survival from witnessed ventricular fibrillation with bystander CPR was 35%, (18 / 52).

DiscussionThe rhythm on arrival was ventricular fibrillation in 33% (112) patients and asystole/PEA in 67% (231) patients. Overall 36 patients survived to discharge. 6 patients that survived to hospital discharge were from the asystole/PEA group. Non-ventricular rhythms

grouped under designation asystole/PEA are being reported with greater frequency by advanced life support providers as the first electrocardiographic find-ings in persons with prehospital cardiopulmonary arrest. It is not clear whether such patients experienced VF or VT that ultimately deteriorated to asystole or PEA or whether asystole or PEA was the primary arrhythmia responsible for cardiovascular collapse. In either case, non-ventricular rhythm groups appear to represent the majority of patients in whom prehospital resuscitation is attempted. Experience with asystole and PEA arrest rhythms has yielded a uniformly dismal outcome when these patients are considered separately and an arrest rhythm other that VF is generally believed to be predictive of death despite current advanced interventional efforts. Survival rates are low, 3% or less in both divisions. Under well defined circumstances, it has become necessary to discontinue resuscitative efforts in the prehospital setting for asystole or PEA in patients who do not respond to an adequate trial of resuscitation therapy.

ResultsOverall survival, (defined as discharge from the hospital), in the Western Division improved to 11% in Year 2007 in comparison to Year 2006, in which the overall survival rate was 6%. Survival from bystander witnessed ar-rest with the initial rhythm ventricular fibrillation with bystander CPR, (WitVFCPR) 35%, was greater than large urban cities and above average to cities of comparable size. In the subgroup WitVFCPR, survival in 2007 was 35% compared to 18% in 2006. The survival rate of 35% for (WitVFCPR) is excellent.

In the Eastern Division January 1, 2007 to December 31, 2007Of the 397 cardiac arrests for which resuscitation was attempted, 231 (58%) met entry criteria as primary cardiac events [An arrest is presumed to be of cardiac etiology unless it is known or likely to have been caused by trauma, submersion, drug overdose, asphyxia, exsanguination, or any other non-cardiac cause as best determined by rescuers, hospital diagnosis, or Medical Examiner ruling]. None of the 231 cases lack follow-up. 211 of the 231 cases represented non-EMS witnessed events. The overall survival rate for all cardiac arrests was 12%. 114 patients (54%, 114 / 211, non-EMS-witnessed events) were found in asystole (flat line


[ 36 ]

ECG tracing). From this group, 16 patients were admitted to the hospital after a return of spontaneous circulation with 1 surviving to discharge. 31 patients (15%, 31 / 211, non-EMS-witnessed events) were found in pulseless electrical activity. From this group 9 patients were admitted to the hospital after a return of spontaneous circulation with 3 patients surviving to discharge. 66 patients (31%, 66 / 211, non-EMS- witnessed) were found in ventricular fibrillation. From this group, 39 patients were admitted to the hospital after return of spontaneous circulation with 19 patients surviving to discharge. Survival from witnessed ventricular fibrillation with bystander CPR was 33%, (8 / 24).

DiscussionThe rhythm on arrival was ventricular fibrillation in 31% (66) patients and asystole/PEA in 69% (145) patients. Overall 23 patients survived to discharge. 4 patients that survived to hospital discharge were from the asystole/PEA group. Non-ventricular rhythms grouped under designation asystole/PEA are being reported with greater frequency by advanced life support providers as the first electrocardiographic findings in persons with prehospital cardiopulmonary arrest. It is not clear whether such patients experienced VF or VT that ultimately deteriorated to asystole or PEA or whether asystole or PEA was the primary arrhythmia responsible for cardiovascular collapse. In either case, non-ventricular rhythm groups appear to represent the majority of patients in whom prehospital resuscitation is attempted. Experience with asystole and PEA arrest rhythms has yielded a uniformly dismal outcome when these patients are considered separately and an arrest rhythm other that VF is generally believed to be predictive of death despite current advanced interventional efforts. Survival rates are low, 3% or less in both divisions. Under well defined circumstances, it has become necessary to discontinue resuscitative efforts in the prehospital setting for asystole or PEA in patients who do not respond to an adequate trial of resuscitation therapy.

ResultsOverall survival, (defined as discharge from the hospital), in the Eastern Division was better in Year 2007, 12%, in comparison to Year 2006, in which the overall survival

rate was 9%. Survival from bystander witnessed arrest with the initial rhythm ventricular fibrillation with bystander CPR, (WitVFCPR) 33%, was greater than large urban cities and greater than cities of comparable size. In the subgroup WitVFCPR, survival in 2007 was 33%, which was slightly higher compared to 32% in 2006. The survival rate of 33% for (WitVFCPR) is excellent.


[ 37 ]

0

100

200

300

400

500

Choking

Drowning

Sepsis

Liver Disease

Diabetes

Metabolic

Hanging

End-Stage Renal Disease

Intoxication

Intracranial Event

Trauma

SIDS Exsanguination

Cancer

Drug Ingestion

Hypoxia

Acute Cardiac Events

64% 380

14% 53 6%

33 3% 20

3% 17

3% 16

2% 13

2% 12

1% 6

<1% 5

<1% 5

<1% 5

<1% 4

<1% 3

<1% 3

<1% 2

<1% 2

Smoke Inalation

Pneumonia

<1% 2

<1% 2

Complications/HIV

<1% 2

Cardiomyopathy

Heart Transplant

Hepatitis

Acute Abdonmen/Peritotontis

Hypothermia

<1% 1

<1% 1

<1% 1

<1% 1

<1% 1

Pulmonary Embolus

<1% 1

Western DivisionPrecipitating EventTotal Cases: 591

50

0

150

100

250

200

300

350

Smoke Inhalation

Pneumonia

SepsisChoking

Intoxication

Exsanguination

SIDSCancer

Trauma

Hypoxia

Acute Cardiac Events

58%231

12%46

Drug Ingestion

8%33 4%

143%10

3%10

2%6

2%6

2%6

1%5

1%5

1%4

Drowning

1%4

Liver Disease

1%4

Metabolic

1%3

CO Poisoning

<1%2

Hyperthermia

<1%1

End-Stage Renal Disease

<1%1

Diabetes

<1%1

Electrocution

<1%1

Excited Dellrium Syndrome

<1%1

Auto Immune Disorder

<1%1

Muscular Dystrophy

<1%1

Complications/HIV

<1%1

Eastern DivisionPrecipitating EventTotal Cases: 397

Cardiac Arrest Registry - 2007


[ 38 ]

Western DivisionSite of Cardiac Arrest Total Cases: 591

0

100

200

300

400

500

68% 384

16% 96

7% 41

4% 26

2% 14

2% 9

1% 8

1% 8

Workplace

Other Dr. Office

<1% 4 Jail

<1% 1 Rehab. Ctr.

Ambulance

Street

Public Places

Nursing Home

Home

50

0

100

150

200

250

300

350

Ambulance

Workplace

Other Dr. Office

Public Places

Street

Nursing Home

Home

68%272

14% 57

6% 22 3%

12 4% 14

2% 8

2% 7

1% 4

Rehab. Ctr.

Mass Gathering

<1% 1

<1% 1

Eastern DivisionSite of Cardiac Arrest Total Cases: 397


[ 39 ]

0

20

40

60

80

100

91-99 100+

71-80 81-90

61-70

51-60 31-40

41-50 Unknown

18-30

3 5 8

46

57

71 72

64

16 1

0

20

40

60

80

100

91-99 100+

71-80 81-90

61-70 51-60

31-40 41-50

Unknown

18-30

3 2 8

22

37 45

51

36

7 0

Western DivisionCardiac Arrests Yr 2007, Comparison by AgeEtiology: Acute Cardiac Event Average Age: 67Total Cases: 343, (Non-EMS-Witnessed)

Eastern DivisionCardiac Arrests Yr 2007, Comparison by AgeEtiology: Acute Cardiac Event Average Age: 67Total Cases: 211, (Non-EMS-Witnessed)


[ 40 ]

Western Division Yr. - 2007Comparison by Sex

Western DivisionCardiac Arrests: 343Etiology: Acute Cardiac EventNon-EMS- Witnessed

Etiology: Acute Cardiac Event

Eastern DivisionCardiac Arrests: 211Etiology: Acute Cardiac Event

Male 59.2%

Male 62.1%

Female 40.8%

Female 37.9%

140

80

203

131


[ 41 ]

Cardiac Arrest Registry - 2007Etiology: Acute Cardiac Event, EMS Witnessed Arrests ExcludedInitial Rhythm Upon ArrivalTotal Cases: 554

Asystole57.4%Asystole

54.0%

31

114

Eastern Division Western DivisionVF

31.3%

PEA14.7%

PEA9.9%

VF32.7%

112

34

19766

Etiology: Acute Cardiac EventWitnessed/Unwitnessed ArrestsTotal Cases: 611

Bystander-witnessed40.8%Unwitnessed

49.4%

97

114

Eastern Division Western Division

EMS-Witnessed8.7%

Bystander-witnessed42.0%

Unwitnessed49.5%

EMS-Witnessed9.7%

2037

188

155


[ 42 ]

Cardiac Arrest Registry – Year 2005, 2006, 2007Bystander CPR

% with Bystander CPR Eastern (%) Eastern (%) Eastern (%) Western (%) Western (%) Western (%) 2005 2006 2007 2005 2006 2007

Total Primary 55 43 45 52 41 48 Cardiac Arrests

Bystander Witnessed 64 56 49 42 52 55 Cardiac Arrests

Unwitnessed 44 32 41 57 31 41 Cardiac Arrests

Overall Cardiopulmonary resuscitation (CPR) by bystanders was not as good from 2005 to 2007. Still more than half of sudden cardiac arrest victims did not receive CPR befor EMS arrival.

Cardiac Arrest Registry – Year 2007Comparison of Outcomes

% Survival Eastern % Western %

Overall 12 11

Bystander Witnessed 16 19

Unwitnessed 6 4

Bystander Witnessed 27 32 VF/VT

Bystander Witnessed 33 35 VF/VT/CPR

Events Witnessed by a Bystander:

In the Eastern Division 97 of 211 cardiac arrest events were witnessed. Sixteen of those 97 patients survived to discharge (16%). In the Western Division, 155 of 343 cardiac arrest events were witnessed with 29 of the 155 patients surviving to discharge, (19%). In the Eastern Division, of the 114 unwitnessed cardiac arrest events only 7 patients survived to discharged, (6%). In the Western Division, of the 188 patients whose cardiac arrest was not witnessed, only 7 patients survived, (4%). Overall 252 of the 554 (45%) cardiac arrest events were witnessed of those witnessed 45 (18%) survived to hospital discharge, while only 14 (5%) patients of the 302 patients whose cardiac arrest was unwitnessed survived to discharge. This evaluation indicated that survival after unwitnessed out-of-hospital cardiac arrest is unlikely. Withdrawal of resuscitation should be considered in an adult victim of unwitnessed cardiac arrest if found in asystole or PEA and the arrest is of obvious cardiac origin. For Bystander Witnessed VF/VT/CPR there was an insignificant difference in survival when comparing the two divisions.


[ 43 ]

Cardiac Arrest Registry - 2007Cardiac Arrest Statistical Summary (Acute Cardiac Event) Western Division 2007

Count Percent Events 591 100 All Cardiac Events 380 64 AC Events 58 15 Resuscitations Halted in Field After Trial Advanced Life Support 42 11 AC Events Discharged 155 41 AC Events Witnessed (Bystander) 56 36 AC Events Witnessed (Bystander) ROSC in Field 29 19 AC Events Witnessed (Bystander) Discharged 37 10 AC Events Witnessed by (EMS) 13 35 AC Events Witnessed by (EMS) ROSC in Field 6 16 AC Events Witnessed by (EMS) Discharged 192 51 AC Events Witnessed (Bystander and EMS) 69 36 AC Events Witnessed (Bystander and EMS) ROSC in Field 35 18 AC Events Witnessed (Bystander and EMS) Discharged 82 22 AC Events Witnessed (Bystander) - VF/VT 41 50 AC Events Witnessed (Bystander) - VF/VT ROSC in Field 26 32 AC Events Witnessed (Bystander) - VF/VT Dischaarged 92 24 AC Events Witnessed (Bystander and EMS) - VF/VT 48 52 AC Events Witnessed (Bystander and EMS) - VF/VT ROSC in Field 31 34 AC Events Witnessed (Bystander and EMS) - VF/VT Discharged 52 14 AC Events Witnessed (Bystander) - VF/VT and CPR 27 52 AC Events Witnessed (Bystander) - VF/VT and CPR/ROSC in Field 18 35 AC Events Witnessed (Bystander) - VF/VT and CPR/Discharged 34 9 AC Events Witnessed (Bystander) - CPR - Non VF/VT 9 27 AC Events Witnessed (Bystander) - CPR - Non VF/VT ROSC in Field 3 9 AC Events Witnessed (Bystander) - CPR - Non VF/VT/Discharged 188 49 AC Events Not Witnessed 28 15 AC Events Not Witnessed/ROSC in Field 7 4 AC Events Not Witnessed/Discharged 97 26 AC Events ROSC in Field 39 40 AC Events ROSC in Field/Discharged 17 5 AC Events ROSC in ED 2 12 AC Events ROSC in ED/Discharged 197 52 AC Events (Non-EMS Witnessed) Initial Rhythm Asystole 66 34 AC Events (Non-EMS Witnessed) Initial Rhythm Asystole/ROSC in Field 4 2 AC Events (Non-EMS Witnessed) Initial Rhythm Asystole Discharged 34 9 AC Events (Non-EMS Witnessed) Initial Rhythm PEA 11 32 AC Events (Non-EMS Witnessed) Initial Rhythm PEA/ROSC in Field 2 6 AC Events (Non-EMS Witnessed) Initial Rhythm PEA/Discharged 30 8 AC Events (Unwitnessed) Initial Rhythm VF/VT 6 20 AC Events (Unwitnessed) Initial Rhythm VF/VT ROSC in Field 4 13 AC Events ( Unwitnessed) Initial Rhythm VF/VT Discharged


[ 44 ]

Cardiac Arrest Registry - 2007Cardiac Arrest Statistical Summary (Acute Cardiac Event) Eastern Division 2007

Count Percent Events 397 100 All Cardiac Events 231 58 AC Events 58 25 Resuscitations Halted in Field After Trial Advanced Life Support 27 12 AC Events Discharged 97 42 AC Events Witnessed (Bystander) 45 46 AC Events Witnessed (Bystander) ROSC in Field 16 16 AC Events Witnessed (Bystander) Discharged 20 9 AC Events Witnessed by (EMS) 9 45 AC Events Witnessed by (EMS) ROSC in Field 4 20 AC Events Witnessed by (EMS) Discharged 117 51 AC Events Witnessed (Bystander and EMS) 54 46 AC Events Witnessed (Bystander and EMS) ROSC in Field 20 17 AC Events Witnessed (Bystander and EMS) Discharged 45 19 AC Events Witnessed (Bystander) - VF/VT 27 60 AC Events Witnessed (Bystander) - VF/VT ROSC in Field 12 27 AC Events Witnessed (Bystander) - VF/VT Discharged 52 23 AC Events Witnessed (Bystander and EMS) - VF/VT 31 60 AC Events Witnessed (Bystander and EMS) - VF/VT ROSC in Field 16 31 AC Events Witnessed (Bystander and EMS) - VF/VT Discharged 24 10 AC Events Witnessed (Bystander) - VF/VT and CPR 18 75 AC Events Witnessed (Bystander) - VF/VT and CPR/ROSC in Field 8 33 AC Events Witnessed (Bystander) - VF/VT and CPR/Discharged 24 10 AC Events Witnessed (Bystander) - CPR - Non VF/VT 7 29 AC Events Witnessed (Bystander) - CPR - Non VF/VT/ROSC in Field 3 13 AC Events Witnessed (Bystander) - CPR - Non VF/VT/Discharged 114 49 AC Events Not Witnessed 32 28 AC Events Not Witnessed/ROSC in Field 7 6 AC Events Not Witnessed/Discharged 86 37 AC Events ROSC in Field 27 31 AC Events ROSC in Field/Discharged 10 4 AC Events ROSC in ED 0 0 AC Events ROSC in ED/Discharged 114 49 AC Events (Non - EMS Witnessed) Initial Rhythm Asystole 48 42 AC Events (Non - EMS Witnessed) Initial Rhythm Asystole/ROSC in Field 1 1 AC Events (Non - EMS Witnessed) Initial Rhythm Asystole/Discharged 31 13 AC Events (Non - EMS Witnessed) Initial Rhythm PEA 13 42 AC Events (Non - EMS Witnessed) Initial Rhythm PEA/ROSC in Field 3 10 AC Events (Non - EMS Witnessed) Initial Rhythm PEA/Discharged 21 9 AC Events (Unwitnessed) Initial rhythm VF/VT 12 57 AC Events (Unwitnessed) Initial rhythm VF/VT ROSC in Field 7 33 AC Events (Unwitnessed) Initial rhythm VF/VT


[ 45 ]

Cardiac Arrest Registry - 2007Utstein Report – Western DivisionShowing Data on Cardiac Arrests in Resuscitation Attempted in 591 Patients

Utstein Style Template Showing Data on Cardiac Arrests in Resuscitation Attempted in 591 PatientsWestern Division, 2007

N = 591

n = 380n = 211

n = 188Bystander CPR, n = 78

n = 155Bystander CPR, n = 86 n = 37

AsystoleN = 197

VFn = 112

PEAn = 34

n = 19

n = 84n = 259

n = 58

n = 65

n = 29 n = 36

n = 23n = 13 n = 1

n = 5 n = 9

n = 3 n = 6


[ 46 ]

Cardiac Arrest Registry - 2007Utstein Report – Eastern DivisionBeginning Date: 01/01/07Ending Date: 12/31/07

Utstein Style Template Showing Data on Cardiac Arrests in Resuscitation Attempted in 397 PatientsEastern Division, 2007

N = 397

n = 231n = 166

n = 114Bystander CPR, n = 47

n = 97Bystander CPR, n = 48 n = 20

AsystoleN = 114

VFn = 66

PEAn = 31

n = 19

n = 77n = 134

n = 38

n = 58

n = 35 n = 23

n = 11n = 9 n = 0

n = 2 n = 7

n = 3 n = 4


[ 47 ]

Difference in Survival between the Eastern and Western Divisions

There is only a slight variability in survival, particularly for Bystander Witnessed Arrest/VF/CPR, in Eastern Division of 33% and Western Division of 35%, which may be explained by demographics, protocols, study methodologies, terminology and case definitions, which are consistent across the two divisions.

There are several ways to approach the question as to any difference in survival between the Eastern and Western Divisions. While the same protocols are in place in both divisions, there may be some differences in time of spe-cific therapies brought to the resuscitation, specifically, CPR, defibrillation, IV medications and endotracheal intubation. It may be necessary to look at the differenc-es in the small subset of surviving patients to determine the answer.

Both systems have increased the number of paramed-ics with the largest increase in paramedics occurring in the Western Division. While adding more paramed-ics may have contributed to improved cardiac arrest survival rates for 2007, this one aspect alone cannot be solely contributed to an overall improvement in survival. Other features of system design, based on actual experi-ence and careful analysis, should be considered.

In the end, the number in the survival patient subset may be so small that the percentages may vary widely from year to year. Therefore statistics have been captured for the previous seven years and are currently being ana-lyzed to detemine the differences in survival.

Future Study:

A joint clinical research project between the Office of the Medical Director and the Oklahoma Institute for Disaster and Emergency Medicine has been designed to determine if there are statistically significant factors playing a role in determining survival to discharge from cardiac arrest in the Regulated Service Area. Compo-nents of the study to be performed in 2008 will include:

• A comparison of the last seven year’s results for Acute Cardiac Events between the two Divisions;

• A comparison of certain performance standards such as number of paramedics, response times and time to first shock; and

• A separate analysis comparing the demograph-ics and performance standards between the subset of survivors versus non-survivors.

The following table illustrates an example of the type of comparisons that the Cardiac Arrest Registry is capable of generating for the separate Divisions. Although the seven year average is similar for both Divisions, there are wide variations in results reflected in certain years.


[ 48 ]

Cardiac Arrest Registry - 2007

Division %BystanderCPR %Bystander %Bystander %Bystander %Bystander (ACEvent) WitnessedVF WitnessedVF WitnessedVF/CPR WitnessedVF/CPR 2000 (ACEvent)2000 (ACEvent)2000, (ACEvent)2000, (ACEvent)2000, ROSC Discharged ROSC DischargedEastern 33% 38% 20% 44% 23%Western 36% 41% 19% 43% 24%Division %BystanderCPR %Bystander %Bystander %Bystander %Bystander (ACEvent) WitnessedVF WitnessedVF WitnessedVF/CPR WitnessedVF/CPR 2001 (ACEvent)2001, (ACEvent)2001, (ACEvent)2001, (ACEvent)2001, ROSC Discharged ROSC DischargedEastern 30% 48% 27% 44% 20%Western 32% 49% 27% 56% 41%

Division %BystanderCPR %Bystander %Bystander %Bystander %Bystander (ACEvent) WitnessedVF WitnessedVF WitnessedVF/CPR WitnessedVF/CPR 2002 (ACEvent)2002, (ACEvent)2002, (ACEvent)2002, (ACEvent)2002, ROSC Discharged ROSC DischargedEastern 33% 38% 17% 48% 24%Western 39% 35% 14% 37% 18%Division %BystanderCPR %Bystander %Bystander %Bystander %Bystander (ACEvent) WitnessedVF WitnessedVF WitnessedVF/CPR WitnessedVF/CPR 2003 (ACEvent)2003, (ACEvent)2003, (ACEvent)2003, (ACEvent)2003, ROSC Discharged ROSC DischargedEastern 35% 59% 33% 81% 62%Western 41% 37 17% 44% 27%

Division %BystanderCPR %Bystander %Bystander %Bystander %Bystander (ACEvent) WitnessedVF WitnessedVF WitnessedVF/CPR WitnessedVF/CPR 2004 (ACEvent)2004, (ACEvent)2004, (ACEvent)2004, (ACEvent)2004, ROSC Discharged ROSC DischargedEastern 33% 39% 11% 56% 19%Western 43% 54% 23% 61% 32%Division %BystanderCPR %Bystander %Bystander %Bystander %BystanderWitnessed (ACEvent) WitnessedVF WitnessedVF WitnessedVF/CPR VF/CPR 2005 (ACEvent)2005, (ACEvent)2005, (ACEvent)2005, (ACEvent)2005, ROSC(ACEvent) Discharged ROSC DischargedEastern 55% 48% 17% 42% 20%Western 52% 37% 21% 31% 15%Division %BystanderCPR %Bystander %Bystander %Bystander %Bystander (ACEvent) WitnessedVF (ACEvent)2006, WitnessedVF/CPR WitnessedVF/CPR 2006 (ACEvent)2006, Discharged (ACEvent)2006, (ACEvent)2006, ROSCWitnessedVF ROSC DischargedEastern 43% 46% 22% 50% 32%Western 41% 41% 15% 51% 18%

Division %BystanderCPR %Bystander %Bystander %Bystander %Bystander (ACEvent) WitnessedVF WitnessedVF WitnessedVF/CPR WitnessedVF/CPR 2000-2006 (ACEvent) (ACEvent) (ACEvent) (ACEvent) 2000-2006, 2000-2006, 2000-2006, 2002-2006, ROSC Discharged ROSC DischargedEastern 37% 45% 21% 52% 29%Western 41% 42% 19% 46% 25%

Division

%BystanderCPR (AC

Event)2005

%BystanderWitnessed VF

(AC Event)2005,ROSC

%BystanderWitnessed

VF(AC Event)

2005,Discharged

%BystanderWitnessed

VF/CPR(AC Event)

2005, ROSC

%BystanderWitnessed

VF/CPR(AC Event)

2005,Discharged

Total No. CardiacArrests with

Cardiac Etiology.2005

% ofPatients in

VFAC Event,

2005

% ofWitnessed

CardiacArrests,

AC Event,2005

% ofUnwitnessed

CardiacArrests,

AC Event,2005

AverageAge

CardiacArrest,

AC Event,2005

% of ROSCfor

Patientsnot

meetingfield term.

criteria,2005

Eastern 55% 48% 17% 42% 20% N = 301, 70% 34% 49% 44% 65 31%Western 52% 37% 21% 31% 15% N = 375, 63.0% 33% 42% 49% 68 27%

Division

%BystanderCPR (AC

Event)2006


(AC Event)2006,ROSC

%BystanderWitnessed

VF(AC Event)

2006,Discharged

%BystanderWitnessed

VF/CPR(AC Event)

2006, ROSC

%BystanderWitnessed

VF/CPR(AC Event)

2006,Discharged


Cardiac Etiology,2006

% ofPatients in

VFAC Event,

2006

% ofWitnessed

CardiacArrests,

AC Event,2006

% ofUnwitnessed

CardiacArrests,

AC Event,2006

AverageAge

CardiacArrest,

AC Event,2006

% ofROSC forPatients

notmeeting

field term.criteria,

2006

Eastern 43% 46% 22% 50% 32% N = 249, 65% 27% 41% 49% 68 21%Western 41% 41% 15% 51% 18% N = 352, 62% 30% 42% 50% 66 38%

Division

%BystanderCPR (AC

Event)2007


(AC Event)2007,ROSC

%BystanderWitnessed

VF(AC Event)

2007,Discharged

%BystanderWitnessed

VF/CPR(AC Event)2007, ROSC

%BystanderWitnessed

VF/CPR(AC Event)

2007,Discharged



% ofPatients in

VFAC Event,

2007

% ofWitnessed

CardiacArrests,

AC Event,2007

% ofUnwitnessed

CardiacArrests,

AC Event,2007

AverageAge

CardiacArrest,

AC Event,2007

% ofROSC forPatients

notmeeting

field term.criteria,

2007Eastern 45% 60% 27% 75% 33% N = 231, 58% 31% 42% 49% 67 37%Western 48% 50% 32% 52% 35% N = 380, 64% 33% 41% 49% 67 33%

Division

%BystanderCPR (AC

Event)2000 - 2007


(AC Event)2000 - 2007,

ROSC

%BystanderWitnessed

VF(AC Event)2000 - 2007,Discharged

%BystanderWitnessed

VF/CPR(AC Event)2000 - 2007,

ROSC

%BystanderWitnessed

VF/CPR(AC Event)2000 - 2007,Discharged


Cardiac Etiology,2000 - 2007

% ofPatients in

VFAC Event,

2000 - 2007

% ofWitnessed

CardiacArrests,

AC Event,2000 - 2007

% ofUnwitnessed

CardiacArrests, AC

Event,2000 - 2007

AverageAge

CardiacArrest,

AC Event,2000 - 2007

% of ROSCfor

Patientsnot

meetingfield term.

criteria,2000 - 2007

Eastern 38% 47% 22% 55% 29% N = 2,220, 72% 31% 45% 44% 66 34%Western 41% 43% 21% 47% 26% N = 3,174, 68% 37% 42% 49% 67 30%

Division

%BystanderCPR (AC

Event)2000


(AC Event)2000,ROSC

%BystanderWitnessed

VF(AC Event)

2000,Discharged

%BystanderWitnessed

VF/CPR(AC Event)

2000, ROSC

%BystanderWitnessed

VF/CPR(AC Event)

2000,Discharged



% ofPatients in

VFAC Event,

2000

% ofWitnessed

CardiacArrests,

AC Event,2000

% ofUnwitnessed

CardiacArrests,

AC Event,2000

AverageAge

CardiacArrest,

AC Event,2000

% of ROSCfor Patientsnot meetingfield term.

criteria,2000

Eastern 33% 38% 20% 44% 23% N = 303, 74% 33% 47% 41% 67 22 %Western 36% 41% 19% 43% 24% N = 462, 77% 45% 42 % 50% 68 29%

Division

%BystanderCPR (AC

Event)2001


(AC Event)2001,ROSC

%BystanderWitnessed

VF(AC Event)

2001,Discharged

%BystanderWitnessed

VF/CPR(AC Event)

2001, ROSC

%BystanderWitnessed

VF/CPR(AC Event)

2001,Discharged



% ofPatients in

VFAC Event,

2001

% ofWitnessed

CardiacArrests,

AC Event,2001

% ofUnwitnessed

CardiacArrests,

AC Event,2001

AverageAge

CardiacArrest,

AC Event,2001

% of ROSCfor Patientsnot meetingfield term.

criteria,2001


Division

%BystanderCPR (AC

Event)2002


(AC Event)2002,ROSC

%BystanderWitnessed

VF(AC Event)

2002,Discharged

%BystanderWitnessed

VF/CPR(AC Event)

2002, ROSC

%BystanderWitnessed

VF/CPR(AC Event)

2002,Discharged



% ofPatients in

VFAC Event,

2002

% ofWitnessed

CardiacArrests,

AC Event,2002

% ofUnwitnessed

CardiacArrests,

AC Event,2002

AverageAge

CardiacArrest,

AC Event,2002

% of ROSCfor

Patientsnot

meetingfield term.

criteria,2002

Eastern 33% 38% 17% 48% 24% 32% 45% 40% 65 36%Western 39% 35% 14% 37% 18% N = 407, 68% 41% 41% 50% 67 21%

Division

%BystanderCPR (AC

Event)2003


(AC Event)2003,ROSC

%BystanderWitnessed

VF(AC Event)

2003,Discharged

%BystanderWitnessed

VF/CPR(AC Event)

2003, ROSC

%BystanderWitnessed

VF/CPR(AC Event)

2003,Discharged



% ofPatients in

VFAC Event,

2003

% ofWitnessed

CardiacArrests,

AC Event,2003

% ofUnwitnessed

CardiacArrests,

AC Event,2003

AverageAge

CardiacArrest,

AC Event,2003

% of ROSCfor

Patientsnot

meetingfield term.

criteria,2003


Division

%BystanderCPR (AC

Event)2004


(AC Event)2004,ROSC

%BystanderWitnessed

VF(AC Event)

2004,Discharged

%BystanderWitnessed

VF/CPR(AC Event)

2004, ROSC

%BystanderWitnessed

VF/CPR(AC Event)

2004,Discharged



% ofPatients in

VFAC Event,

2004

% ofWitnessed

CardiacArrests,

AC Event,2004

% ofUnwitnessed

CardiacArrests,

AC Event,2004

AverageAge

CardiacArrest,

AC Event,2004

% of ROSCfor

Patientsnot

meetingfield term.

criteria,2004



[ 49 ]

Virtually all Emergency Medical Service systems utilize a tiered response to emergency calls. The first tier or First Response is traditionally provided by fire depart-ments. Their fixed geographical locations strategically placed throughout a community make them the ideal agency for the provision of this component. First Re-sponse may be provided by manpower at the Basic Life Support or Advanced Life Support levels. Its role is to respond quickly and stabilize patients with “time sensi-tive” or potentially serious conditions. First Response then transfers the patient to the next tier for continued care and transport, allowing the First Responders to return to service in a timely manner. The second tier, or Transport, is provided by a variety of agencies depending upon the local EMS design. The most common configurations are a separate agency, such as the Public Utility Model (PUM) utilized by EMSA, a separate and added responsibility of fire, or a combination of private providers. It is beyond the scope of this section to discuss the pros and cons of each but suffice it to say that First Response and Transport are distinct and separate components that must work together with a high degree of cooperation to provide cost-effective and high quality pre-hospital emergency care. Some patients require the combined resources and personnel from both First Response and Transport, not only for their initial stabilization but continued care as well. In certain instances, Transport may arrive before First Response because of the location of the patient in relationship to the providers dispatched. In EMSA’s Regulated Service Area, the utilization of fire for First Response and EMSA (PUM) for Transport has proven to be both cost efficient and clinically effective. In fact, the EMSA system has a national reputation for excellence and the PUM model is known as a high performance design providing quality care and low cost with independent medical oversight. The implementation for Advanced Life Support First Response has been tailor-made to meet the needs and demands in each Division. For example, in Tulsa ALS providers are based in seven fire stations, the seven stations with the greatest number of EMS calls in the Division. In Oklahoma City ALS is currently deployed in twenty-two sites and in Edmond ALS is currently deployed in three sites based again on EMS call volume.

In both Divisions, training continues to run smoothly and cooperation between First Response and Transport has never been better.

Our system continues to study the clinical effective-ness of ALS First Response. Recent medical literature was supported by the findings published in USA Today show that those cities which simply add paramed-ics without carefully considering integration into the system actually see a detrimental effect on patient care. Simply adding resources can increase costs for cities and worsen patient outcomes. The ongoing Strategic Planning Process is ensuring that for both divisions new resources and approaches will have a positive impact on patient care.

There are several advantages to a combined system including rapid delivery of Advanced Life Support and the availability of two ALS providers at the scene for multiple patients or complicated conditions. The combined system uses a sophisticated System Status Management System, with the Fire Department arriv-ing at the patient’s side first in about 60% of the calls. Transport arrives first 40% of the time and consistently within minutes even when Fire is first on scene.

As independent medical oversight for this system, the Office of the Medical Director works to assure the high-est level of patient care consistent with the resources available. Further increases in ALS have the support of the Office of the Medical Director only under the con-dition that the increased resources are fully integrated into the combined system. Performance of ours and other systems across the country demonstrates the importance of utilizing an evidenced based medicine approach and analyzing avail-able data to guide changes in an EMS system. The ultimate goal of the combined system is to provide the most clinically effective care, utilizing Fire as First Response and EMSA as the Transport Agency while realizing the budgetary constraints faced by both Divi-sions.

First Response Advanced Life Support (ALS)


[ 50 ]

Oklahoma City Fire DepartmentALS Engine LocationsStation 1 820 NW 5th StreetStation 3 11601 N MacArthurStation 5 22nd & N Broadway AvenueStation 7 218 SW 23rd StreetStation 9 1415 SW 89th StreetStation 10 2039 NW 16th StreetStation 11 900 NW 50 StreetStation 12 2121 Martin Luther King AvenueStation 14 3129 NW 23 StreetStation 15 2817 NW 122nd StreetStation 16 405 SE 66th StreetStation 17 2716 NW 50th StreetStation 18 4016 N ProspectStation 19 940 SW 44 StreetStation 21 3240 SW 29th StreetStation 22 333 NW 92nd StreetStation 23 2812 S Eastern AvenueStation 24 1500 N Meridian AvenueStation 25 2701 SW 59th StreetStation 30 4343 S. Lake Hefner DriveStation 31 618 N Rockwell AvenueStation 34 8617 N Council Road

Tulsa Fire DepartmentALS Engine LocationStation 22 616 S 73rd East AvenueStation 23 4348 E 51st StreetStation 24 3520 N PeoriaStation 26 2170 W. 51st StreetStation 27 11707 E 31st StreetStation 29 7429 S LewisStation 30 104333 East 11th Street

Edmond Fire DepartmentALS Engine LocationStation 2 1315 S. BroadwayStation 3 1540 W. Danforth Station 4 1701 S I-35


[ 51 ]

Air Medical Report

Air Medical Utilization continues to be an important part of our Continuous Quality Improvement process. Due to the high risk and cost, use of helicopters must be limited to patients who will receive potential benefit. Studies have shown that in some systems fewer than 23 percent of patients transported by helicopter had potential benefit from air transport. This fact combined with the risk of crashes for air ambulance services, ne-cessitates strict criteria for helicopter deployment. This need is particularly true in metropolitan areas where ground ambulances can transport patients at faster rates for a fraction of the cost.

Since the medical literature demonstrates that helicopter utilization is not justified in an urban setting unless there are extenuating circumstances and since there is a high cost involved, as well as potential danger to the helicopter crew, other EMS providers and citizens, the following criteria apply to helicopter utilization in the Regulated Service Area.

“No Fly” Patient ConditionsHelicopter utilization is seldom indicated for patients

without a chance for survival or without serious injury or illness. The following are incidents when a helicopter should not be used:

1. Cardiac Arrest without Return of Spontaneous Cir-culation in the field,

2. Trauma Patients with trauma scores of 4 or less,3. Trauma Patients not meeting the criteria for Priority

One Trauma Alert,4. Patients with stable vital signs and without signs of

serious illness.

“No Fly” ZoneHelicopter utilization is seldom indicated within a ten mile radius of the hospital-based helicopter unless there are extenuating circumstances. Indications are as follows:

1. Hazardous or impassible road conditions resulting in significant delays for ground transport of seriously injured or ill patients with time sensitive conditions,

2. Multiple patients of serious nature requiring rapid transport, overwhelming available ground units,

3. At the paramedic’s discretion, if lengthy extrication is required and transport by ground would be extended or delayed for other reasons.

Helicopter UtilizationAt the First Response or Transport medic’s discretion,

helicopter utilization may be appropriate in the area of ten miles or greater from the hospital-based helicopter.

1. If the EMSA or transport agency is on scene, the paramedic may elect to dispatch a helicopter if time and distance would allow the patient with a time sensitive problem to be delivered significantly faster by air than ground.

2. If the EMSA or transport agency is not on scene, the First Response medic should request an ETA for ground transport. If transport time by ground is believed to be detrimental to the patient, the First Response medic may request helicopter dispatch. This decision should be communicated to the EMSA Communications Center by the dispatched helicopter communications center.

Cancellation of HelicopterEither First Responder or transport medics may cancel helicopters dispatched by another agency if a patient’s condition warrants it.

Landing ZoneEither Fire or the appropriate law enforcement agency will be responsible for a safe landing zone.

Utilization ReviewAll helicopter dispatches in the EMSA Regulated Service Area will undergo utilization review by the Office of the Medical Director of the Medical Control Board.

Air Medical Services Utilization Review in the Regulated Service Area consists of external review of all flights in accordance to screening criteria established by the Medical Control Board. During 2007, the Office of the Medical Director reviewed (53) flights with only 2 flights not meeting criteria.

Results of this process have helped to improve utiliza-tion of Air Medical Service (AMS) and have identified specific patient groups of interest. Most AMS transports were cases of multi-system blunt or penetrating trau-matic injuries. Review of all flights over a period of twelve-months us-ing utilization review criteria demonstrated a very high rate of compliance with the established criteria.


[ 52 ]

Table 1Air Medical Services Utilization Review

Description Eastern Division Western Division

Priority One Adult Trauma 9 32Priority Two Adult Trauma 0 1Priority One, Pediatric Trauma 3 2Priority Two, Pediatric Trauma 0 0Priority One, Adult Medical 0 2Priority One, Pediatric Medical 0 1Priority One, Adult Burn 2 1 14 39

Ninety-six percent (96.22%) of the AMS requests met screening criteria because of either patient condition or time and distance to hospital.

Two cases or (4%) of the AMS requests did not meet screening criteria.

Table 2Air Medical Services Utilization Review

Description Eastern Division Western Division

Total Cases 14 (26.41%) 39 (73.58%)

Did not meet screening criteria 1 (7%) 1 (3%)

Priority 1 Trauma w/o extenuating circumstances/inside “No Fly Zone” 0 0Priority 2 Trauma 0 1Priority 3 Trauma 0 0Traumatic Cardiac Arrest 0 0Priority 1 Adult Medical 0 0 Priority 1 Pediatric Medical 1 0 Total cases not meeting criteria 1 1

Patients did not meet screening criteria because of either patient condition or time and distance to receiving hospital.


[ 53 ]

The utilization review identified several factors of interest. These were:

• Western Division utilization of AMS was significantly higher than the Eastern Division. Isolated areas and distance from Level 1 Trauma Care justified the higher use of AMS.

• Most flights involved trauma patients. These patients were transported to appropriate facilities.• The screening criteria, in most cases, clearly separated the need for AMS from the need for ground transpor-

tation. It was felt that no adjustments were needed to the screening criteria.• Prehospital providers are generally using AMS appropriately but continued education is necessary.• No prehospital care provider was identified as having a high rate of inappropriate use.• Patients who are unstable, complicated, or a long distance from the appropriate receiving hospital can poten-

tially benefit from air medical care and transport.• The utilization review process was not designed to determine if AMS improved survival of trauma patients

in either Division.

Findings:• EMSA and area Fire Departments utilize air medical evacuation for patient transports very infrequently. The parameters of the Eastern and Western large urban environments may not be conducive to air medical trans-port. Our data seems to be consistent with experiences of other large urban cities. • It should be noted that, as applied to helicopter transport, our utilization procedures are for response, not necessarily transport. There is the occasional case where air transport was activated appropriately, but upon avail-ability of further information it becomes clear that completion of the transport by air is not indicated. Examples of such cases include situations where patients at the trauma scene are re-evaluated and found to be either obviously uninjured or to have un-survivable injuries.• Safety is always a consideration in the debate about utilization of air medical transport. During 2007, there were no air ambulance crashes while utilizing helicopters within the regulated service area.• Those patients who were critically injured, complicated by extenuating circumstances, i.e., lengthy extri-cation, multiple patients of serious nature requiring rapid transport, or distance from the appropriate receiving hospital, can potentially benefit from air medical care and transport.

The utilization review identified several factors of interest. These were:

Western Division utilization of AMS was significantly higher than the EasternDivision. Isolated areas and distance from Level 1 Trauma Care justified the higheruse of AMS. Most flights involved trauma patients. These patients were transported toappropriate facilities.The screening criteria, in most cases, clea rly separated the need for AMS from theneed for ground transportation. It was felt that no adjustments were needed to thescreening criteria.Prehospital providers are generally us ing AMS appropriately but continuededucation is necessary.No prehospital care provider was identifie d as having a high rate of inappropriateuse.Patients who are unstable, complicated, or a long distance fr om the appropriatereceiving hospital can potent ially benefit from air medical care and transport. The utilization review process was not designed to determine if AMS improvedsurvival of trauma patie nts in either Division.

Year

2004

# Of Helicopter Scene Flights by Year

7974

65

53

0

10

20

30

40

50

60

70

80

90

100

Period

Average of Data Shown: 68 flights

Indivi

dual

Value

Year

2004

Year

2006

Year

2005

Year

2007


[ 54 ]

Western Division

Western Division


[ 55 ]

Eastern Division Eastern Division Eastern Division


[ 56 ]

Community Wide On-Call System

The diversion of patients by overcrowded emergency departments is a national problem. Since ambulance diversion often causes delays in the treatment for some of the most serious patients and reflects a lack of an organized approach to ensure the availability of care for critical patients, the Office of the Medical Director has taken a proactive approach in addressing this issue. In response to patient diversion as well as a maldistribution of injured patients, a Community Wide On-Call Sys-tem was established in 2004 in the Western Division.

The effort established prehospital criteria which catego-rized patients by priority and identified the correspond-ing resources required for caring for these patients. While original efforts were directed at reducing diverts, the Communitywide On-Call System had far reaching benefits. The first goal was to assure that patients got to the right facility with the right resources in an appropri-ate amount of time. A second goal was to assure that the highest level of resources, those only available at the Level 1 Trauma Center, would be available for the most seriously injured rather than tied up with lesser injured patients. A plan for distributing patients to the right facility and establishing back up facilities has somewhat curtailed the need to divert ambulances.

The Community Wide On-call System continued to evolve during 2007 with the EMS, hospital and phy-sician communities working cooperatively to solve essential issues.

Ultimately a Community Wide On-call System—

• Defines patients with time-sensitive conditions requiring specialized care• Establishes predictable community needs utiliz-ing EMS data• Designates the appropriate number of on-call specialists and receiving hospitals• Develops patient identification criteria and des-ignates on-call receiving facility with on-call appropriate specialists• Establishes a system for potentially funding stand-by costs• Seeks Limited Liability for the on-call resources• Continually collects data and performs CQI

• Satisfies the on-call requirements established by the Emergency Medical Treatment and Labor Act (EMTALA)• Becomes a nucleus for the development of a regional call center that monitors the appropriateness of referrals.

The Community Wide On-Call System created in the Western Division established three patient categories. Priority One patients are those with severe, multi-sys-tem, time-sensitive injuries. Priority Two patients are at risk for or have a single system injury. Priority Three patients have minor or non-time sensitive injuries. In the Western Division, five to six percent of all patient transports are Priority One patients. Twelve to fifteen percent are Priority Two patients with the remainder categorized as Priority Three.

Priority One patients are delivered to the Level 1 Trau-ma Center where appropriate resources are available to provide multi-system care to patients with time-sensi-tive, serious injuries. In an effort to decompress the volume received by the Level 1 Trauma Center, Priority Two patients are delivered to the designated trauma receiving hospital based on a rotation established by a steering committee of the Oklahoma County Medi-cal Society. Priority Three patients are delivered to the patient’s hospital of choice or the closest hospital, if there is no patient preference.

Divert statistics are gathered and analyzed monthly. The analysis includes a breakdown by cause of divert, number of patients impacted, and trends. The data is shared with Emergency Department staff and the ad-ministrator for each hospital in the system. Due to the combined efforts of the Office of the Medical Director, Emergency Medical Services Authority and the Emer-gency Departments in the Regulated Service Area the patients diverted in 2007 decreased in both Divisions, 29% in the Western Division and 53% in the Eastern Division. 2007 statistics are included here.

The Community Wide On-Call System has been extremely successful in organizing the existing resources and assuring that triage of patients and delivery of


[ 57 ]

patients is based on the patient’s condition. The estab-lishment of the trauma receiving hospital for Priority Two patients has been effective in providing some relief to the Level 1 Trauma Center. Regional Call Centers, which are extensions of EMSA’s Communication Cen-ters and supported by the State Department of Health, are now utilizing the criteria as well. While there have been great strides, many challenges remain. The Com-munity Wide On-Call System continues to evolve in the Western Division even as similar efforts begin in the Eastern Division. There is now a back-up system in the Eastern Division for injured patients—Saint Francis Hospital is backed up by Oklahoma State University Medical Center and Saint John Medical Center is backed by Hillcrest Medical Center.

The Regional Emergency Call Center, or TReC, has progressed with the development of guidelines for placement of patients based on the following three cri-teria: the severity of injury, the geographical location of the patient and the closest hospital with the capability and capacity to care for that patient’s injuries.

Future efforts in Oklahoma will explore financial sup-port of system readiness costs and avenues for limiting liability exposure incurred by on-call specialists. Com-munities have long accepted the reality of stand-by costs associated with public safety related to law enforcement and fire. Having physicians on stand-by and paying them for their time is essential for maintaining a public health safety net for the seriously ill or injured with time sensitive conditions. The cost of not having this safety net is too high. Funding for these stand-by costs must be explored.

By recognizing the potential disastrous ramifications of the escalating number of patient diversions and working to find a solution, the communities of Tulsa and Okla-homa City have an opportunity to create an efficient, effective public health model which meets the needs of patients, hospitals and physicians.


[ 58 ]

Divert Statistics – Patients Diverted 2007Western Division

Hosp

ital

Jan-

06

Feb-

06

Mar

-06

Ap

r-06

M

ay-0

6

Jun-

06

Jul-

06

Aug-

06

Sep-

06

Oct-

06

Nov-

06

Dec-

06

Tota

l To

tal

2006

20

05

BM

C

69

61

19

10

26

34

17

17

7 4

4 1

269

263

B&J

0 0

0 0

0 0

0 0

0 0

0 0

0 1

CV

H

0 0

0 0

0 0

0 0

0 0

0 0

0 12

D

H

16

19

10

6 10

11

18

17

1

5 5

3 12

1 19

8 EM

C

0

0

0

0

0

0

0

0 0

0 0

0 0

12M

HC

26

30

30

17

32

9

23

14

5 5

6 8

205

242

MW

CR

7

1 2

0 0

4 1

0 0

0 0

0 15

64

N

RM

C

0 1

0 0

1 0

0 0

0 0

0 0

2 3

OH

H

5 10

8

1 3

10

11

0 1

0 1

0 50

28

O

U/C

T

2 2

2 0

6 2

0 0

1 1

2 0

18

13

OU

/ET

0

0 0

0 0

0 0

0 0

0 0

0 0

61

OU

/PT

17

33

38

15

66

47

27

43

16

8

12

22

344

297

PH

0 0

1 0

0 0

0 1

0 0

0 0

2 2

SAH

9

5 5

4 2

12

4 7

0 2

7 1

58

57

SWM

C

15

24

21

22

2 17

13

4

8 5

0 4

135

451

VA

17

0 21

8

4 2

0 0

0 0

0 0

52

186

Tota

l 18

3 18

6 15

7 83

15

2 14

8 11

4 10

3 39

30

37

39

12

71

1890

1/

06-1

2/06

WES

TER

N D

IVIS

ION

DIV

ERT

STAT

ISTI

CS

PATI

ENTS

DIV

ERTE

D20

07H

ospi

tal

Jan-

07Fe

b-07

Mar

-07

Apr-

07M

ay-0

7Ju

n-07

Jul-0

7Au

g-07

Sep-

07O

ct-0

7N

ov-0

7D

ec-0

7To

tal

Tota

l20

0720

06

BMC

44

168

43

210

12

728

8926

9B&

J0

00

10

00

00

00

01

0C

VH0

01

35

11

31

40

120

0D

H2

1212

39

75

50

53

1881

121

EMC

00

22

03

15

14

35

260

MH

C10

913

517

1719

1217

510

2415

820

5M

WC

R0

05

00

01

10

00

07

15N

RM

C0

00

00

00

00

10

01

2O

HH

01

00

00

01

12

12

850

OU

/CT

011

33

20

01

00

00

2018

OU

/ET

00

00

00

00

00

00

00

OU

/PT

1113

1721

1618

1515

74

63

146

344

PH0

00

00

00

00

10

12

2SA

H1

1013

15

57

611

52

1379

58SW

MC

48

1213

53

136

175

06

9213

5VA

00

2222

2728

1022

013

1020

174

52

Tota

l 1/0

7-12

/07

3268

116

8290

8574

8756

5142

121

904

1271

divp

tsw

est2

007


[ 59 ]

Divert Statistics – Patients Diverted 2007Eastern Division

EAST

ERN

DIV

ISIO

ND

IVER

T ST

ATIS

TIC

SPA

TIEN

TS D

IVER

TED

2007

Hos

pita

lJa

n-07

Feb-

07M

ar-0

7Ap

r-07

May

-07

Jun-

07Ju

l-07

Aug-

07Se

p-07

Oct

-07

Nov

-07

Dec

-07

Tota

lTo

tal

2007

2006

HM

C6

74

43

39

63

13

857

420

SCH

103

47

29

31

81

24

5475

SCH

103

47

29

31

81

24

5475

SFH

1020

1012

1228

1912

2225

1415

199

207

SFH

H0

01

11

80

00

00

011

0SJ

MC

137

1 43

150

159

2324

1760

200

340

OSU

MC

31

31

13

52

31

05

2813

2

Tota

l 1/0

7-12

/07

4238

3628

3451

5130

5952

3692

549

1174

divp

tsea

st20

07


[ 60 ]

Western DivisionPriority One Trauma Patient Disposition—January 2007 – December 2007

Weste

rn D

ivis

ion

Pri

ori

ty O

ne T

rau

ma P

ati

en

t D

isp

osit

ion

Jan

uary

2007 -

Decem

ber

2007

Mo

nth

MH

CB

MC

SW

MC

SA

HO

U/C

TM

WC

RO

U/P

T

Jan-07

11

00

10

46

Feb-07

10

00

00

30

Mar-07

10

00

10

50

Apr-07

01

00

00

57

May-07

21

00

10

65

Jun-07

01

11

01

57

Jul-07

03

10

00

47

Aug-07

00

01

01

75

Sep-07

12

00

00

72

Oct-07

01

10

10

58

Nov-07

11

00

00

67

Dec-07

02

00

00

53

To

tals

20

07

713

32

42

677


[ 61 ]

Western DivisionPriority Two Trauma Patient Disposition—January 2007 – December 2007

We

ste

rn D

ivis

ion

Pri

ori

ty T

wo

Tra

um

a P

ati

en

t D

isp

os

itio

n

Ja

nu

ary

20

07

- D

ec

em

be

r 2

00

7

Da

teM

HC

BM

CD

HS

AH

SW

MC

MW

CR

EM

CO

U/C

TO

U/P

TC

VN

RM

CV

A

Jan

-07

18

78

33

41

02

32

00

Fe

b-0

71

41

49

58

21

12

62

00

Ma

r-0

71

411

115

115

41

13

11

0

Ap

r-0

71

59

16

77

31

03

43

10

Ma

y-0

71

32

311

10

81

30

25

01

0

Jun

-07

12

19

78

115

21

34

01

0

Jul-0

71

81

81

37

83

52

20

00

1

Au

g-0

79

12

63

49

30

29

01

0

Se

p-0

71

02

08

12

95

20

24

00

0

Oct

-07

23

19

41

49

11

02

11

00

No

v-0

79

16

91

21

02

22

50

01

De

c-0

71

09

51

47

30

01

80

00

Tota

ls 2

00

71

65

17

71

07

10

08

64

12

57

29

29

52



Western DivisionPriority Three Trauma Patient Disposition—January 2007 – December 2007

[ 62 ]

Wes

tern

Div

isio

n

Prio

rity

Thre

e Tr

aum

a Pa

tient

Dis

posi

tion

Janu

ary

2007

- D

ecem

ber 2

007

Dat

eSW

MC

BM

CM

HC

DH

SAH

OU

/PT

EMC

MW

CR

OU

/CT

CV

VAN

RM

CB

&J

MH

McB

ride

Jan-

0712

711

197

8683

9256

186

340

00

00

Feb-

0710

210

089

6172

7640

125

265

12

00

Mar

-07

126

120

9685

7897

3423

519

00

00

0

Apr-0

712

213

084

7410

174

2824

1022

53

30

0

May

-07

179

127

9577

8711

045

2610

307

15

12

Jun-

0714

014

410

492

9810

942

179

399

43

00

Jul-0

715

614

510

781

143

101

3016

1135

88

20

0

Aug-

0716

813

111

181

129

8943

1610

359

11

26

Sep-

0715

014

010

386

114

105

4024

1526

00

00

0

Oct

-07

161

156

1 14

7711

486

3520

1234

84

30

0

Nov

-07

124

134

9076

109

8227

1410

2211

33

01

Dec

-07

145

150

121

7011

278

3030

1235

71

66

3

Tota

ls 2

007

1700

1588

1211

946

1240

1099

450

240

115

357

6926

289

12



[ 63 ]

Eastern DivisionPriority One Trauma Patient Disposition—January 2007 – December 2007

Eastern Division

Priority One Trauma Patient Disposition

January 2007 - December 2007

Date SFH SJMC HMC OSUMC

Jan-07 18 20 2 0

Feb-07 9 17 1 0

Mar-07 10 20 3 0

Apr-07 18 19 3 0

May-07 20 25 2 0

Jun-07 17 24 1 0

Jul-07 16 23 2 0

Aug-07 17 25 0 0

Sep-07 14 20 2 0

Oct-07 13 26 2 1

Nov-07 14 10 1 0

Dec-07 14 29 3 0

Total 2007 180 258 22 1



[ 64 ]

Eastern DivisionPriority Two Trauma Patient Disposition—January 2007 – December 2007

Eastern Division

Priority Two Trauma Patient Disposition


Date SFH OSUMC SJMC HMC SCH SFHS

Jan-07 41 0 39 14 2 0

Feb-07 18 4 21 15 1 0

Mar-07 25 3 22 9 2 0

Apr-07 36 2 29 8 1 0

May-07 37 6 22 12 5 0

Jun-07 42 4 35 8 3 0

Jul-07 25 4 30 11 5 0

Aug-07 25 9 41 13 3 0

Sep-07 36 1 25 10 3 0

Oct-07 41 14 40 20 1 0

Nov-07 30 5 29 7 4 2

Dec-07 37 4 32 17 1 0

Total 2007 393 56 365 144 31 2



[ 65 ]

Eastern DivisionPriority Three Trauma Patient Disposition—January 2007 – December 2007

Eastern Division

Priority Three Trauma Patient Disposition


Date SFH OSUMC SJMC HMC SCH SFHS

Jan-07 167 68 158 82 41 0

Feb-07 123 17 116 75 18 0

Mar-07 177 35 161 89 25 0

Apr-07 170 34 155 80 27 0

May-07 196 41 161 95 28 0

Jun-07 182 51 189 84 33 0

Jul-07 201 51 186 108 36 0

Aug-07 218 41 164 88 47 0

Sep-07 214 47 165 105 36 0

Oct-07 186 49 173 115 45 0

Nov-07 173 52 150 122 27 5

Dec-07 215 51 186 92 40 0

Total 2007 2222 537 1964 1135 403 5


[ 66 ]

Emergency Medical Services Authority

C l i n i c a l Q u a l i t y I m p r o v e m e n t R e p o r t

2007AnnualReport


[ 67 ]

Executive Summary ReportCalendar Year 2007

IntroductionThe report that follows is a summary of the clinical CQI actions for the year 2007.

Paramedic Clinical ManagementThis report represents 100% of all electronic patient care reports for the year. Approximately 5% of the PCR’s are selected for manual review based on an ap-parent protocol deviation. The PCR’s are reviewed manually to determine if the deviation was clinically indicated.

There was a 99% and 99% rate for correct assessment in East and West respectively and a 99% rate for correct management in Tulsa with a 99% rate in OKC.

Protocol UtilizationThe most frequent protocol deviations in the Eastern Division were Trauma Supportive Care, Pulmonary Edema, and Acute Coronary Syndrome. The most frequent protocol deviations in the Western Division were trauma destination, refusals and Acute Coronary Syndrome.

Procedure ReportTThe procedural report is based on 54,102 transports in the Eastern Division and 55,706 transports from the Western Division for a total of 109,808 transports within the system.

The overall success rate for IV placement in the Eastern and Western divisions were 92% and 90% respectively.

Eastern Division Airwaytotal # of caSeS 525 % Successful 481 of 525 patients attempted or 92%# of Oral and 473 of 515 patients success rate attempted or 92%# of Cardiac Arrests 286 of 314 patients attempted or 91%# of Nasal and Success Rate 8 of 10 patients attempted or 80%% Airway correctly Managed 100%

Western Division Airwaytotal # of caSeS 579 % Successful 515 of 579 patients attempted or 89%# of Oral and Success Rate 494 of 554 patients attempted or 89%# of Cardiac Arrests 361 of 394 patients attempted or 92%# of Nasal and Success Rate 21 of 25 patients attempted or 84%% Airway Correctly Managed 100%


[ 68 ]

Percentage of Patients Evaluated by Age Group

Priority One Trauma Returns

eaSterN DiviSioN:

461 total returned priority one to receiving Emergency Departments, 415(90%) met the Trauma Alert criteria by documentation on the patient care form. The destinations of the priority one-trauma case are as follows:

WeSterN DiviSioN:708 total returned priority one to receiving Emergency Departments, 658(93%) met Trauma Alert criteria by documentation on the patient care form.

Percentage of Patients Evaluated by Age Group

39.34%

17.83%


1.76%1.17%

35.31%

4.55%

18.26%

2.02%

37.89%

5.04%

35.18%

1.61%

Age <1

Age 1-5

Age 6-18

Age 19-35

Age 36-64

Age 65+

Percentage of Patients Evaluated by Age Groups


Priority One Trauma Returns:

Eastern Division:

461 total returned priority one to receiving Emergency Departments,

415(90%) met the Trauma Alert criteria by documentation on the patient care form.

The destinations of the priority one-trauma case are as follows:

1.17%

1.76%

4.55%

17.83%

39.34%

35.34%

Age<1

Age1-5

Age6-18

Age19-35

Age36-64

Age65+

1.61%

2.02%

5.04%

18.26%

37.89%

35.18%

Age<1

Age1-5

Age6-18

Age19-35

Age36-64

Age65+

Western Division:

708 total returned priority one to receiving Emergency Departments,658(93%) met Trauma Alert criteria by documentation on the patient care form.

2 14 1437


[ 69 ]

Priority Two Trauma Returns

eaSterN DiviSioN

WeSterN DiviSioN

Priority Two Trauma

Eastern

Western

Priority Two Trauma

Eastern

Western


[ 70 ]

Trauma Scene Times

Trauma scene times are comprised from trauma cases returned Priority One to the appropriate Trauma Center. Trauma Scene Times

Trauma scene times are comprised from trauma cases returned priority one to the

appropriate Trauma Center.

Eastern Division

Western Division

8:5

5 10

:54

11

:16

9:4

0

9:0

9 10

:32

11

:26

11

:01

11

:49

9:5

1

11

:13

10

:56

0:00

2:24

4:48

7:12

9:36

12:00

14:24

Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec

Scene Times

9:0

9

9:1

3

8:0

3

9:1

9 12

:40

9:2

8

9:5

1

9:0

2

9:1

1 10

:42

9:1

7

10

:02

0:00

2:24

4:48

7:12

9:36

12:00

14:24

Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec

Scene Times


[ 71 ]

Non-Transport After Contact

eaSterN DiviSioN

Compliance to completed assessment was 99%. The medics that were non-compliant were counseled individually.

4394 calls were canceled by TPD, of those 3674(84%) were after EMSA was on scene.1913 calls were canceled by TFD, of those 993(52%) were after EMSA was on scene.

WeSterN DiviSioN

Compliance to completed assessment was 99%. The medics that were non-compliant were counseled individually.

3840 calls were canceled by OCPD, of those 2663(69%) were after EMSA was on scene.2158 calls were canceled by OCFD, of those 1406(65%) were after EMSA was on scene.

Non-Transports after contact

Eastern Division

Compliance to completed assessment was 99%. The medics that were non-compliant

were counseled individually.

4491 calls were canceled by TPD, of those 3788(84%) were after EMSA was on scene.

1982 calls were canceled by TFD, of those 1106(56%) were after EMSA was on scene.

Western Division

Compliance to completed assessment was 99%. The medics that were non-compliant

were counseled individually.

3922 calls were canceled by OCPD, of those 2518(64%) were after EMSA was on scene.

2703 calls were canceled by OCFD, of those 1556(58%) were after EMSA was on scene.

15%

14%

16%

14%

16%

16%

14%

16%

16%

15%

14%

17%

January

February

March

April

May

June

July

August

September

October

November

December

Non-Transport%

10%

10%

11%

10%

11%

11%

10%

10%

10%

10%

10%

10%

January

February

March

April

May

June

July

August

September

October

November

December

Non-Transport%


[ 72 ]

Employee Feedback Information:This section will identify the total number of feedback charts that have been returned to the individual employees based on the errors noted in their management of individual cases. System Totals Eastern Western Commendations 530 214 316

FYI’s 527 228 299

OMDComm/Eval 272/377 78/20 194/357

System CQI Employee Recommendations:This section will include feedback from employees for future education topics, or other changes to the system.

eMployee feeDback QICommitteeRecommendations

• The map in the protocol books need to be changed to put the focus of the “No Fly” zone to center at OUMC, not the center of OKC.

• Add “n” to the control charts on this report.

• Remove the control charts for nasal intubation since the number of attempts is too small each month to chart effectively.

• We need the actual time 911 was called on all cardiac arrests. We have the time the call is transferred to our call center and need to track the delay in accessing our center.

• Ensure that the 911 clock and our CAD clock are synchronized for accuracy.

• Memo was generated and distributed to all agen-cies re-emphasizing the importance of capnogra-phy placement on all intubated patients.

• Add the percent of intubated patients where capnography was placed to the CQI report.


[ 73 ]

Oklahoma City Fire DepartmentEmergency Medical Services


2006AnnualReport


Preface

[ 74 ]

The goal of the Oklahoma City Fire Department in the delivery of pre-hospital medicine is to provide all citizens with immediate and exceptional medical care with compassion and respect to human dignity. Fore-sight, hard work, and dedication of the EMS section staff along with professionalism and quality care by Oklahoma City Firefighters, ensure our citizens the best pre-hospital medicine available.

The Fire Department in accord with the City Council, has impacted pre-hospital emergency medicine delivery by upgrading twenty-two (22) Basic Life Support (BLS) engine companies to Advanced Life Support (ALS). The benefit this system provides to the public, along with continued commitment from the City Council, has been the catalyst behind our ALS program. We antici-pate continued advocacy from the Council and the Medical Director’s Office as we work toward upgrading all fire department engine companies to the Paramedic level, extending first response ALS to all citizens of Oklahoma City.

Pre-hospital emergency medicine continues to evolve at a rapid pace. As a result, EMS Administration, Training, and Quality Assurance have become more complex and challenging. Understanding how critical and demanding pre-hospital medicine is, the Fire Department’s EMS Section will continue to optimize medical care and well being of all patients through educational excellence and continuous quality improvement.

The Oklahoma City Fire Department is unwavering in our commitment to provide appropriate pre-hos-pital medicine anytime, anyplace, and in any situa-tion. Twenty-seven (27) Fire Department Paramedics are trained as Medical Specialist for the Departments Search and Rescue Team. Medical Specialists are trained to operate in the hazardous and austere environments often associated with technical rescue. Fire Department Paramedics also coordinate and train with the police department to ensure medical coverage is available to citizens in hostile environments. Fire Department Para-medics are responsible for police, civilian, and suspect casualties within the “hot zone” of potentially violent scenes where entrance by civilian medical personnel would be unsafe and impractical. In 2007, Fire De-partment Paramedics received 384 hours of specialized police training and responded to multiple high-risk

Tactical Unit call-outs. Thirty-six Paramedics are also trained as Hazardous Materials Technicians and five are on the Fire Department’s Dive Team.


[ 75 ]

and 774 Heath Care Providers. This totals over 2,700 persons trained under American Heart Association guidelines accounting for 14,000 total man-hours!

A summary of each course taught, and the contact hours for the 2007 training year have been provided for your convenience.

upDatiNg aDvaNceD care eDucatioNAs part of the effort to move as much classroom train-ing to the field as possible, the EMS Training Office moved the required intubation training to the field for all paramedics. Each month all Paramedics are required to complete at least one intubation through manikin training or during an incident. With the assistance of District Intubation Coordinators, we are able to accom-plish the required training.

reDuctioN of out of Service eDucatioN hourSThe EMS Training Office continues to have success with the Mobile EMS Skills Training Lab. In 2007, the EMS Training Lab rotated to a different District Officer’s station every month. The purpose of this training was to introduce new procedures, new equip-ment, review infrequently used skills, and improve the provider’s overall EMS knowledge. This training will continue in 2008.

iMpact oN the eMS eDucatioN coMMuNityThe EMS Office staff and suppression personnel maintain involvement with the medical community serving on various boards, committees, and advisory groups. This ac-tive participation establishes a close working relationship between the Fire Department and the medical commu-nity ensuring an efficient and integrated medical system.

cliNical iNtubatioN prograMThe Clinical Intubation Program has been a great learning opportunity for Fire Department Paramedics. Paramedics are able to perform advanced level airway procedures under the direction of experienced physicians. Dr. Steve Rhodes and Associates with the help of the staff in the business office, make this program possible by giving their time, experience, and technical expertise to further the training and education of our Paramedics.

Community Health Awareness and Injury Prevention Activities

citizeN cpr traiNiNg The Oklahoma City Fire Department not only supports citizen CPR programs but also continues to be a very powerful force in CPR training. Over 2,000 citizens received CPR training through the Fire Department’s CPR program. The Friends and Family CPR course continues to be offered to the citizens every other Satur-day at Fire Stations throughout the City.

eMS traiNiNg aND eDucatioN For the 2007 training year, the EMS Training Office and Field Instructors continued to provide training for all Fire Department personnel. The EMS Training Of-fice coordinated the education of approximately 6,484 students amounting to over 86,114 contact hours. EMS Training Officers and Field Instructors worked together to ensure a great training year for 2007.

The majority of training conducted for 2007 were ALS and BLS refreshers. We are continuing to develop our refresher program, which uses the Intranet to provide for basic didactic material and then supplement the remainder of the refresher with required protocol, skills, and pediatric education. The response from the field continues to be overwhelmingly positive.

In addition to our annual refresher courses, the EMS Training office conducted several impromptu courses requested by citizens, the Medical Directors Office, and OCFD Administration. These courses included but were not limited to CPR Training courses, Pediatric Education for Prehospital Provider courses, remedial paramedic, EMT-Basic and First Responder education. The EMS Training office was also involved in training of a non-emergency medical nature. As part of a larger OCFD training group, we frequently assisted with res-cue, extrication, and fire tactics training when advanced medical knowledge was necessary.

The EMS Training office manages the American Heart Association Training Center for three EMS agency sites: OCFD, Will Rogers Fire, and Oklahoma City’s Parks and Recreation. During the period of the 2007 training year, 70 OCFD-Affiliated AHA instructors provided over 309 AHA courses to approximately 2,000 citizens

2007 In Review


[ 76 ]

DiSeaSe preveNtioNIn 2007, the EMS Training/Administrative Staff admin-istered 1,265 influenza vaccinations to Fire, police, and civilian personnel. 712 firefighters received Tuberculosis PPD testing and 36 received hepatitis A/B vaccinations.

iNtraNet coMMuNicatioNAs pre-hospital medicine continues to evolve, one of our biggest challenges is the dissemination of continu-ous improvements and changes. To accomplish this, all areas of the EMS section are represented on the OCFD Intranet site. Training schedules, student rosters, lesson plans, reference areas, PowerPoint presentations and online EMS protocols, are all incorporated into the site. Further advances by the EMS Office included automa-tion of the EMT and paramedic renewal process by importing database information into electronic renewal forms. This automation ensured consistency of data submitted, allowed personnel to effortlessly complete the renewal process, and saved countless man-hours. The ability to harness available technologies has allowed the EMS Office to further its mission of continuous quality improvement


[ 77 ]

The Quality Assurance (QA) Officers are responsible for overseeing pre-hospital clinical management provided by Oklahoma City Fire Department personnel. First and foremost as patient advocates, QA Officers ensure protocol compliance and clinical proficiency through the quality improvement process. System changes are re-searched, developed, and implemented through the QA office working in concert with the Office of the Medical Director ensuring optimal pre-hospital patient care and performance by Oklahoma City Firefighters. The Fire Department employs three QA officers for the provi-sion of around-the-clock EMS administrative coverage and Advanced Life Support (ALS) response. Additional responsibilities include; Exposure Control Officer, Risk Management, Narcotics Officer, Preceptor, Medical Of-ficer for Haz-Mat and large-scale incidents, including all third alarm fires.

QA Officers are also utilized for a variety of other EMS-related duties ranging from responding on medical emergencies, operating as a field operations supervisor, equipment/inventory control as well as hospital equip-ment pickup. The QA Officers function as liaisons be-tween the medical community and the Fire Department under the direction of the Deputy Chief of Operations. The EMS Quality Improvement Program is coordinated closely with the Office of the Medical Director (OMD) and the Fire Department’s EMS training staff.

The Quality Assurance Office utilizes all available resources to enhance our system and ensure optimal pre-hospital patient care and performance. Historically, pre-hospital advanced life support has not been heavily researched or studied. Therefore the Quality Assur-ance Office studies current trends, reviews pre-hospital medicine literature, recommendations, and research, as well as systems in other cities to help determine the most efficient and effective methods of EMS delivery. The Quality Assurance office has been in operation since 1999 and collects data to identify trends within the EMS system to determine efficiency of emergency care delivered.

The Quality Assurance Office performed an average of 303 incident audits monthly in 2007. Auditing ensure quality, identifies trends, and determines train-ing needs. The QA officers review every cardiac arrest, exposure event, and incidents in which Level II orders

are utilized. All Fire Department medical responses are subject to random audit. A total of 3,631 incidents were audited in 2007.

The skills performed by Fire Department Paramedics increased in 2007. 5274 IV’s were initiated successfully, 305 intubations performed successfully, and 2,362 med-ications administered. Patients received electrocardio-grams 5,059 times and a method used to identify acute coronary syndromes (12-lead EKG) was performed 460 times.

Quality Improvement Office


[ 78 ]

INFORMATION TYPE 2007 TOTALS Total Incidents 71,841 Total EMS Incidents 59,311 Percentage of EMS Incidents to all Incidents types 83% Total BLS Unit Response 18,981 Total ALS Unit Response 38,372 Percent od ALS Unit Response Time 68% Response Times Total Incidents < 6 Minutes Received Call-Scene 41,301 Percent of Incidents < 6 Minutes Received Call to Scene 70% Total Incidents < 5 Minutes Received Call-Scene 37,722 Percent of Incidents < 5 Minutes Received Call to Scene 64% Average Response Time Received Call-Scene 00:05:03 ALS Incident Responses Only Percent of ALS Incidents < 5 Minutes Received Call to Scene 70% Average Response Time of ALS Incidents Received Call to Scene 00:04:36

Audits Total number of Random BLS Incidents reviewed 1,124Total number of Random ALS Incidents reviewed 1,917Total number of Cardiac Arrest Incidents reviewed 528Total number of Trauma Incidents reviewed 62Total number of Incidents reviewed 3,631Rate of Correct Assessment 100%Rate of Correct Management 100%Rate of Correct Management 100%

EMS Incident Response Report


[ 79 ]

ALS Skills and Skills Accuracy Charts

EEMMSS IINNCCIIDDEENNTT AAUUDDIITTSS

Total number of Random BLS Incidents reviewed 1,124Total number of Random ALS Incidents reviewed 1,917Total number of Cardiac Arrest Incidents reviewed 528Total number of Trauma Incidents reviewed 62Total number of Incidents reviewed 3,631Rate of Correct Assessment 100% Rate of Correct Management 100%

AALLSS SSKKIILLLLSS AANNDD SSKKIILLLLSS AACCCCUURRAACCYY CCHHAARRTTSS


[ 80 ]

Skills by Shift AALLSS SSKKIILLLLSS BBYY SSHHIIFFTT


[ 81 ]

ALS Skills Totals by YearAALLSS SSKKIILLLLSS TTOOTTAALLSS CCOOMMPPAARRIISSOONN BBYY YYEEAARRAALLSS SSKKIILLLLSS TTOOTTAALLSS CCOOMMPPAARRIISSOONN BBYY YYEEAARR

*

*

*

* Due to programmatic issues with OCFD's new VisualFire reporting system implemented on January 1, 2007, statistics shown for the year 2007 are estimated.


[ 82 ]

ALS Skills Accuracy by shiftAALLSS SSKKIILLLLSS AACCCCUURRAACCYY BBYY SSHHIIFFTT


[ 83 ]

ALS Skills Accuracy Comparison by YearAALLSS SSKKIILLLLSS AACCCCUURRAACCYY CCOOMMPPAARRIISSOONN BBYY YYEEAARRAALLSS SSKKIILLLLSS AACCCCUURRAACCYY CCOOMMPPAARRIISSOONN BBYY YYEEAARR

*

*

*

* Due to programmatic issues with OCFD's new VisualFire reporting system implemented on January 1, 2007, statistics shown for the year 2007 are estimated.


[ 84 ]

EMS Training Office Educational Activities

COURSE TYPE STUDENTS INSTRUCTORS TOTAL MAN HOURS ACLS Instructor 18 1 19 304ACLS Provider 19 4 23 184BLS Instructor 270 15 285 1,140CPR for Friends and Family 109 14 123 369Healthcare Provider 1,224 110 1,334 10,672Heartsaver AED 218 32 250 2,000Heartsaver CPR 193 23 216 864Heartsaver First Aid 788 97 885 3,540EMS Instructor 11 1 12 480EMS Instructor Refresher 38 5 43 344Skills Trailer 1,896 72 1,968 3,936Continuing Education 948 0 948 43,608OCPD Tactical Team Training 1 0 1 192OCPD First Aid/CPR Training 42 2 44 704OCFD Recruit School 50 5 55 1,760BLS Refresher 376 47 423 3,384ALS Refresher 90 12 102 3,264Recruit POPS Class 30 4 34 1,088EMS Conferences 1 0 1 16Departmental Meetings 0 5 5 2,983Citizens Academy 30 5 35 105PEPP 73 13 86 1,290Remediation 4 1 5 10Fire Department Tours 20 1 21 21Promotional Academies 15 1 16 16EMT - Basic Class 10 2 12 2,880Medical Directors Academy (paramedic) 8 4 12 960

TOTALS STUDENTS INSTRUCTORS TOTAL # MAN HOURS 6,484 471 6,957 86,114


[ 85 ]

Tulsa Fire DepartmentEmergency Medical Services


2007AnnualReport


[ 86 ]

1-3 Incident Review

Total 53850 EMS 40717 Fire 13133 % EMS 76%

Total 53850 Total BLS Unit Response 34639 Total ALS Unit Response 19211 ALS Unit Response Percentage 36%

Measurements 1 thru 3, Incident Review These tables indicate the number of fire incidents, EMS incidents, percentage of EMS incidents, advanced life sup-port incidents (ALS), and basic life support incidents (BLS). ALS care provides the patient with advanced cardiac monitoring, cardiac medications, and advanced airway management skills and techniques. However, all TFD dispatches are dispatched as BLS incidents.

1-tfD iNciDeNtS for perioD

2-tfD iNciDeNtS for perioD

1-3 Incident Review

Measurements 1 thru 3, Incident Review

570314285314178

75%

570313832518706

33%

These tables indicate the number of fire incidents, EMS incidents, percentage of EMS incidents, advanced life support incidents (ALS), and basic life support incidents (BLS). ALS care provides the patient with advanced cardiac monitoring, cardiac medications, and advanced airway management skillsand techniques. However, all TFD dispatches are dispatched as BLS incidents.

% EMS

TotalEMS

1-TFD Incidents For Period

Fire

ALS Unit Response Percentage

2-TFD Incidents For PeriodTotal

Total BLS Unit ResponseTotal ALS Unit Response

42853

14178

05000

1000015000200002500030000350004000045000

1-TFD Incidents For Period

EMS Fire

38325

18706

0

5000

10000

15000

20000

25000

30000

35000

40000

45000

BLS ALS

Page 1


[ 87 ]

3-eMS iNciDeNtS

Type BLS ALS Total Number 4718 35999 40717 % 12% 88% 100%

1-3 Incident Review

Type ALS BLS TotalNumber 4570 38283 42853

% 11% 89% 100%

3-EMS Incidents

4570

38283

05000

1000015000200002500030000350004000045000

EMS Incidents

ALS BLS

Page 2


[ 88 ]

4-5 Patient Contacts

Measurements 4 and 5, On Scene First and Patient ContactsThis table represents the agency that arrives first on scene and makes patient contact. Patient contact means that the TFD unit actually made it to the scene and began the on scene assessment. It does not include wrong address, false alarm, or cancelled by EMSA, or the Fire Alarm Office.

4-oN SceNe firSt

5-patieNt coNtactS

EMS Incidents 40717 Patient Contacts 34439 CX by EMSA prior to patient contact 6278 Contact Percentage 85%

Total 40717 EMS 19719 Fire 10815 Simultaneous Arrival 10183 %Simultaneous Arrival 25% % EMSA 48% % TFD 27%

4-5 Patient Contacts

Measurements 4 and 5, On Scene First and Patient Contacts

42853216711090310279

24%51%25%% TFD

Simultaneous Arrival%Simultaneous Arrival

This table represents the agency that arrives first on scene and makes patient contact. Patient contact means that the TFD unit actually made it to the scene and began the on scene assessment. It does not include wrong address, false alarm, or cancelled by EMSA, or the Fire Alarm Office.

TotalEMS

4-On Scene First

Fire

% EMSA

EMS, 21671

Fire, 10903Simultaneous,

1027910000

15000

20000

25000

4285335970688384%

5-Patient ContactsEMS Incidents

Contact Percentage

Patient ContactsCX by EMSA prior to patient contact

0

5000

5-On Scene 1st

Pt Contact, 35970

No Contact, 6883

0

5000

10000

15000

20000

25000

30000

35000

40000

6- Patient Contacts

Page 1


[ 89 ]

Measurements 6 and 7, Cardiac Arrests and ROSCThis table indicates the number of 1st Response incidents presenting in acute cardiac arrest and provides informa-tion on the Return of Spontaneous Circulation (ROSC). The data represents those considered to be of cardiac etiology. Therefore, non-cardiac related arrests are excluded.

6-carDiac arreStS

7-carDiac arreStS With roSc prior to arrival at the hoSpital

Type ALS BLS Both Total All Tulsa Cardiac Arrests 152 217 4 373 EMSA On Scene First 50 72 1 123 TFD On Scene First 102 145 3 250 TFD On Scene First AC Arrests 71 118 3 192 TFD On Scene First Non-AC Events 33 29 0 62

6-7 Cardiac Arrests and ROSC

Type ALS BLS Both Total TFD On Scene First 102 145 3 250 Number w/ ROSC 23 15 2 40 Percentage 23% 10% 67% 16%

6-7 Cardiac Arrests and ROSC

ALS BLS Both Total141 221 3 36584 128 2 21440 93 0 13370 103 0 17314 24 0 38

ALS BLS Both Total84 128 2 21422 32 2 56

26% 25% 100% 26%

All Tulsa Cardiac ArrestsTFD On Scene First

EMSA On Scene FirstTFD On Scene First AC Events

Measurements 6 and 7, Cardiac Arrests and ROSCThis table indicates the number of 1st Response incidents presenting in acute cardiac arrest and provides information on the Return of Spontaneous Circulation (ROSC). The data represents those considered to be of cardiac etiology. Therefore, non-cardiac related arrests are excluded.

6-Cardiac ArrestsType

TFD On Scene FirstNumber w/ ROSC

Percentage

TFD On Scene First Non- AC Events

7-Cardiac Arrests with ROSC prior to arrival at the hospitalType

22

32

20

10

20

30

40

ROSC PTA at the Hospital

ALS BLS Both

84

128

20

50

100

150

TFD On Scene First

ALS BLS Both

Page 1


[ 90 ]

8-11 Cardiac Shocks

Measurements 8-11, Cardiac ShocksThis table indicates the number of cardiac arrests presenting shockable rhythms. BLS units shock VFIB rhythms. ALS units can shock rhythms other than VFIB, including VFIB. To do this they must read the EKG of the patient and manually determine the necessary shock. Under the current system guidelines, the goal is to provide the first shock within 2:15 from arrival on scene. Additionally to provide the first shock within 6:00 from the time the call is recieved.

8-carDiac arreStS patieNtS ShockeD With roSc at the SceNe

9-carDiac arreStS With firSt Shock <2:15 after arrival at SceNe

Type ALS BLS Both Total TFD On Scene First 102 145 3 250 Patients Shocked 12 22 0 34 Number Shocked <2:15 3 7 0 10 % of Cardiac Arrests by TYPE of EMS Level 25% 32% 29%

Type ALS BLS Both TFD On Scene First 102 145 3 Patients Shocked 12 22 0 Patients Shocked w/ROSC 5 4 0 % of Total Cardiac Arrests 42% 18% 60%

8-11 Shocks

Measurements 8-11, Cardiac Shocks

Type ALS BLS Both TotalTFD On Scene First 84 128 2 214

Patients Shocked 11 23 1 35Patients Shocked W/ROSC 5 6 1 12

% of Patients Shocked W/ROSC by Type of EMS Level 45% 26% 100% 34%

This table indicates the number of cardiac arrests presenting shockable rhythms. BLS units shock VFIB rhythms. ALS units can shock rhythms other than VFIB, including VFIB. To do this they must read the EKG of the patient and manually determine the necessary shock. Under the current system guidelines, the goal is to provide the first shock within 2:15 from arrival on scene. Additionally to provide the first shock within 6:00 from the time the call is recieved.

8-Cardiac Arrests Patients Shocked with ROSC @ the Scene

5

6

11

2

3

4

5

6

7


Patients Shocked 11 23 1 35Number Shocked < 2:15 1 2 0 3

% of Cardiac Arrests by Type of EMS Level 9% 9% 0% 9%

9-Cardiac Arrests with 1st Shock < 2:15 After Arrival @ Scene

0

1

ALS BLS Both

1

2

00

0.5

1

1.5

2

2.5

ALS BLS Both

Page 1


[ 91 ]

10-11 Cardiac Shocks

Measurements 10 and 11, Cardiac Shocks

10-carDiac arreStS With 1St Shock <6:00 after call receiveD

11-fractile reSpoNSe tiMe aNalySiS for all tfD carDiac arreStS

Type ALS BLS Both Total TFD On Scene First 102 145 3 250 Patients Shocked 12 22 0 34 Number Shocked <6:00 6 14 0 20 % of Cardiac Arrests by Type of EMS Level 50% 64% 59%

All TFD Cardiac Arrests 373 Responses <4:30 256 Responses <4:30 Percentage 69% 0-1 minute 6 1-2 minutez 25 2-3 minutez 69 3-4 minutez 105 4-5 minutez 75 5-6 minutez 27 >6 minutez 21

8-11 Shocks


Patients Shocked #REF! #REF! #REF! #REF!Number Shocked < 6:00 8 22 1 31

% of Cardiac Arrests by Type of EMS Level #REF! #REF! #REF! #REF!

365All TFD C di A t

10-Cardiac Arrests with 1st Shock < 6:00 After Call Received

11-Fractile Response Time Analysis for All TFD Cardiac Arrests

8

1

0123456789

ALS Both

365245

67%36

55136902729

3-4 minute4-5 minute5-6 minute>6 minute

All TFD Cardiac Arrests

0-1 minute1-2 minute2-3 minute

Responses <4:30Reponses <4:30 Percentage

3 6

55

136

90

27 29

0

20

40

60

80

100

120

140

160

0-1 minute 1-2 minute 2-3 minute 3-4 minute 4-5 minute 5-6 minute >6 minute

Page 2


[ 92 ]

12-14, Intubations and IV

Measurements 12-14, Intubations and IVThis table indicates the number of intubations & IVs tracked by the Office of the Medical Director. The Director of Clinical Affairs for the Eastern Division tracks two kinds of intubations; field and classroom airway management skills. Each system medic is expected to successfully perform at least one intubation per month, either field or class-room. The Director of Clinical Affairs and the TFD EMS Branch conduct the Intubation & IV Skill Audits. The results are forwarded to the Office of the Medical Director.

12-14 Intubations & IV

Measurements 12-14, Intubations & IV

Oral Nasal TotalField 134 1 135

Classroom 0 0 0Successful 116 0 116

This table indicates the number of intubations & IVs tracked by the Office of the Medical Director. The Director of Clinical Affairs for the Eastern Division tracks two kinds of intubations; field and classroom airway management skills. Each system medic is expected to successfully perform at least one intubation per month, either field or classroom. The Director of Clinical Affairs and the TFD EMS Branch conduct the Intubation & IV Skill Audits. The results are forwarded to the Office of the Medical Director.12-Intubations

116

00

20

40

60

80

100

120

140

Type Oral Nasal TotalPerformed Successful 116 0 116

Successful 87% 0% 86%

13-Sucessful Intubation Percentage

87%

0%0%

20%

40%

60%

80%

100%

24-Successful Intubation Percentage

Oral Nasal

025-Intubations

Oral Nasal

Page 1


[ 93 ]

Measurements 14 IVs

14-ivs Suc Unsuc Total 1262 245 1507 84% 16% 100%

12-14 Intubations & IV

Suc Unsuc Total1319 259 157884% 16% 100%

14-IVs

84%

16%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

25-IV Success Rate

Sucessful Unsuccessful

Page 2


[ 94 ]

15-16 OMD Incident Auditd

ALS BLS Total Incidents 4611 3500 8111 Audits 98% 10% 100%

Measurements 15-16-OMD Incident AuditsThis table indicates the number of Continuous Quality Improvement (CQI) audits conducted by the EMS Branch of the department. Audit goals for the Branch include 100 percent of the cardiac arrests, 100 percent of the ALS activity, and a random sample of 10 percent of the BLS activity. Each case selected for audit undergoes a very thorough review of all protocols, procedures, skills, medications, and documentation. Any breach of the “standard of care” prescribed by the OMD results in a follow-up discussion, remedial training if necessary, and/or recommendations for corrective actions. Each CQI audit requires about thirty minutes to complete.

15-oMD cQi iNciDeNt auDitS

16-oMD cQi iNciDeNt auDitS

15-16 OMD Incident Audits

Measurements 15 and 16, OMD Incident Audits

ALS BLS TotalIncidents 4570 38283 42853

Audits 2797 2445 5242

This table indicates the number of Continuous Quality Improvement (CQI) audits conducted by the EMS Branch of the department. Audit goals for the Branch include 100 percent of the cardiac arrests, 100 percent of the ALS activity, and a random sample of 10 percent of the BLS activity. Each case selected for audit undergoes a very thorough review of all protocols, procedures, skills, medications, and documentation. Any breach of the “standard of care” prescribed by the OMD results in a follow-up discussion, remedial training if necessary, and/or recommendations for corrective actions. Each CQI audit requires about thirty minutes to complete.

15-OMD CQI Incident Audits

2797

2445

2300

2400

2500

2600

2700

2800

2900

ALS BLS TotalIncidents 2797 2445 5242

Audits 61% 6% 12%

16-OMD CQI Incident Audits

61%

6%

0%10%20%30%40%50%60%70%

27-CQI Audit Percentage

ALS BLS

2200

26-CQI Audits

ALS BLS

Page 1


[ 95 ]

17-Procedures Review

Measurements 17, ProceduresThis table reflects the procedures used by ALS and BLS units. The department tracks all skills performed by the medics. There are ten basic skills, and five advanced skills that are tracked. ALS personnel use both BLS skills and ALS skills. BLS personnel use only BLS skills.

17-proceDureS revieWAirway Insertion 304Assisted Ventilation 402Bleeding Control 395CPR 308Defibrillation BLS 25Extrication 30Oxygen Therapy 3561Spinal Immobilization 913Splinted Extremities 70Ventilator 0 Total BLS Skills 6010

Breathing Treatment 113Chem-Strip/Glucometer 740Defibrillation ALS 17EKG Monitoring 1052Pacing 3 Total ALS Skills 1925

BLS Skills 6010ALS Skills 1925Other 2194 Total Skills 10129

17 Procedures Review

Measurement 17, Procedures

3044023953082530

3561913720

6010

11374017

10523

1925

Breathing TreatmentChem-Strip/GlucometerDefibrillation ALS

Total ALS SkillsPacing

ExtricationOxygen Therapy

Splinted ExtremitiesVentilator

Spinal Immobilization

Total BLS Skills

This table reflects the procedures used by ALS and BLS units. The department tracks all skills performed by the medics. There are ten basic skills, and five advanced skills that are tracked. ALS personnel use both BLS skills and ALS skills. BLS personnel use only BLS skills.

17-Procedures ReviewAirway InsertionAssisted VentilationBleeding Control

EKG Monitoring

CPRDefibrillation BLS

1925

601019252194

10129

Total ALS Skills

Total Skills

ALS SkillsBLS Skills

Patient Assessment/Other

6010

1925

02000400060008000

17-Procedures Review

Total BLS Skills Total ALS Skills

Page 1


[ 96 ]

18-Medications Review

Measurements 18, MedicationsThis table reflects the primary use of the medications used by ALS and BLS units. The department tracks twenty medications. Seventeen medications are non-controlled substances, and three medications are controlled substanc-es. Nine of the seventeen non-controlled medications are primarily dispensed for cardiac arrests, four are dispensed for irreglar blood sugar levels, two are for allergic reactions, and one group used in combination for breathing dif-ficulties. Three medications are controlled substances. Morphine sulfate is dispensed for acute pain. Valium is a first line medication for seizure. Versed is a second line medication for seizure.

18-MeDicatioNS revieWAdenocard (Supraventricular Tachycardia) 7Albuterol (used with Atrovent unless allergic to peanuts) 132Aspirin (Acute Coronary Syndromes) 149Atropine (Sinus Bradycardia & Cardiac Arrest) 67Atrovent (used with Albuterol unless allergic to peanuts) 100Amiodarone 3 Benadryl (allergic reactions) 10D50W (Diabetic Emergency) 85Dopamine (Cardiogenic Shock) 3Epinephrine 1:1000 (Asthma and allergic reactions) 9Epinephrine 1:10000 (Cardiac Arrest) 82Glucagon (Diabetic Emergency) 1Lasix (Congestive Heart Failure- Pulmonary Edema) 21Lidocaine (Anti- arrhythmic) 0Lidocaine Drip ( Maintenance Anti-arrhythmic) 4Magnesium Sulfate 1Morphine Sulfate (Pain Management & ACS & Pulmonary Edema) 24Narcan (Anti-opiate) 60Nitroglycerine (Acute Coronary Syndromes & Pulmonary Edema) 197Oral Glucose (Diabetic Emergency) 2Sodium bicarbonate (Cardiac-alkaline for acidosis) 31Solu-medrol 30Valium ( Seizures) 7Versed ( Seizures & Intubation ) 10

Total Medications Administered 1035


[ 97 ]

19-Provider Impression Summary

Measurements 19, Provider Impression SummaryThis measurement is a summary of Provider Impressions from only the medical emergencies that TFD was first on-scene.

19-proviDer iMpreSSioN SuMMary30-Provider Impression Count PercentageNot Specified 4 0.04%Impression/assessment, other 1439 14.69%Abdominal pain 312 3.19%Airway obstruction 33 0.34%Allergic reaction, excludes stings & venomous bite 45 0.46%Altered level of consciousness 488 4.98%Behavioral - mental status, psychiatric disorder 205 2.09%Burns 30 0.31%Cardiac arrest 253 2.58%Cardiac dysrhythmia 92 0.94%Chest pain 1078 11.01%Diabetic symptom 380 3.88%Do not resuscitate 3 0.03%Electrocution 4 0.04%General illnes 791 8.08%Hemorrhaging/bleeding 233 2.38%Hyperthermia 10 0.10%Hypothermia 1 0.01%Hypovolemia 9 0.09%Inhalation injury, toxic gases 13 0.13%Obvious death 125 1.28%Overdose/poisoning 165 1.68%Pregnancy/OB 86 0.88%Respiratory arrest 29 0.30%Respiratory distress 1242 12.68%Seizure 404 4.13%Sexual Assault ( Apparent) 1 0.01%Sting/bite 21 0.21%Stroke/CVA 148 1.51%Syncope, fainting 217 2.22%Trauma 1720 17.56%None/no patient or refused treatment 212 2.16%

Total Patients 9793 100%


[ 98 ]

State of the System and Future Direction

This exceptional pre-hospital system continued to function at a high level of medical quality during 2007 while looking for opportunities for improvement. The sections below provide more details on sustained ef-forts to create a patient-center system based on medical evidence, the continued involvement of the Oklahoma Institute for Disaster and Emergency Medicine, results from our Continuous Quality Improvement process and a new iteration of strategy planning.

Strategic PlanningThe vigorous and stimulating discussion surrounding the “window of opportunity” in 2006 illustrated the need for a thoughtful, more deliberate examination of our EMS system. During the dialogue, all participants were more acutely aware of the impact of system design on the ability to provide quality care. The two compo-nents of the quality of any system are the caliber of the individual medic (including training, equipment, pro-tocols) and system design. In a flawed system design, even the best medics cannot succeed.

The strategic planning process based on 14 guiding principles with core issues and operational concepts is moving toward consensus. When the process is com-plete, stakeholders will seek approval of the beneficiary cities and smaller task forces will be created to opera-tionalize plans. Quality patient care delivered in the most cost efficient manner possible is the focus of all planning.

Early conclusions drawn from strategic planning efforts this year demonstrate the need for common educational offerings for First Response and Transport as well as the need for seamless, patient-centered protocols regard-less of whether First Response or Transport arrives first. The Continuous Quality Improvement process shows a blurring of Basic Life Support and Advanced Life Support interventions and we are now examining other time-sensitive clinical conditions beyond cardiac arrest to determine which procedures and medications have a beneficial impact on patient outcome.

While cardiac arrest is obviously a very important response to get right, it represents only about 2% of all responses. Other time-sensitive clinical conditions identified by this process represent somewhere between

50 and 60% of all responses. The Office of the Medi-cal Director project in Sand Springs utilized EMT-Intermediates to perform certain ALS procedures and has proved extremely successful. We look forward to gathering more information to determine the value of BLS as the Paramedic shortage impacts EMS across the nation.

Here are two examples. For a patient with chest pain, it is extremely important to render care quickly so if the patient is experiencing a heart attack muscle damage is minimized. Interventions may also prevent cardiac arrest from occurring. The measures which make the most difference to patient’s with chest pain are BLS interventions—administration of aspirin, oxygen and nitroglycerin.

For a patient with respiratory distress and this num-ber is significant in our system, a nebulized breathing treatment (a BLS intervention) can often prevent the deterioration of this clinical condition. CPAP is yet another useful intervention for those with respiratory distress and again, this is a BLS intervention.

As our cities look for ways to contain costs, utilizing the most medically appropriate provider may be of great help. Further integration of dispatch functions will ensure that the right provider arrives at the patient’s side in an appropriate amount of time with protocols that ensure that the patient receives timely and proven interventions.

The strategic planning process is also alert to revising protocols to ensure a patient focus. Protocols were pre-viously designed for either First Response or Transport but are now moving toward a patient-centered focus. Patient-centered protocols instruct medics on the care of the patient regardless of whether First Response or Transport is first on scene.

During the 2007 strategic planning process, we con-solidated some guiding principles while adding two additional principles including one on disaster response. In all we have determined that the strategic planning process is a journey rather than a destination and once the plan is complete and implemented we will begin anew to evaluate and improve.


[ 99 ]

The Oklahoma Institute for Disasterand Emergency MedicineThe relationship with the Oklahoma Institute for Disas-ter and Emergency Medicine at the University of Okla-homa, College of Medicine Tulsa continues to evolve. Plans call for the Medical Director position for this EMS system to move into the Institute by July 2009. This move will enhance medical direction by placing it in an academic setting with the support of clinical research, the synergism of multiple faculty members and the interaction of Emergency Medicine Residents.

During 2007, Jeffrey Goodloe, M.D., a native Okla-homan and board certified Emergency Physician with special training and interest in EMS was recruited and began two years of orientation to the system as the suc-cessor to Dr. John Sacra, the current Medical Director. During the last six months of 2007, Dr. Goodloe began learning the system, worked to build relationships with both First Response and Transport, and successfully leads the strategic planning process.

Another benefit of ties with the Institute is in the availability of a computerized simulation center with clinically accurate and programmable training man-nequins. Pre-hospital providers within the system will have opportunities to utilize these training tools.

The Institute also serves as the first statewide training center for the National Disaster Life Support courses. A minimum of eight Basic Disaster Support and four Advanced Disaster Life Support courses are being held each year and EMS personnel have already attended these courses with a number being training at the in-structor level.

Summary In addition to progress made in many areas from strategic planning, analysis of BLS versus ALS interven-tions, development of seamless protocols and work with the Institute, the overall combined system design of Fire First Response and Transport from the Emergency Medical Services Authority continued during the year to provide the Regulated Service Area with proven, reliable and cost effective pre-hospital care. One of the most valuable attributes of today’s system remains the willing-ness of all players to put patient care and the commu-nity ahead of other agendas.

Documents

Office of the Medical Director - -- Emergency Medical Services