OLD DOMINION EMERGENCY MEDICAL SERVICES ALLIANCE INC. 1463 Johnston-Willis Drive Richmond, VA 23235-4730 804-560-3300 FAX: 804-560-0909 www.odemsa.vaems.org Medical Control Committee Meeting August 9, 2012 Dr. Allen Yee, Chair; [email protected] Article VI, Section 5 states: “A quorum shall consist of 8 members and 1 officer.” ODEMSA CONFERENCE AND EDUCATION CENTER Attendance: Drs. Allen Yee, Frank Ramsey, Joe Ornato, Richard Gill, and Cam Crittenden, Al Thompson, Mike Watkins Via Tele-conference: Drs. Joanne Lapetina, and Lori Harbour Staff: Lynn Barbour, Holly Sturdevant. Materials Distributed: Agenda, Previous Minutes Recommendations, Topic/Subject Discussion Action/Follow-up; Responsible Person Dr. Allen Yee called the meeting to order at 08:05 a.m. There was no quorum at the time Call to Order the meeting was called to order. Reports St Med Control Dr. Yee - getting rid of physician’s signature, working on white papers. ODEMSA Lynn – all new drug kits are in the field. We are still pulling old boxes in and are offering them for sale once we get ODEMSA insignia removed. Staff is slowly getting back to normal from this massive undertaking. Clearly Inventory is moving along nicely. Still tweaking areas with company. Hospitals – Cam – construction moving along at St. Marys. The ambulance entrance is almost done. St. Francis Stroke Survey being completed today. Cam introduces Dr. Richard Gill, Emergency Department Director for St. Francis. Frank Ramsey – new hospital administrator at Chippenham, Tim McManus, and we have some new hospitalists joining group. Agencies - 7/10/2014 4:01 PM Al - Mike Harmon retiring at Chesterfield. In addition, Chief Ed Smith is resigning at Henrico and Lisa Baber has assumed the Interim Chief role with New Kent. 1 OLD DOMINION EMERGENCY MEDICAL SERVICES ALLIANCE INC. 1463 Johnston-Willis Drive Richmond, VA 23235-4730 804-560-3300 FAX: 804-560-0909 www.odemsa.vaems.org Old Business Heart Failure / CHF Protocol Dr. Yee - Inadvertently left morphine in this protocol. This has created confusion, as morphine is no longer in the drug kit. Do we make exclusion; do we change to fentanyl or eliminate opiates? Discussion follows. Dr. Ornato – Erik Peterson’s work through clinical research done about 4 or 5 years ago, looked at differences in outcomes in patients with ACS. There seemed to be a higher mortality rate in those who did not receive morphine, but we should point out this was not a randomized trial. IT is perfectly logical to speculate that patients who got morphine were probably sicker. Sort of a teaser as it doesn’t really answer the questions but means these may be valid questions. Don’t know if it’s a class opiate effect or morphine effect. Real statement is very little likelihood that anyone would do randomized trial so we would all know what to do. Morphine is generic, inexpensive but so are many of the others. No pharmaceutical company will pay to do the trial. So what do we do? No real way to resolve. ACLS guidelines acknowledged this also, which dumps it back into the OMD’s lap. Some systems say get rid of it, others say continue to use it. We could defend any position we take. Dr. Yee - Morphine has been taken out in Chesterfield and something similar in Henrico and Will Mills is saying take it out. Consensus is to remove morphine in those affected protocols and change to Fentanyl. Data is only for ACS not Heart Failure but consensus is not to use narcotics or fentanyl either, for heart failure. New Business Intranasal Meds 7/10/2014 4:01 PM Dr. Yee - Protocol training went very well throughout the region. ODEMSA did a great job. Randy Geldreich is interested in adopting regional intranasal meds, especially Fentanyl. Discussion follows. We should consider intranasal for fentanyl, versed, glucagon, and narcan. We could put medication kit for nasal sprays in the drug boxes and make it system wide or have agencies purchase themselves. Need to consider whether rural agencies would be able to adopt if it was agency specific due to education and association of use. What would the impact be at our hospital facilities – that’s a pharmacy question. How many times would we actually use since only real indication is for PEDS? Can also use for people who you cannot get IV access to, or even heroin overdose. If OMD endorsed the use of intranasal drugs, but utilize it like we do epi pens, then it could be agency specific. Consensus is to endorse agency specific use of intranasal meds. 2 OLD DOMINION EMERGENCY MEDICAL SERVICES ALLIANCE INC. 1463 Johnston-Willis Drive Richmond, VA 23235-4730 804-560-3300 FAX: 804-560-0909 www.odemsa.vaems.org Advanced PEDS Practices Cam –what is OMD’s take on this? It would be a 64-hour course at the community college level. Completely new role and scope of practice for ALS. However, it is not new. It is used on Indian reservations in areas where physician access is limited and proven to be very successful. VCU and RAA tried to put in an intra-grant to explore something close to that. Cheryl Garland put grant together and at last minute submitted but there was a glitch in the submission. They are still looking for a future opportunity to submit one, perhaps a NIH grant at the end of the year. As OMD’s, do you feel liability is increased? Discussion - Okay provided the protocols are reasonably validated. RAA did what was called the CHAPS program. Used OMEGA protocols to determine if we could stop dispatching the ambulance; instead arrange for that patient to be seen elsewhere, clinic, patient first, etc. Data showed that patient care went well, but the program was eventually stopped. If we put in a community paramedic, we would want to look at other communities and tailor it so we had some means of follow up so we could make sure there was nothing missed, no patient harm, etc. Great idea for rural areas or inner city. Concept is viable but there is no national certification. Just a course that is taken. Non-Use of KEDS OMD consensus is to endorse the non-use of KEDS but cannot remove them from the system. Gentle reminder to OMD’s to share this information as appropriate with their agencies. Double check with Mike Berg, as a KED type device is required on the ambulance. Spinal Motion Restriction Protocol We have stated in the past that we were going to develop spinal motion restriction protocols. Facial trauma is good example. Scoop stretchers would be a better use. Most of those in use are so old the mechanisms have broken down, but it is definitely gentler on the patient. Variations on immobilizations are seen in the ED but not with scoop. The science behind c-collars and backboards is not solid. Obesity is so prevalent, collars don’t fit right and patients can’t breathe when they are laid flat. We will review the studies and bring up at next meeting. Safety Program Joe –RAA was featured in JEMS last month for their safety program. It is a neat program, and we encourage others to become familiar and utilize. Has tremendously increased employee and patient safety. Insurance rates have dropped substantially due to this good program. It has received national accolades. 7/10/2014 4:01 PM 3 OLD DOMINION EMERGENCY MEDICAL SERVICES ALLIANCE INC. 1463 Johnston-Willis Drive Richmond, VA 23235-4730 804-560-3300 FAX: 804-560-0909 www.odemsa.vaems.org Intubation / Resuscitation Outcomes Joe – Dan Davis, part of resuscitation outcomes consortium, has two analyses that are making their way to press. The consortium was created 6-7 yrs. ago, with ten sites in Canada and U.S. Together, they have generated 150,000 cardiac arrests and 40,000 trauma cases. They have built one heck of database. Dan has done some wonderful things for EMS by working with the data set and publishing these items. There are two papers – CA and trauma patients who were intubated with king airway. It found that there was a better outcome in those who were intubated correctly. However, it was not a randomized trial study and you were not able to determine if the King was used first. There is a high probability that there will be a randomized study to follow to tell whether you use King first or what. Will be the next big project and flurry you will probably see. Utilizing D50 out of the box Mike Watkins – How do we address utilizing D50 on a patient who then does not want to be transported to the hospital. Must obtain physician signature within 7 days. Regs are so old they do not address the computer entry of patient data. No resolution for signing a PCR that is computer generated. Get signature on a paper copy within 7 days. CYANO Kits Expiring CYANO kits expire end of August. Keep on units despite expiration date, until we get a replacement. This is being addressed tomorrow at the GAB meeting with Mike Berg. The restocking delay is due to several factors beyond control. There will probably be a 6 week delay before restocking. Richmond Metro agencies down to Petersburg are the primary agencies affected. Alternate Triage Model Another item to be discussed at the GAB tomorrow – different triage model called SALT or MUCK triage was not endorsed initially, then GAB stepped in and asked for presentation. If endorsed, it would affect the MCI Committee who is looking at doing a triage Tuesday. This needs to be clarified before MCI Committee rolls out the triage Tuesday practice sessions with the hospitals. November 15, 2012; 8:30-10:30 a.m. Meeting was adjourned at 10:00 a.m. Next Meeting Adjourn 7/10/2014 4:01 PM 4
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