DEMSOC ANNUAL REPORT - 2005 Executive Summary The Delaware Emergency Medical Services Oversight Council (DEMSOC) presents this annual report in accordance with Title 16, Subsection 9703 of the Delaware Code. The main purpose of this report is to inform those interested in our State’s EMS efforts about current practices and initiatives and to provide measurements useful for monitoring the performance of our EMS system. Our inaugural report in 2000 allowed DEMSOC to begin the process of establishing a baseline from which to measure the impact of future changes and growth in Delaware’s Emergency Medical Services (EMS) system. Since EMS was first developed in the 1960s, systems throughout the country have struggled with finding the best methods to measure and evaluate system performance. Delaware is no exception. One common method is to use response times, but response time data cannot readily measure the quality of care provided to a patient. Our EMS system sets the standard for quality in patient care, and although we continually strive to improve response times, the improvements in other areas of the system are far more impressive and more crucial to the survival of the patient. In this sixth annual report, we will highlight some of the many recent improvements that bring our system national recognition. National Highway Traffic Safety Administration Review (NHTSA) In 2005, DEMSOC began through review of the NHTSA report and created internal recommendations. DEMSOC has formed various subcommittees including: legislative, finance and medical information to address the report recommendations. The medical information subcommittee is addressing the integration of EMS data programs with Public Health Emergency Preparedness and Public Safety data resources. The Office of Emergency Medical Services (OEMS) and the State Fire Prevention Committee (SFPC) have met to address the recommendation of the development of a statewide Quality Assurance program. OEMS, SFPC and the Board of Medical Practice (BOMP) are engaged in ongoing efforts to improve communication and streamline provider certification processes. A complete list of recommendations is located at Appendix I. Data Collection Delaware continues to make tremendous progress in our EMS data collection abilities. The data collection system used to monitor and measure EMS efforts in Delaware is a statewide system. This is notable in that this ability is not available in many other states. As the EMS system in Delaware advances in its data collection abilities, the availability and reliability of the data will increase. Data collection is crucial to system analysis and improvement; and it supports much needed EMS research, ultimately improving EMS care worldwide. Delaware has become a national leader in data collection. Since 1999, Delaware has fully implemented the EMS Data Information Network (EDIN) at the ALS level and in about 95% of the BLS level incidents (As opposed to 65% in 2002). EDIN was developed “in house” by Delaware Health and Social Services, with assistance from many provider agencies. The EDIN system collects EMS report data electronically on a real-time basis and provides administrators with a powerful resource management and research tool. EDIN project personnel are currently focusing on the integration of dispatch data, which will eliminate the possibility of human error associated with the recurrent entry of response times on the various incident reports. EMS data collected through EDIN is now linked with other databases through a project known as the Crash Outcome Data Evaluation System (CODES). The CODES project links State Police crash data with hospital discharge data provided to the Division of Public Health and EDIN data. This enables us to evaluate the medical impact and costs associated with certain behaviors such as failing to wear seat belts during a crash. The technology associated with the CODES project is now being used in new projects to link hospital discharge data with EDIN data to provide more detail into the care of our patients. Medical Direction The Delaware EMS system maintains an extremely involved and dedicated medical direction program. The OEMS employs eight emergency physicians to provide medical oversight to the system. They include the state EMS medical director, the state BLS medical director, three county EMS medical directors and three county associate EMS medical directors. The BLS and county medical directors are accountable to the state EMS medical director. This degree of medical oversight has enabled Delaware to promulgate some of the most progressive and innovative ALS standing orders in the country. The EMS medical directors are committed to the provision of quality prehospital medical care. At the request of the Director of Public Health, the EMS Medical Directors have instituted an agency visitation program. This program facilitates clear and open channels of communication with the EMS providers. Our EMS providers have unprecedented direct (one-on-one) access to medical directors. Emergency Department Statistics This years DEMSOC report has enhanced statistics from the hospital emergency departments within our state. Overcrowding of Emergency Departments has the potential to significantly impact Emergency Services within our state through increased “turn-around” times, and hospital diversions. DEMSOC has noted the potential for EMS system impact and closely monitors this issue. Advanced Life Support Services The single greatest challenge to our ALS service remains the dramatic increases in patient volume, on a year to year basis. To combat this increase, additional Advanced Life Support units have been allocated to New Castle and Sussex Counties. In 1999, we deployed five paramedic units in Sussex County and seven units in New Castle County. We now deploy up to eight paramedic units in Sussex County and as many as nine paramedic units in New Castle County, adding additional units based on availability of staffing or for special needs. Kent County EMS deploys three paramedic units and Delaware State Police Aviation Section provides 24/7 helicopter medevac coverage statewide. Adding paramedic resources requires improvements in our training and recruitment. We are in the sixth year of an innovative program in cooperation with Delaware Technical and Community College to provide initial training and recertification to our paramedics, as well as offer them the opportunity to obtain a meaningful college degree. Additionally, over 100 paramedics have been recruited into Delaware to help fill vacancies created by system expansion and routine turnover. In an environment where a nationwide paramedic shortage exists, our county EMS agencies have been aggressive and creative in their attempts to bring quality personnel to Delaware Delaware paramedics work under demanding standards relative to many systems in the country, hence it takes additional time for personnel to be trained and deployed. Our medics were among the first in the nation to use 12-lead EKG devices. They were among the first to use pulse oximetry and also among the first nationwide to use Constant Positive Air Pressure (CPAP) techniques. Our paramedics are employing numerous cutting edge techniques to improve patient care, and for this reason, Delaware EMS is known nationally as an innovative system. Bioterrorism and Disaster Management Delaware continues to receive grant funding from several federal sources to address bioterrorism and public health preparedness. EMS providers in the field are now equipped with personal protective gear, detection equipment and Mark-1 injector kits. The focus is now shifting to other first responders. In June of 2005, the Public Safety Response to Nerve Agent protocol was approved by the both the Division of Public Health and Department of Safety and Homeland Security. This protocol enables public safety agencies to protect themselves in the event of a nerve agent release. Providers from various agencies have been involved in numerous state, county and local exercises designed to assess capability in the event of a disaster. System Cost No improvement to the EMS system is attained without cost. This report shows that the cost of Delaware’s system is on the increase as care improvements are implemented for a growing population. Accurate cost information is available for ALS, and cost measures are improving for BLS agencies. A standardized BLS financial report form was developed in 2002 to measure BLS costs in a consistent and uniform manner throughout the state. BLS system costs have been extrapolated from data submitted. Automatic External Defibrillation Perhaps the greatest enhancement to our EMS system since 1999 is the expansion of our Automatic External Defibrillation (AED) program. To support the 1999 goal of defibrillation within 6 minutes of a cardiac arrest, the use of automatic external defibrillators has been extended to law enforcement vehicles in all jurisdictions in the state. Using funding from the tobacco settlement and other sources, over 2,600 devices are in-service throughout the state (compared to 1,365 devices in 2002). Increased AED deployment and the accompanying training increase the chances for resuscitation of cardiac arrest victims. Data from 2005 showed a significant increase in Return of Spontaneous Circulation in cardiac arrest patients (29% in 2005 compared to 19% reported in 2002). These statistics are among the best in the nation, and show the significant role that the AED program has played in Delaware. EMS Research Delaware remains among the leaders in EMS research. Research allows EMS managers to make decisions based on solid evidence derived through scientific method. Science-based decision-making has been difficult to do, since there is a worldwide lack of EMS research in general. Delaware’s involvement nationally in EMS research is demonstrated by the volume of work highlighted at Appendix E of the report. Delaware was a key study site in the EMS use of Polyheme blood substitute, which has significant implications nationwide. A Delaware study presented at the American Heart Association Scientific Assembly in November of 2005 showed a distinct correlation between a systematic response to heart attack treatment and reduced hospital stays and death rates. Statewide Trauma Care System Traumatic injury is the # 1 killer and disabler of Delawareans ages 1 to 44 years, and the # 4 killer for all age groups combined. It includes injuries such as those caused by highway crashes involving motor vehicles, bicycles or pedestrians, falls, assaults, shootings, and farm or industrial mishaps. Because trauma so often involves children and young people, it is responsible for the loss of more years of life than any other cause of death, both nationally and in Delaware. It robs our nation of its most precious resource--- its youth. Trauma can occur at any time. It can happen to anyone. Those with critical injuries need to receive definitive care within a short period of time in order to minimize the risk of death and disability. The role of a Trauma System is to organize resources and assure their immediate availability to the injured at all times and in all geographic areas of the system. This means that our care for those receiving traumatic injuries is examined using a “system-wide” approach. Quality standards are set and maintained for care throughout the entire continuum from dispatch, through prehospital and hospital care, to patient discharge and rehabilitation. The trauma system ensures timely, consistent and appropriate trauma care for our patients throughout the state. This system also enables us to better utilize available air and ground EMS transport resources. Membership in the statewide trauma system includes all hospitals in the state that receive emergency patients. Each hospital is reviewed by the American College of Surgeons and must adhere to strict standards to maintain their accreditation as a Trauma Center. Continuing Challenges The ongoing challenges seen the Delaware EMS system are consistent with those seen nationwide. These challenges include: addressing the increased call volume related to the aging of our state’s population, and increases in the development of our counties. Issues with system finance and sustainability will continue. Many agencies receive funding through state and federal sources. Current federal funding cuts may adversely impact our system. In general, EMS systems nationwide are facing issues with personnel recruitment and retention. Our system must take a proactive approach to this issue if we are to maintain the quality and efficacy of our EMS services. It is the pleasure of DEMSOC to deliver this 2005 Annual Report to the Governor and the citizens of Delaware. The members of DEMSOC are committed to the continuous quality improvement of the EMS system in Delaware, and we welcome comments and suggestions from readers of this report. DEMSOC ANNUAL REPORT – 2005 Table of Contents I. INTRODUCTION........................................................ page 6 II. DELAWARE EMS PROVIDER OVERSIGHT..................................... page 9 III. MEDICAL DIRECTOR’S REPORT........................................... page 15 IV. SYSTEM RESPONSE PERFORMANCE......................................... page 20 V. ESTIMATE OF EMS SYSTEM COSTS........................................ page 32 VI. HUMAN RESOURCES..................................................... page 37 VII. HOSPITAL DIVERSION & EMERGENCY DEPARTMENT DATA...................... page 39 VIII. EMS EDUCATION AND TRAINING.......................................... page 45 IX. IMPROVEMENT INITIATIVES............................................. page 49 X. DELAWARE STATEWIDE TRAUMA SYSTEM.................................... page 54 XI. CARDIOVASCULAR CARE PROGRAMS........................................ page 59 XII. EMERGENCY MEDICAL SERVICES FOR CHILDREN............................. page 66 XIII. DOMESTIC PREPAREDNESS............................................... page 74 APPENDICES Appendix A- Delaware EMS System Improvement Act of 1999 & recent changes Pre-Hospital Advanced Care Directives (PACD) Appendix B- County Advanced Life Support response time data Appendix C- Medical Director’s report and clinical performance report Appendix D- Delaware EMS research summary Appendix E- Scratch Report Appendix F- Kent County EMS Improvement Initiatives Appendix G- New Castle County EMS Improvement Initiatives Appendix H- Sussex County EMS Improvement Initiatives Appendix I– Recommendations from DEMSOC Subcommittee in response to NHTSA report SECTION I I. INTRODUCTION The Delaware Emergency Services Oversight Council (DEMSOC) was formed pursuant to the Delaware Emergency Medical System Improvement Act of 1999 (HB332). The council is charged with monitoring Delaware’s EMS system to ensure that all elements of the system are functioning in a coordinated, effective, and efficient manner in order to reduce morbidity and mortality rates for the citizens of Delaware. It is also charged to ensure the quality of EMS services in Delaware. DEMSOC consists of 19 members appointed by the Governor. Secretary of The Department of Safety and Homeland Security, David B. Mitchell, J.D. serves as the Chairman. Also serving on the Council is the Secretary of Delaware Health and Social Services. DEMSOC also includes representatives from the following agencies: the Governor’s Office, each County government, the Delaware State Fire Prevention Commission, the Delaware Volunteer Firemen’s Association and its Ambulance Committee, the Delaware Healthcare Association, the Delaware Police Chief’s Council, the Delaware Chapter of the American College of Emergency Physicians, the State Trauma System Committee, the Medical Society of Delaware, the Delaware State Police Aviation Section, and the State EMS Medical Director. There is a representative for practicing field paramedics and there are three at-large appointments for interested citizens. The Delaware Office of Emergency Medical Services provides staff support for DEMSOC. The Office of Emergency Medical Services is assigned to Delaware Health and Social Services’ Division of Public Health, and is responsible for coordination of the state’s EMS system. The Office of Emergency Medical Services is the regulatory authority for the statewide trauma system, the coordinating authority for the statewide paramedic system and it also provides medical oversight to the state’s EMS system. The EMS system in Delaware is commonly known as a “two-tiered” system, meaning that two different levels of providers respond to emergency calls. The nature of the emergency is determined by the Emergency Medical Dispatch System. This determination is then used to dispatch the appropriate level of response. The first of these levels is known as Basic Life Support, or BLS. BLS responders provide ambulance transport, and are typically dispatched on all emergency calls. The 51 BLS agencies are affiliated with the fire service or else exist as an independent local ambulance provider. The City of Wilmington and Dover contract with commercial ambulance services for their emergency BLS response. The Delaware State Fire Prevention Commission is an independent state agency that oversees and regulates BLS operations, ambulances and apparatus, and manages all ambulance licensing and certification. BLS responders include the “Emergency Medical Technician-Basic (EMT-B)”, and the “First Responder”. Each type of BLS responder is trained to a different level, with the EMT-B being the highest level of BLS training. The second tier in the system is known as Advanced Life Support, or ALS. The ALS responder is known as an “Emergency Medical Technician-Paramedic (EMT-P)”, or “Paramedic” (the terms are synonymous). Paramedics are trained to a higher lever than BLS providers and are dispatched to the most serious medical emergencies. Most paramedics certified in Delaware are employed by one of the certified ALS agencies, one located in each County, or the Delaware State Police Aviation Section. Two private ALS providers, Christiana Care LifeNet and Washington Hospital Medstar, also employ paramedics and provide ALS helicopter transport in Delaware. The State EMS Office within Delaware Health and Social Services’ Division of Public Health is the lead agency for Advanced Life Support activities. The Office monitors the availability of EMS services throughout the state, ensuring appropriate coverage, and coordinating EMS training and certification. The Office also provides all medical direction for the Emergency Medical Dispatch System, BLS, and ALS. Each ALS agency has a state-assigned medical director. The State Fire Prevention Commission also has a state-assigned medical director for BLS issues. Christiana Care LifeNet and Washington Hospital Medstar, employs a state-approved medical directors. Delaware has 8 general acute care hospitals, 961 First Responders, 1,138 EMT-B’s, 246 EMT-P’s, 17 ALS units, 51 BLS agencies, and 2 air medical agencies. SECTION II II. DELAWARE EMS PROVIDER OVERSIGHT Delaware is a frontline leader in prehospital emergency care through comprehensive coordination, development and evaluation of the statewide emergency medical services system. There are two agencies that share oversight of the EMS system in our state, The Office of Emergency Medical Services oversees Advanced Life Support services and the State Fire Prevention Commission oversees Basic Life Support Services. The EMS Improvement Act articulates the roles of the two agencies. Delaware EMS Provider Oversight Triangle Service: Employer Volunteer Agency EMS Provider: Paramedic EMT-B Medical Direction: Certification: Office of EMS: Board of Medical Practice: Paramedic State EMS Medical Director State Fire Prevention Commission: EMT-B Office of Emergency Medical Services The Office of Emergency Medical Services is a section within the Division of Public Health, Department of Health and Social Services. It plays a vital role in the integration of emergency medical services into the state’s public health system. The goal of the Office of Emergency Medical Services (OEMS) is to provide resources, coordination and oversight of the Emergency Medical Services Systems (EMS), resulting in a reduction of death and disability in the State of Delaware. The OEMS coordinates with other state agencies, hospitals and laboratories to ensure that the citizens of our state are provided quality prehospital care. The OEMS is a catalyst for EMS system improvement and sustainment. OEMS oversees programs including: Advanced Life Support Services (ALS) - The ALS (Paramedic) Program is considered by many to be a state of the art program that ensures highly trained paramedics are providing quality emergency care to the citizens and visitors to our state. The OEMS is responsible for coordination of training, certification, financing and oversight of the state’s paramedic system. Statewide Trauma System & Injury Prevention - The Division of Public Health, Office of Emergency Medical Services were mandated in 1996 (Title 16, Chapter 97) to develop, implement, and maintain a Statewide Trauma System. This program is responsible for coordination of hospitals and provider agencies to ensure optimal care for trauma patients, and serves as a leader in statewide injury prevention efforts. Recent analyses of Trauma System data show significant improvements in patient triage and distribution since the Trauma System became functional in 2000. OEMS leads the Coalition for Injury Prevention and Safe Kids Delaware programs in response to Chapter 97’s public information, prevention, and education mandate. Emergency Medical Services Data Information Network (EDIN) - This program is responsible for maintaining a system of electronic data submission for EMS patient care reports and is the basis for EMS quality assurance and assessment of training needs. The EDIN system has been utilized nationally as a model for patient care reporting. EMS Medical Direction - This program is responsible for providing medical oversight of the statewide EMS system (ALS and BLS), review and modification of the Statewide Standard Treatment Protocols, oversight of Medical Command Facilities, conducting research and oversight of the statewide EMS Quality Assurance program. The primary role of the medical director is to ensure quality patient care. Emergency Medical Services for Children (EMSC) - The goal of Emergency Medical Services for Children is to improve emergency care for children in the State through activities that will: develop the EMSC system, prevent childhood injuries, collect pediatric data, expand EMS provider training to include pediatric and family-centered needs, and initiate the Special Needs Alert Program for families of children with special health care needs. First State, First Shock Early Defibrillation Program - Delaware recognizes the need for a statewide plan for reducing death and disability associated with cardiac arrest. The EMS Improvement Act of 1999 charged OEMS with coordinating a statewide effort to promote and implement widespread use of AEDs, including increasing the number of publicly available AEDs. Also included was the task of equipping all law enforcement vehicles with an AED by January 1, 2001, subject to legislative appropriations. This program is responsible for providing data collection, training and prevention activities in support of initiatives to reduce cardiac arrest deaths in Delaware. Agencies with above average amounts of persons at risk for cardiac arrest on their premises may be eligible for the First State, First Shock program. Crash Outcome Data Evaluation System (CODES) - By analyzing data generated through CODES, state administrators gain a more comprehensive understanding of the causes and impacts, both medical and financial, of motor vehicle crashes, and are better equipped to develop injury prevention programs with demonstrated potential for improved outcomes. The CODES Board has established the following as research priorities: 1) hospitalizations and associated medical costs due to crashes for young and elderly drivers, 2) incidence and cost of traumatic brain injuries due to motor vehicle related causes, 3) payers of medical injury costs due to motor vehicle crashes, 4) age and gender differences in crash outcomes, 5) geographical location of crashes, and 6) EMS response times based on geographic location. Organ and Tissue Donor Awareness Board – The Office of EMS provides staff support to the Delaware Organ and Tissue Donor Awareness Board. Created by Delaware Code, Title 16, Chapter 27, Anatomical, Gifts and Studies, Section 2730, this Governor-appointed Board has the responsibility of promoting and developing organ donor awareness programs in Delaware. These programs include, but are not limited to, various types of public education initiatives aimed at educating residents about the need for organ donation and encouraging them to become designated organ donors through the State drivers' license program. Poison Control Center Programs – The OEMS administers Delaware’s contract with the Poison Control Center (PCC) at The Children's Hospital of Philadelphia to provide a 24-hour-a-day emergency hotline for poisoning incidents and poison information for Delaware residents. The Poison Control hotline provides, at no charge to the public, immediate treatment advice in poisoning emergencies through access to a staff of registered pharmacists and nurses with medical oversight by a board-certified toxicologist 24 hours a day, 7 days per week. The PCC is certified by the American Association of Poison Control Centers and provides monthly data to the Office of EMS on the number and types of calls received from Delaware residents. In addition to these programs, the Office of Emergency Medical Services promulgates and implements regulations overseeing: Air Medical Ambulance Services - The purpose of these regulations is to provide minimum standards for the operation of Air Medical Ambulance Services in the State of Delaware. It is the further intent of these regulations to ensure that patients are quickly and safely served with a high standard of care and in a cost-effective manner. Advanced Life Support Inter-facility Transfers - The purpose of these regulations is to permit the use of paramedics, under the oversight of the Division of Public Health, to manage patients while in transit between medical facilities or within a healthcare system. It includes approval of an organization to provide a service with a paramedic, as well as define their scope of practice and medical oversight. Data reporting to the Division of Public Health is included for the purposes of evaluating the performance of the State EMS system, of which Inter-facility Transport is a component, regardless of the level of medical care provided. Early Defibrillation Providers - This regulation establishes the criteria for training and right to practice of emergency responders to administer automatic external cardiac defibrillation in an out-of-hospital environment. Standards are identified by the State Emergency Medical Services Medical Director for certification of Early Defibrillation Services through the Office of Emergency Medical Services. Procedures are outlined to assure equipment and training standardization, quality assurance/improvement and uniform data collection. Prehospital Advanced Care Directives. – The purpose of this regulation is to address the recognition of Prehospital Advanced Care Directives (Do-Not- Resuscitate Orders) as stated in the Delaware Code Title 16, Chapter 25 in the prehospital emergency environment. These regulations require the use of a specific form of individual identification that can be readily recognized and verified during a pre-hospital emergency. The regulations also detail the legislated immunity for certified providers honoring this order. State Fire Prevention Commission The State Fire Prevention Commission is charged with the protection of life and property from fire for the people of Delaware and to oversee the operation of the Delaware State Fire Marshal’s Office and the Delaware State Fire School. • Delaware State Fire School o The mission statement of the Delaware State Fire School is “To provide professional and volunteer firefighters with needful professional instruction and training at a minimum cost to them and their employers.” o The State Fire Prevention Commission has complete jurisdiction over, management and control of, the Delaware State Fire School and is invested with full power and authority. o The Delaware State Fire School is the lead agency for First Responder and EMT- B education within the state. o BLS operations, ambulances and apparatus, and manages all ambulance licensing and certification. o Ambulance Service Regulations – The purpose of this regulation is to ensure a consistent and coordinated high quality level of ambulance service throughout the state focusing on timeliness, quality of care and coordination of efforts. This regulation addresses BLS Ambulance Service as well as Non-Emergency Ambulance Service. It clearly defines the administrative and operational requirements for such entities. • Office of the Fire Marshall o The mission statement of the Office of the Fire Marshal is "To provide the citizens of this State and all who visit a Fire Safe Environment be it in the home, the workplace or wherever they pursue their varied lifestyles or interests." The Statutory responsibilities of the Delaware Fire Prevention Commission are to promulgate, amend and repeal regulations for the safeguarding of life and property from hazards of fire and explosion. The Statutory responsibilities of the State Fire Prevention Commission may be found in Title 16, Chapter 66 & 67 of the Code and are summarized as follows but not limited to: • The Commission shall consist of seven persons appointed by the Governor. • They shall also have the power to promulgate, amend and repeal regulations for the safeguarding of life and property from hazards of fire and explosion. • Prior to promulgation, they shall hold at least one public hearing on each regulation, amendment or repealer and shall have the power to summon witnesses, documents and administer oaths for the purpose of giving testimony. • They shall appoint the State Fire Marshal and State Fire School Director. • The Commission shall have power to authorize new fire companies or substations; resolve boundary and other disputes; prohibit cessation of necessary fire protection services. • The Commission is empowered to enforce its orders in the Court of Chancery. SECTION III III. MEDICAL DIRECTOR’S REPORT All data used for this section was extrapolated from the EMS Data Information Network (EDIN). Please note for this report, Advanced Life Support (ALS) and BLS data are separately reported. While reading this report please do not combine the ALS and BLS data. Doing so would lead to inaccurate totals. Types of Patients Seen by EMS Providers in 2005 Agency Level Medical Trauma Medical/Trauma OB/GYN Total Calls Calls Calls Calls Reports Advanced Life Support 47,350 8,729 1,585 79 57,743 Basic Life Support 62,108 19,750 4,342 50 86,250 Paramedic (ALS) Reports Entered into the EDIN System According to Incident Location Report Type New Castle Kent Sussex Non- Total County County County Delaware Reports Assist 1,304 423 680 16 2,423 BLS Release 2,761 826 913 5 4,505 Cancellation 9,331 2,438 3,764 56 15,589 DOPA 549 195 269 3 1,016 Public Service 33 35 20 1 89 Refusal 1,294 502 915 1 2,712 Stand By 282 116 219 2 619 Transport 16,335 5,251 8,646 61 30,293 Transfer of Care 172 139 183 3 497 Total 32,061 9,925 15,609 148 57,743 Description: The above numbers represent the number of patient care reports entered into the EDIN system for 2005 BLS Reports Entered into the EDIN System According to Incident Location Report Type New Castle Kent Sussex Non- Total County County County Delaware Reports Assist 865 111 746 12 1,734 Cancellation 4,846 1,119 1,232 91 7,288 DOPA 331 123 178 5 637 Public Service 2,198 427 697 7 3,329 Refusal 3,016 1,032 2,182 19 6,249 Stand By 689 337 764 23 1,813 Transport 41,390 9,332 13,700 233 64,655 Transfer of Care 165 169 209 2 545 Total 53,500 12,650 19,708 392 86,250 ALS/BLS On-Scene Field Impression-2005 62% No Change 36% Improved 2% Worsened 76% No Change 22% Improved 2% Worsened The above graph excludes cancellations, patient refusals and dead on paramedic arrival (DOPA) data. 2005 Delaware Endotracheal Tube (ETT) Template Number of Patients With an ETT Attempt 1,051 Patients Overall Success Rate Number of Patients NOT 939 Patients/ 89.3% Number of Patients in Cardiac Arrest in Cardiac Arrest 394 patients/ 37.5% 657 patients/ 62.5% Overall Success Rate Success Rate 394 Patients/82.0% 616 patients/ 93.8% Endotracheal intubation, the passage of an artificial airway past the vocal cords, is the most common, critical patient care procedure performed by Delaware paramedics. This measurement is an important indicator of critical patient care and helps provide a sense of overall system clinical performance. Paramedic (ALS) Perception of ETT Patient Outcomes 2005 66% No Change 23% Improved 11% Worsened The above chart depicts the EMS provider’s perception of ETT patient improvement versus deterioration while in the pre-hospital environment. While this measure is subjective, there are objective data points that influence the provider’s perception of outcome. Worsened patients are primarily the result of disease or injury processes that could not be halted or reversed in the pre-hospital setting. Delaware Endotracheal Tube (ETT) Template 2001-2005 2001 2002 2003 2004 2005 Intubation Attempts 874 1032 1050 1004 1051 Patients NOT in Cardiac 277 317 397 368 394 Percentage 31.8% 30.7% 37.8% 36.7% 37.5% Success Rate:Non-Cardiac 232 274 349 309 323 Percentage 83.5% 86.4% 87.9% 84.0% 82.0% Patients in Cardiac Arrest 597 715 653 636 657 Percentage 68.2% 69.3% 62.2% 63.3% 62.5% Success Rate:Cardiac 581 691 619 598 616 Percentage 97.3% 96.6% 94.8% 94.0% 93.8% Overall Success Rate 813 965 966 907 939 Percentage 93.0% 93.5% 92.2% 90.3% 59.3% Medical Directors visits to BLS Ambulance Companies There is an effort underway among the volunteer fire/ambulance service, fire commission, public health and the OEMS to ensure the quality of patient care and to improve relationships and communication between providers and Medical Direction. The EMS medical directors are committed to the provision of quality prehospital medical care. The provision of this care is reliant upon open lines of communication, quality improvement measures and the medical coordination of emergency dispatch, first responder, EMT-Bs, paramedics and medical control physicians. Although EMS medical directors interact on a regular basis with EMT-Bs and paramedics in the emergency departments, increased efforts are being made to ensure closer ties between providers and medical direction. The medical directors, fire commission, volunteer fire/ambulance services and the OEMS, recognize the value of interacting with providers in their “home” environment. To facilitate clear and open channels of communication, the EMS medical directors and a representative of the OEMS would like to visit all provider agencies for the purpose of education, problem solving, and quality assurance development and to discuss other medical issues as they may arise. EMS medical directors are setting aside time on their schedules to make in person visits to each ambulance provider agency. The OEMS is developing presentations and will provide continuing education credit hours for those in attendance. SECTION IV. IV. SYSTEM RESPONSE PERFORMANCE The performance goals for Delaware’s EMS System recognize that not all emergencies are life threatening and do not require maximum resource response. The Emergency Medical Dispatch system is capable of discriminating between the different emergency response requirements and identifies calls as 5 different types: • Alpha – Requires BLS response. Example is minor burns. • Bravo – Requires BLS response. Example is burns with unknown patient status. • Charlie – Requires ALS and BLS response. Example is burns with difficulty breathing. • Delta - Requires ALS and BLS response. Example is unconscious burn victim. • Echo – Response type not addressed in current goals, but it requires maximum response to include available first responders. Example would be a cardiac arrest. The Delaware EMS system measures response performance in fractile response. Fractile response refers to the measurement of response times performance against an established goal. For example, if a response goal is 8 minutes, the fractile response is a percentage of the responses within that 8-minute goal. So a 90% fractile response indicates that 90% of the time the response time was 8 minutes or less. The response time goals for the Delaware EMS system adopted by the EMS Improvement Committee are based on Cardiac Arrest survival research. These response goals are nationally recognized and cited by both NFPA (1710) and the American Ambulance Association guidelines. It is recognized that these are IDEAL goals. There are numerous factors that affect response time performance. DELTA/ECHO RESPONSE PERFORMANCE ADVANCED LIFE SUPPORT (ALS) KENT COUNTY 2001 2002 2003 2004 2005 6 Minutes or less 898 936 1,031 1,171 1,140 8 minutes or less 512 606 778 777 772 10 mins or less 403 486 632 593 603 12 mins or less 304 335 460 456 505 NEW CASTLE COUNTY 2001 2002 2003 2004 2005 6 Minutes or less 2,638 3,256 3,195 3,294 4,532 8 minutes or less 1,496 2,029 1,949 1,848 2,723 10 mins or less 998 1,413 1,382 1,312 2,092 12 mins or less 588 783 741 723 1,244 SUSSEX COUNTY 2001 2002 2003 2004 2005 6 Minutes or less 1,239 1,347 1,267 1,678 1,625 8 minutes or less 780 858 872 1,085 1,119 10 mins or less 762 863 882 1,073 1,149 12 mins or less 537 672 775 806 914 BASIC LIFE SUPPORT (BLS) 10 MINUTES OR LESS 2004 2005 Dover 82.05% 85.00% Kent 70.08% 71.00% NCC-Urban 90.16% 90.10% NCC-Rural 88.78% 71.00% Sussex 69.26% 89.00% Delaware 76.07% 77.22% CHARLIE RESPONSE PERFORMANCE ADVANCED LIFE SUPPORT (ALS) KENT COUNTY 2001 2002 2003 2004 2005 6 Minutes or less 991 964 840 880 918 8 minutes or less 536 608 598 590 644 10 mins or less 438 421 456 471 494 12 mins or less 254 312 321 280 292 NEW CASTLE COUNTY 2001 2002 2003 2004 2005 6 Minutes or less 3,040 4,552 4,520 5,668 4,963 8 minutes or less 2,169 3,114 3,292 3,646 3,185 10 mins or less 1,704 2,495 2,593 2,548 2,360 12 mins or less 946 1,440 1,437 1,396 1,379 SUSSEX COUNTY 2001 2002 2003 2004 2005 6 Minutes or less 1,406 1,314 1,254 1,370 1,307 8 minutes or less 866 830 749 862 873 10 mins or less 818 758 719 824 821 12 mins or less 616 563 599 619 653 BASIC LIFE SUPPORT (BLS) 12 MINUTES OR LESS 2004 2005 Dover 93.0% 93.0% Kent 80.0% 81.0% NCC-Urban 95.0% 94.0% NCC-Rural 87.0% 82.0% Sussex 83.0% 78.0% Delaware 87.6% 85.6% BRAVO RESPONSE PERFORMANCE BASIC LIFE SUPPORT (BLS) 12 MINUTES OR LESS 2004 2005 Dover 89.0% 91.0% Kent 81.0% 75.0% NCC-Urban 95.0% 93.0% NCC-Rural 80.0% 84.0% Sussex 82.0% 80.0% Delaware 85.6% 84.6% ALPHA RESPONSE PERFORMANCE BASIC LIFE SUPPORT (BLS) 18 MINUTES OR LESS 2004 2005 Dover 95.0% 95.0% Kent 95.0% 92.0% NCC-Urban 99.0% 96.0% NCC-Rural 95.0% 92.0% Sussex 95.0% 91.0% Delaware 95.8% 93.4% 2005 BLS Omega Calls (PMD codes: 23O1, 17O) NCC- Dover % Kent % Urban % Sussex % Total % of Total 8 minutes or less 2 33% 4 57% 36 64% 14 58% 56 66% 10 minutes or less 2 33% 0 0% 7 13% 2 8% 11 18% 12 minutes or less 1 17% 0 0% 8 14% 4 17% 13 2% 14 minutes or less 0 0% 2 29% 2 4% 1 4% 5 6% Others 1 17% 1 14% 3 5% 3 13% 8 8% Total 6 100% 7 100% 56 100% 24 100% 93 100% Update on the EMS Data Information Network (EDIN): On January 1, 2000, the EDIN system became available to all EMS providers in Delaware. For 2005, 151,668 total reports were entered into the database, an increase of 19,110 reports from 2004. This represents 100% of the Advanced Life Support (ALS) and approximately 90% of the Basic Life Support reports that are recorded yearly. This allows DEMSOC a continued review of operational and clinical data for the ALS and BLS providers. In past years, the Office of EMS collected a copy of each BLS patient care report so 20 fields could be entered into a database. This data only encompassed operational data such as response times. With the majority of the BLS reports being entered into the EDIN system, the OEMS now receives at least 120 data points for each patient care report. Total number of reports sent to the Office of EMS by the particular EMS service (EDIN or Paper). Agency Total Agency Total Aetna Hose Hook and Ladder 6,784 Hartly Fire Company 638 Ambulance Service Incorporated 30 Hockessin Fire Company 1,221 Belvedere Volunteer Fire Company 2 Holloway Terrace Fire Company 938 Bethany Beach Fire Company 220 Kent County EMS 9,640 Blades Fire Company 750 Laurel Fire Company 1,335 Bowers Fire Company 239 Leipsic Fire Company 116 Brandywine Hundred Fire Company 2,000 Lewes Fire Dept. 1,989 Bridgeville Volunteer Fire Co 769 Little Creek Fire Dept. 8 Camden - Wyoming Fire Company 1,701 Magnolia Fire Company 326 Carlisle Fire Company (Milford) 1,750 Mid-Sussex Rescue Squad 1,260 Cheswold Fire Company 1,391 Millcreek Fire Company 2,761 Christiana Care LifeNet 7 Millsboro Fire Dept 1,756 Christiana Fire Company 6,303 Millville Fire Company 1,691 Christiana Health Care Services 2 Milton Fire Company 502 Claymont Fire Company 2,624 Minquadale Fire Company 1,343 Clayton Fire Company 1 Minquas Fire Company 1,570 Cranston Heights Fire Company 2,194 New Castle County EMS 31,484 Dagsboro Fire Company 358 Odessa Fire Company 727 Delaware City Fire Company 1,561 Port Penn Fire Company 106 Delaware Park 8 Primecare Medical Transport(PMT) 4,554 Delaware State Police 1,837 Rehoboth Beach Fire Company 1,516 Delmar Fire Company 86 Roxana Fire Company 680 Ellendale Fire Company 126 Seaford Fire Company 2,023 Elsmere Fire Company 1,602 Selbyville Fire Company 434 Farmington Fire Company 5 Slaughter Beach Fire Company 84 Felton Fire Company 862 Smyrna American Legion Ambulance 1,703 First State Quality Transport 10,841 Sussex County EMS 14,776 Five Points Fire Company 1,075 Talleyville Fire Company 2,962 Frankford Fire Company 324 Townsend Fire Dept 528 Frederica Fire Company 317 University of Delaware- UD1 591 Georgetown American Legion Amb 1,605 Volunteer Hose (Middletown) 1,578 Goodwill Fire Company 1,195 Wilmington Fire Department 1,406 Greenwood Fire Company 553 Wilmington Manor Fire Company 1,997 Gumboro Fire Company 283 Harrington Fire Company 1,236 SECTION V. V. ESTIMATE OF EMS SYSTEM COSTS One important factor in measuring an EMS system is its efficiency, measured in terms of cost. Delaware continues to refine the process to accurately reflect total EMS system costs. A standardized BLS Financial Form was developed and distributed to all agencies in 2002. Additionally, all 911 centers involving EMS dispatch have reported their costs to run their departments during 2005. The population figures below for 2005 were obtained from the most recent report of Delaware Population Consortium (Oct.11, 2005). The County Cost Per Capita was obtained by calculating the total population for 2005 by the expended budget for 2005 for each agency. The ALS Cost per Patient was obtained by calculating the number of runs for 2005 by the expended budget for 2005 for each agency. Area Population County Cost ALS Cost Per Geographic (2005) Per Capita* Patient Size Kent County 141,022 persons $19.45 $276.35 594 square miles New Castle County 523,852 persons $18.14 $296.45 438 square miles Sussex County 175,818 persons $48.25 $543.43 950 square miles Delaware 840,692 persons $24.65 $359.92 1,982 square miles *Cost per Capita is unavailable for the BLS agencies. Please also note that the County Cost Per Capita calculation does not include the visiting population to the state, including: commuters in New Castle, racing fans in Kent, and beach visitors in Sussex. BLS Program Costs BLS agencies are requested to send fiscal sheets to the Delaware Volunteer Fireman’s Association (DVFA), Delaware State Fire Prevention Commission, and the Delaware Office of EMS. The BLS agencies have up to 60 days after the end of their fiscal year to send their report. The last possible day of Fiscal Year 2005 was December 31, 2005. They had until March 1, 2006 to send in the Fiscal Year 2005 reports. 2005 Total 2005 Total 2005 Total Agencies Reported Extrapolated Estimated 2005 REPORTING Reporting Disbursements Disbursements Disbursements Total for Kent County 5 $ 2,598,163.42 $ 880,925.28 $ 3,479,088.70 Total for New Castle County 12 $ 8,525,469.31 $2,940,506.88 $11,465,976.19 Total for Sussex County 10 $ 3,751,245.97 $2,097,800.64 $ 5,849,046.61 Total for All Agencies 27 $14,874,878.70 $5,919,232.80 $20,794,111.50 2004 Total 2004 Total 2004 Total Agencies Reported Extrapolated Estimated 2004 REPORTING Reporting Disbursements Disbursements Disbursements Total for Kent County 7 $ 1,837,491 $ 2,123,375 $ 3,960,867 Total for New Castle County 14 $ 6,849,645 $ 3,616,749 $10,466,394 Total for Sussex County 12 $ 4,631,350 $ 1,689,386 $ 6,320,736 Total for All Agencies 33 $13,318,487 $ 7,429,510 $20,747,997 Total Estimated Disbursements for BLS agencies was derived by taking the median disbursement for agencies that reported in a given year this was divided by the median transports to get the cost per transport. The extrapolated cost per transport was multiplied by the reported number of transports for an agency not reporting financial data to obtain an estimated disbursement. Estimated disbursements were added to actual reported disbursements to get Total Estimated Disbursements for a given year. (In cases where there are no estimated disbursements for a county actual data was available for that period) Delaware State Police Aviation Total Costs: $ 1,244,012* Personnel: $ 819,000* Helicopter Maintenance: $ 349,091* Fuel Costs: $ 70,921* Medical Supplies: $ 5,000* *only that portion allocated to EMS costs Dispatch Center Costs Kent County 911 Center: Total Costs: $ 1,212,500 Personnel: $ 1,028,300 Equipment: $ 174,200 Training: $ 10,000 New Castle County 911 Center: (Includes City of Wilmington EMS Dispatch) Total Costs: $ 1,247,056 Personnel: $ 1,148,543 Equipment: $ 94,513 Training: $ 4,000 Sussex County 911 Center: Total Costs: $ 1,399,107 Personnel: $ 1,158,207 Equipment: $ 202,900 Training: $ 38,000 Seaford 911 Center: Total Costs: $ 386,364 Personnel: $ 363,989 Equipment: $ 20,000 Training: $ 2,375 Rehoboth 911 Center: Total Costs: $ 376,497 Personnel: $ 309,366 Equipment & Contracts: $ 66,416 Training & Misc.: $ 715 County ALS Agency Costs FY 2005 Total 60% County 40% State County Expense Contribution Contribution New Castle $ 9,504,550 $ 5,702,731 $3,801,820 Kent $ 2,763,129 $ 1,657,877 $1,144,252 Sussex $ 8,482,373 $ 5,089,424 $3,392,949 Total #20,750,052 $12,450,032 $8,339,021 Advanced Life Support agency costs are assumed by each county ALS agency. Reimbursement for the direct costs of providing care is provided by paramedic grant-in-aid, administered by the State Budget Office through the Division of Public Health and the Office of Emergency Medical Services. Prior to 2003, State reimbursement for such expenses was 60% of submitted costs. This was changed in 2004 to a 50% reimbursement rate, and in 2005 the rate moved to 40%. SECTION VI. VI. HUMAN RESOURCES THE NUMBER OF EMS PROVIDERS IN DELAWARE - 2005 EMT-B's (BLS) 43.5% 1,138 FIRST RESPONDERS (BLS) 35.9% 942 PARAMEDICS (ALS) 9.4% 246 MEDICAL CONTROL PHYSICIANS 7.1% 185 EMERGENCY MEDICAL DISPATCHERS 4.1% 106 SECTION VII. VII. HOSPITAL DIVERSION REPORT Total Hours of Diversion Delaware Hospitals 2000-2005 Hospital 2000 2001 2002 2003 2004 2005 AI DuPont 5.00 0.0 0.00 11.00 29.50 20.00 Beebe Med Ctr. 47.00 10.00 30.00 40.00 54.00 199.27 Christiana 740.00 619.00 292.00 329.75 289.75 170.75 Kent General 0.00 31.00 6.00 10.25 109.93 407.96 Milford 56.00 96.00 68.00 81.00 259.00 65.06 Nanticoke 101.00 128.00 142.00 523.00 116.00 77.06 St. Francis 1,322.00 539.00 568.00 618.50 148.25 245.00 Veterans 586.00 343.00 237.00 381.50 303.50 205.00 Wilmington 1,034.00 518.00 441.00 679.25 572.95 531.50 This graph shows EMS hours of diversion from hospital emergency departments. Delaware acute care hospitals continued to experience increases in emergency department patient visits during 2005, and in many cases, overcrowding. This overcrowding has many times resulted in increased ambulance diversions to other hospitals. Information provided by the Delaware Healthcare Association indicates that there were 314,455 visits to the Delaware acute care hospital emergency departments in 2005. This is an increase of 16,486 hospital emergency department visits (5.53 %) statewide from the same period in 2004, and an overall increase of 18,473 visits (6.24%) compared to the same period for calendar year 2003. Consistent with the previous year, there were still as many as 75 – 100 patients in Delaware acute care hospitals on any given day that no longer required hospital care, but the patient remained in the hospital awaiting discharge to post acute care settings. This inability to discharge inpatients results in a shortage of inpatient beds available for the admission of emergency patients. This also has a direct negative impact on the frequency of hospital diversions and the BLS providers that must take patients to other hospitals outside of the BLS provider’s immediate service area. Total Hours of Diversion Compared to Total Patients Brought In By Delaware Paramedics 2005 Hospital Hours Patients AI DuPont 20.00 454 AGH 3.75 239 Beebe Med Ctr. 199.27 4,100 Christiana 170.75 10,767 Crozier 105.75 88 Kent General 407.96 4,539 Milford 65.06 2,090 Nanticoke 77.06 2,255 PRMC 34.83 520 St. Francis 245.00 1,925 Union 31.00 64 Veterans 205.00 120 Wilmington 531.50 3,088 This graph depicts the 2005 EMS hours' diversion from a hospital emergency department and compares those hours of diversion to the number of paramedic patients that were transported to those hospitals. This comparison provides the reader with a sense of the impact that a facility's diversion may have on the EMS system. For example, Christiana Hospital receives a higher number of EMS patients. Therefore an hour of Christiana Hospital diversion will have a greater effect than the same hour of diversion at a hospital receiving fewer patients, requiring EMS providers to transport patients to more distant hospitals. Emergency Department Visits 2000-2005 Hospital 2000 2001 2002 2003 2004 2005 AI DuPont 23,075 24,868 25,561 26,571 26,516 28,431 Bayhealth 51,945 51,931 53,281 55,108 55,967 55,940 Beebe 25,971 28,219 30,663 31,944 34,639 37,707 Christiana 129,020 128,481 133,423 135,876 134,638 141,317 Nanticoke 21,274 25,737 23,432 24,605 25,355 28,800 St. Francis 23,246 22,666 25,700 21,878 20,854 22,260 Kent/Sussex Cty 99,190 105,887 107,376 111,657 115,961 122,447 New Castle Cty 175,341 176,015 184,684 184,325 182,008 192,008 DE Hospitals 274,531 281,902 292,060 295,982 297,969 314,455 Admissions From Emergency Departments 2000-2005 Hospital 2000 2001 2002 2003 2004 2005 AI DuPont 2,587 2,883 3,517 3,993 3,958 5,078 Bayhealth 8,882 8,576 8,515 8,215 7,857 8,576 Beebe 5,633 5,373 4,108 4,340 4,420 4,321 Christiana 22,629 25,375 25,787 27,659 28,831 29,945 Nanticoke 4,068 4,310 3,926 3,919 4,517 4,915 St. Francis 4,215 4,583 3,997 1,382 4,631 4,937 Kent/Sussex Cty 18,581 18,259 16,549 16,474 16,848 17,812 New Castle Cty 29,431 32,841 33,301 36,034 37,420 39,960 DE Hospitals 48,012 51,100 49,850 52,508 54,286 57,772 Note: Bayhealth Medical Center information is combined for both Kent General Hospital in Kent County and Milford Memorial Hospital in Sussex County. Likewise, Christiana Hospital information includes Wilmington Hospital statistics. The following information, provided by the Delaware Healthcare Association, shows comparative numerical and percentile data from 2000-2005 for both admissions from and visits to Emergency Departments for each County and Delaware Hospitals. Admissions from Emergency Department (not collected untill 2000) 2000 2001 2002 2003 2004 2005 Kent/Sussex Counties 18,581 18,259 16,549 16,474 16,848 17,812 New Castle County 29,431 32,841 33,301 36,034 37,420 39,960 Delaware Hospitals 48,012 51,100 49,850 52,508 54,268 57,772 Admissions From ED Comparisons Kent/ New Sussex Castle Delaware Counties County Hospitals 2001 compared to 2000 -322 3,410 3,088 2001 compared to 2000 -1.73% 11.59% 6.43% 2002 compared to 2001 -1,710 460 -1,250 2002 compared to 2001 -9.37% 1.40% -2.45% 2002 compared to 2000 -2,032 3,870 1,838 2002 compared to 2000 -10.94% 13.15% 3.83% 2003 compared to 2002 -75 2,733 2,658 2003 compared to 2002 -0.45% 8.21% 5.33% 2003 compared to 2001 -1,785 3,193 1,408 2003 compared to 2001 -9.78% 9.72% 2.76% 2004 compared to 2003 374 1,386 1,760 2004 compared to 2003 2.27% 3.85% 3.35% 2004 compared to 2002 299 4,119 4,418 2004 compared to 2002 1.81% 12.37% 8.86% 2005 compared to 2004 964 2,540 3,504 2005 compared to 2004 5.41% 6.36% 6.07% 2005 compared to 2003 1,138 3,926 5,264 2005 compared to 2003 8.12% 10.90% 10.03% Information provided by the Delaware Healthcare Association indicates that there were 314,455 visits to the Delaware acute care hospital emergency departments in 2005. This is an increase of 16,468 hospital emergency department visits (5.24 percent) statewide from the same period in 2004. 1,180 Data from 2005 showed a significant increase in the number of patients treated in Emergency Departments statewide. However, there was not a correlating increase in the number of patients admitted to the hospital from the Emergency Departments. 356 394 As with previous years, there remains an issue with patients that no longer required hospital care, but remain in the hospital awaiting discharge to post acute care settings. This inability to discharge inpatients results in a shortage of inpatient beds available for the admission of emergency patients. This also has a direct negative impact on the frequency of hospital diversions and the BLS providers that must take patients to other hospitals outside of the BLS provider's immediate service area. 1,726 SECTION VIII. VIII. EMS EDUCATION AND TRAINING Emergency Medical Service (EMS) education in Delaware is provided at three nationally recognized levels. They are First Responder, Emergency Medical Technician-Basic (EMT-B), and Emergency Medical Technician-Paramedic (EMT-P). Registration through the National Registry of Emergency Medical Technicians (NREMT) is offered for each of these levels. First Responder 3 First Responder training is 40 hours in length and is aimed primarily at firefighters and industrial first aid squads that do not have ambulances. Training follows a national standard curriculum established by the U.S. Department of Transportation (DOT). The program is offered through the Delaware State Fire School and a few private educational companies in the state. This program consists of basic assessment and first aid techniques and includes automatic external defibrillator (AED) training. A 12-hour refresher course must be completed to re-certify. EMT-Basic EMT-Basic certification is the basic life support (BLS) standard of care for the state. EMT-Basics are the primary care providers required on Delaware ambulances. This was adopted by the State Fire Prevention Commission in 1998. EMT-Basic consists of approximately 120 hours of intensive classroom work with additional clinical experience required. EMT-Basic follows a national standard curriculum established by the U.S. Department of Transportation (DOT). This course provides the student with in-depth knowledge and skill-based training to appropriately assess, stabilize, monitor, and transport the prehospital patient. In addition, the student will become familiar with medic assist functions and the use of an Automatic External Defibrillator (AED). The lead agency for EMT-B education is the Delaware State Fire School. Medical oversight and curriculum review is through the Office of Emergency Medical Services. The cost of training is underwritten by the State Fire Prevention Commission, for students affiliated with a provider agency. EMT-Basics must successfully complete a state sanctioned EMT-B course to be eligible to take the written examination from the National Registry of EMT’s (NREMT). To be eligible for EMT-B certification in Delaware, the providers must successfully complete the National Registry Exam. To remain certified as an EMT- B in Delaware providers must complete a state sanctioned 24 hour refresher program every 2 years as well as a CPR/AED course. To maintain NREMT certification the provider must complete the 24-hour refresher course and a CPR/AED course, consistent with the Delaware requirements. However, providers must also complete 48 hours of continuing medical education to re-certify with NREMT. EMT-Paramedic EMT-Paramedic is the advanced life support (ALS) standard of care for the state. EMT-Paramedics are called to respond to the most life-threatening calls for help and respond separately from the BLS ambulances. EMT-Paramedic education consists of approximately 1500 hours of intensive classroom, clinical and supervised field experience. EMT-Paramedic follows a national standard curriculum established by the U.S. Department of Transportation (DOT). EMT-Paramedics are trained to assess, treat and stabilize ill or injured persons. Treatments include advanced airways, cardiac monitoring and defibrillation, and administration of life-saving medications. The paramedic program is offered through Delaware Technical and Community College as a two-year degree program. The program has undergone an extensive peer review process through the Committee on Accreditation of Educational Programs for the EMS Professions (CoAEMSP) and has received accreditation through the Commission on Accreditation of Allied Health Education Programs (CAAHEP). The mission of the CoAEMSP under the direction of CAAHEP “is to continuously improve the quality of EMS education through accreditation and recognition of services for the full range of EMS professions. EMT-Paramedics must successfully complete a practical examination and written examination from the National Registry of EMT’s in order to receive Delaware certification. To remain certified as a Paramedic within Delaware providers must remain NREMT-P certified as well as maintain ACLS, PALS and PHTLS certifications (or their equivalent). NREMT-P requires they complete a 48-hour refresher course and 24 hours of continuing medical education to re-certify. DTCC Paramedic Training Program: Number of Students Number of Students Number of Students Class Year Beginning Program Completing Program Employed in Delaware 1999-2000 3 2 2 2000-2001 20 15 13 2001-2002 9 4 4 2002-2003 14 11 11 2003-2004 13 13 11 2004-2005 19 12 11 2005-2006 20 18 (As of Spring 2006) N/A Emergency Medical Dispatch All public safety answering points (PSAP) that dispatch ambulance personnel are required to use the Priority Medical Dispatch System (PMDS). All dispatchers employed at those PSAPs must be certified Emergency Medical Dispatchers (EMDs). EMD training is provided on an as-needed basis by in-state EMD trainers. The initial course is 24 hours in length and requires 24 hours of continuing education every 2 years, to maintain national certification. Field Training Officer (FTO) Program The FTO program, used in Delaware for the training and education of paramedic students was developed through a contract between the Office of EMS and Bayhealth Medical Center’s, EMS Education Department. This program has received national recognition through Best Practices in Emergency Services, and was presented at the National Association of Emergency Medical Service Educators Symposium. This program is designed to enhance both student and FTO development. It is recognized that the field training portion of a program can be stressful to both FTO and student. The FTO workshop is a one-day course that addresses basic teaching philosophy and provides the FTO with the skills necessary to provide a positive learning environment for the students. The FTO program uses a standard evaluation tool during the field training process. This tool, clearly defines what is expected of the student. This design enhances communication between students and FTO. The FTO program is well received within the BLS community of Delaware. Approximately 120 BLS providers have attended the workshop. National Scope of Practice In 2005 the National Highway Traffic and Safety Administration (NHTSA) developed The National EMS Scope of Practice Model. “The National EMS Scope of Practice Model is a continuation of NHTSA and the Health Resources and Services Administrations implementation of the EMS Agenda for the Future”. The National EMS Scope of Practice Model identifies and defines four levels of EMS licensure, with each level representing a specific knowledge and skills set that build upon each other. According to NHTSA (2005); “the challenge facing the EMS community is to develop a system that establishes national standards for personnel licensure and their minimum competencies while remaining flexible enough to meet the unique needs of State and local jurisdictions”. The OEMS in conjunction with DEMSOC will review The National EMS Scope of Practice Model to determine the feasibility of incorporating its concept/design into EMS practices in Delaware. Strong rationale for adopting The National EMS Scope of Practice Model is that it will increase public awareness and understanding of EMS personnel, and support the professional image of EMS providers. It will also better integrate EMS into the overall healthcare model practiced throughout the nation. National Registry Adopts Computer Adaptive Testing Beginning January 1, 2007, the National Registry of Emergency Medical Technicians will begin using computer adaptive testing rather than the current pencil and paper testing method. Delaware will be adopting this method of testing in conjunction with the National Registry. Computer Adaptive testing will be more secure and offer more test date options and opportunities for candidates. Seldom will any two tests on the computer will be exactly alike. Testing is also structured so that the computer will move highly qualified candidates through the test more quickly and challenge less knowledgeable students in areas of weakness. Ultimately it is expected that the percentage of first time pass rates on National Registry tests will also improve, as the computer can adapt the test to examine the skills of each individual in a way that cannot be done with paper and pencil testing. SECTION IX IX. IMPROVEMENT INITIATIVES In this section, the DEMSOC committee would like to highlight initiatives taken by the EMS community. AETNA HOSE HOOK AND LADDER COMPANY • Hiring of two additional career emergency service personnel to increase daytime staffing with a total of THREE emergency medical service crews • Increasing late night EMS coverage with an additional EMS crew from 2400 – 0600 hours for a total of two EMS crews from 2400 – 0600 hours seven days a week • Sent seven emergency service personnel to the annual EMS Expo Conference and Exposition in New Orleans, LA • Developed a “Health and Human Services” program run by the EMS QA/QI Lieutenant with appropriate forms. This program enables crews in the field to document citizens in our community needing direct referral to the State of Delaware Department of Health and Social Services for hazardous living needs. • Purchased a 2005 Freightliner M2 medium-duty BLS unit to replace an older unit with over 180,000 miles • Placed three additional Automated External Defibrillators (AEDs) with EMS equipment including oxygen and airway management tools in strategic locations in our service district. These AEDs and EMS equipment will be used by first responder fire and EMS personnel to enable an enhanced response to Echo level incidents. AMERICAN LEGION AMBULANCE SERVICE 2004 • Purchased 2 Stryker Power Pro stretchers, capable of lifting 700 lbs. These stretchers were purchased to help elevate back injuries with lifting patients. • Updated computer system to better enable EDIN system • Hired one additional full time employee (now have a total of 5 full time employees and 3 part time employees). Recognized the need for additional personnel (whether full time or volunteer) to obtain 24 hour coverage with at least one unit. BRANDYWINE HUNDRED FIRE COMPANY • All EMS Career Staff have been certified as Confined Space entry personnel. • Purchased (2) new Stryker stairchairs to prevent back injuries. • Improved our QA/QI system in order to improve our charts that are written. BOWERS FIRE COMPANY • Have joined with Frederica Fire Company to develop Bowers/Frederica EMS • Provides service M-F from 6am-6pm with career staff CAMDEN-WYOMING FIRE COMPANY • Hired three new career EMT’s • Looking to purchase second ambulance CHESWOLD VOLUNTEER FIRE COMPANY • Currently have 2 BLS units in service 24 hours a day, 7 days a week to cover the increased call volume due to the rapid growth of our district and surrounding communities. • Responded to 1579 EMS calls in 2005 with 946 of those EMS responses being out of district mutual aid responses. • Currently have a staff of 15 active volunteers, 2 Full time employees, and recently added 25 part-time employees to provide coverage to the Cheswold EMS district and mutual aid areas. • We currently staff a full “in station” ambulance crew daily from 0600 hrs – 1800 hrs, with combination and volunteer staffing nightly from 1800 hrs - 0600 hrs. We have also recently purchased a new ambulance to be placed in service in May 2006 at a cost $145,000.00. ELSMERE FIRE COMPANY • 14 Firefighters passed their (national) NFPA FireFighter Level 1 Certifications • Purchased 5 new sets of Fire Gear • Purchased a new Compressor for breathing apparatus (SCBA's) • 10 Members re-certified CPR/AED, 6 Members certified first time CPR/AED • 6 EMTS recertified NREMT-B and State of DE Certification • 2 New EMTs passed NREMT-B certification for the first time • EMT Continuing Ed training provided - 10 CEU classes, 3-day EMS conference Dover, 1-24hr Refresher course FARMINGTON VOLUNTEER FIRE COMPANY • Purchased updated equipment for our First Responder unit such as a new Pulse Ox meter. • Implemented a monthly EMS training night for continued education of our EMTs, First Responders, and firefighters. • Upgraded our patient reports to the EDIN system, versus utilizing the outdated hand written paper reports. HARTLY VOLUNTEER FIRE COMPANY • Two quick response teams • Hired one career NREMT-B LEWES FIRE COMPANY • We have re-chasis two of our ambulances this year • Purchased has been the Powered Pro Series Stretcher from Stryker. It is hydraulically powered for lifting, extending the legs and collapsing them. MILL CREEK FIRE COMPANY • Maintained current status of MCI trailer with 25 critical care bags • Joint CPR training with hospital and local health care providers • Finalized plan on improvements to be started in 2006. • Placed in service a new and second ambulance in Dec of 2005. • Upgraded Stair chair to reduce back injuries. • CPR training for community free of charge. • EMS assisted with designing a new rescue that is better served in extricating patients, arrival date pushed back to March of '06. • AED supplied responders in POVs on scene and another 200 of EMS assists with fire apparatus/utility vehicles. ODESSA FIRE COMPANY • Placed two new Stryker MX Power Pro stretchers into service in order to prevent personnel injuries. • Added battery powered Holmatro tools to both ambulances for rapid extrication needs. • Continued providing yearly CEU's to maintain National Registry Standards for EMT-B's. • Sent EMT's to various national conferences to stay abreast of the latest trends and changes in EMS. TOWNSEND FIRE COMPANY • Scheduled volunteer ambulance crew for the period of 10pm - 4am every day of the week (including weekends). This has greatly enhanced the scratch rates and decreased our out of the door timeframes. DELAWARE STATE POLICE • DSP Aviation implemented 24 hour/7days week state-wide helicopter coverage. • Increased the total number of AED Units in Patrol Vehicles. • Issued Personal Protective Equipment (PPE) to all Troopers. KENT COUNTY EMS ACCOMPLISHMENTS & INITIATIVES (Additional information provided in appendix F) Throughout 2005 the concept of Special Operations became more solidified within the Department. The Special Operations concept follows the more universal “all hazards” model mimicking the structure of the Homeland Security Grant Program and the National Response Plan. Within the Department this concept develops a picture of multi-tasking equipment and personnel while allowing for particular specialization by a few self-motivated staff. Special Operations encompasses the response categories of: • Mass Casualty Incident (MCI) • Hazardous Materials Incidents (Hazmat) • Technical Rescue Operations (high angle, trench, collapse) • Explosive Ordnance and Tactical Support (EOD/SORT) • Fire Ground Support (Rehab) • All-Terrain Medical Response (Bikes & Medic-Gator) • Maritime Operations • Weapons of Mass destruction (WMD) preparedness and response NEW CASTLE COUNTY EMS – PARAMEDICS - ENHANCEMENTS (Additional information provided in appendix G) ORGANIZATIONAL STRUCTURE • The New Castle County Government has restructured and renamed the department as the county Department of Public Safety. The restructure restores the Emergency Medical Services component to division-level status, and places the Chief of Emergency Medical Services as a direct report to the Director of Public Safety. OPERATIONS • A ninth medic unit (Medic 9) has been placed in service on a part time basis. • Employee Safety initiatives including soft body armor and full body foul weather gear • Enhancements to the current fleet of response vehicles include, replacement vehicles and utility vehicle PUBLIC EDUCATION AND COMMUNITY SERVICE New Castle County EMS has maintained an active community outreach program during calendar year 2005 including; • Child safety seat inspections • CPR/First Aid training • Student Learn About Mortality (SLAM) SUSSEX COUNTY EMS ACCOMPLISHMENTS & INITIATIVES (Additional information provided in appendix H) OPERATIIONS • Opened Paramedic Station 107 in Bridgeville which provides services to Western Sussex County • Medic Unit 108 “power” unit, provides services during peak times of activity • Special Operations Coordinator position was created FLEET ENHANCMENTS • All-terrain “Gator” vehicle • Hackney hazardous materials truck • A Medical Resources Unit Trailer • A Hazardous Materials Resources Trailer CLINICAL INITIATIVES • Sussex County was the first ALS agency in Delaware and among the first in the country to use the adult intraosseous infusion device, for alternative means of gaining vascular access. 9am to 9:59am • EMS Paramedic Competition Team was in its first year of existence and won 1st place at the EMS Today “Jems Games” Competition. SECTION X X. DELAWARE STATEWIDE TRAUMA SYSTEM Celebrating 10 Years of Excellence On June 30, 2006, we will mark the 10th anniversary of the passage of legislation creating the Statewide Trauma System. That legislation was the culmination of years of hard work by the state’s hospitals, the Division of Public Health, the Delaware Hospital Association and many others to develop one of the nation’s first statewide Trauma Systems. The passage of this enabling legislation was the first step in systematically improving the level of care that Delawareans receive when they sustain a traumatic injury. Traumatic injury is the # 1 killer and disabler of Delawareans ages 1 to 44 years, and the # 4 killer for all age groups combined. It includes injuries such as those caused by highway crashes involving motor vehicles, bicycles or pedestrians, falls, assaults, shootings, and farm or industrial mishaps. Records show that 4465 citizens and visitors of Delaware were injured seriously enough to require hospitalization in 2004 and of these, 157 persons sustained fatal injuries (Delaware Trauma System Registry, 2004). Because trauma so often involves children and young people, it is responsible for the loss of more years of life than any other cause of death, both nationally and in Delaware. It robs our nation of its most precious resource---its youth. Trauma can occur at any time. It can happen to anyone. Those with critical injuries need to receive definitive care within a short period of time in order to minimize the risk of death and disability. The role of a Trauma System is to organize resources and assure their immediate availability to the injured at all times and in all geographic areas of the system. These resources include 911 Emergency Communications Centers, Basic and Advanced Prehospital Providers, multidisciplinary Trauma Teams in hospital Emergency Departments, and in- hospital resources such as Operating Rooms and Intensive Care Units. Studies have shown that the coordination of these resources which takes place as a Trauma System is developed can result in dramatic reductions in preventable deaths due to injury. Delaware’s Division of Public Health (DPH) began organizing the work on the state’s inclusive Trauma System as early as 1994. Legislation needed to enable the work to progress by granting the Division the authority to designate Trauma Centers was passed in 1996. This year marks the tenth anniversary of this landmark legislation. Delaware’s Trauma System regulations are based largely on the guidelines of the American College of Surgeons’ Committee on Trauma (ACS COT). ACS review teams visit each Level 1, 2, and 3 Trauma Center and report to the Division of Public Health on the facility’s compliance with the Trauma Center Standards before a hospital can be designated as a Delaware Trauma Center. Reviews must be completed every 3 years in order for a hospital to retain its state Trauma Center designation status. Trauma System Participating Hospitals are reviewed every three years by an out-of-state physician consultant and DPH staff. Implementation of Delaware’s Statewide Trauma System took place on January 20, 2000. Current Trauma Center and Trauma System Participating Hospital designations are: Regional Level 1 Trauma Center: Christiana Hospital, Christiana Care Health Services A Regional Resource Trauma Center has the capability of providing leadership and comprehensive, definitive care for every aspect of injury from prevention through rehabilitation. Community Level 3 Trauma Center: Beebe Medical Center Kent General, Bayhealth Medical Center Milford Memorial, Bayhealth Medical Center Nanticoke Memorial Hospital Peninsula Regional Medical Center (Maryland) via reciprocity A Community Trauma Center has the capability of providing assessment, resuscitation, stabilization, and triage for all trauma patients, arranging for timely transfer of those patients requiring the additional resources of a Regional Trauma or Specialty Center and delivering definitive care to those whose needs match the resources of this facility. Reciprocity means that Delaware’s Division of Public Health has accepted the Trauma Center designation conferred by Maryland. Participating Hospital: Alfred I. duPont Hospital for Children St. Francis Hospital Wilmington Hospital, Christiana Care Health Services A Participating Hospital is an acute care facility that transfers moderately and severely injured trauma patients that they may receive to a Trauma Center after initial resuscitation. When necessary, this facility may provide care to trauma patients with minor injuries. Participating hospitals contribute data to the Delaware Trauma System Registry and Quality Improvement Program. They do not receive ambulance patients meeting the Prehospital Trauma Triage Scheme criteria. Delaware joins only a handful of states that have succeeded in establishing inclusive statewide Trauma Systems. Analyses of Delaware’s Trauma System Registry data collected for the five year periods preceding and following Trauma System implementation in 2000 have demonstrated positive steps in Trauma System maturation. Comparison of Pre- and Post-Trauma System implementation data shows a significant decrease in the injury mortality rate for the Level 3 Trauma Centers, with a significant increase in the percentage of patients they are transferring to higher levels of care. Further analysis of Post-Trauma System implementation data shows a significantly higher mean Injury Severity Score among patients discharged from New Castle County hospitals and a significantly higher percentage of patients transferred out from the Level 3 Trauma Centers when compared to the New Castle County hospitals, primarily the Level 1 Trauma Center. These changes demonstrate a positive impact of Delaware’s Trauma System through appropriate utilization of the Level 1 and Level 3 Trauma Centers. Trauma Systems DO Save Lives! Delaware’s Trauma System Registry Statistics for 2004* # % Number of patients in the 2004 Trauma Registry: 4465 100% Gender: Female patients: 1710 38.3% Male patients: 2755 61.7% Age: 9 Years old or under: 437 9.8% 10 to 19 years old: 709 15.9% 20 to 29 years old: 726 16.3% 30 to 39 years old: 507 11.4% 40 to 49 years old: 621 13.9% 50 to 59 years old: 433 9.7% 60 to 61 years old: 292 6.5% 70 years old or greater: 738 16.5% Type of Injury: Blunt Trauma: 4008 89.8% Penetrating Trauma: 380 8.5% Burn Trauma: 70 1.6% Cause of Injury: Bicycle Injuries: 115 2.6% Bites and Stings: 21 0.5% Cut/Pierce Injuries: 195 4.4% Drowning/Submersion Injuries: 18 0.4% Fall Injuries: 1590 35.6% Firearm Injuries: 135 3.0% Fire/Burn/Explosion/Electrical Injuries: 63 1.4% Machinery Injuries: 68 1.5% Motorcycle Injuries: 163 3.6% Motor Vehicle Injuries: 1216 27.2% Transport, Other: 248 5.6% Natural Environmental Injuries: 24 0.5% Pedestrian Injuries: 169 3.8% Struck by, Against: 264 5.9% Other Injuries: 178 4.0% Admissions to Emergency Department by Day: Sunday: 704 15.8% Monday: 597 13.4% Tuesday: 577 12.9% Wednesday: 546 12.2% Thursday: 605 13.5% Friday: 653 14.6% Saturday: 783 17.5% Arrival in Emergency Department by Hour: 12:00AM-08:00AM 780 17.5% 08:00AM-04:00PM 1707 38.2% 4:00PM-12:00AM 1,976 44.3% Hospital Length of Stay: 0 Days: 2 0.0% 1 Day: 1871 41.6% 2 Days: 676 15.0% 3 Days: 502 11.1% 4 Days: 349 7.8% 5-6 Days: 400 8.9% 7 + Days: 703 15.6% Hospital Discharge Disposition: Home: 3475 77.2% Acute Care Hospital, Transfer: 119 2.6% Rehab Facility, Inpatient: 282 6.3% Skilled Nursing Facility: 339 7.5% Medical Examiner/Morgue: 157 3.5% Prison/shelter/psychiatric facility: 86 1.9% AMA/Unknown: 45 1.0% Injury Severity Score: A retrospective score derived by applying a prescribed scoring system and mathematical formula to a listing of a trauma patient’s injuries, allowing objective comparison of trauma patients based on injuries. 01-08 Points (Minor Injury): 2306 51.2% 09-15 Points (Moderate Injury): 1388 30.8% 16-24 Points (Significant Injury): 412 9.1% 25-40 Points (Major Injury): 291 6.5% 41-74 Points (Catastrophic Injury): 57 1.3% 75 Points (Incompatible with life): 7 0.2% Unknown Score: 42 0.9% *Latest data available with all hospitals reporting. Excludes patients not transported to a hospital. Data quality may cause discrepancies in total number of patients for some parameters. SECTION XI XI. CARDIOVASCULAR CARE PROGRAMS An essential focus of any EMS system is its ability to effectively treat cardiac arrest patients. As our EMS system matures, we realize that more effort and better organization is needed to provide optimum EMS care for patients with cardiac and cardiovascular related complaints. Two of the leading causes of death in Delaware are Heart-related disease and Stroke, which according to the Delaware Office of Vital Statistics accounts for 34.6% of all deaths. By expanding on the existing CPR/AED program within the OEMS, this initiative will provide a platform of data and research useful in prevention activities, as well as treatment and care. Goals of this initiative include: • Working with EMS providers and other agencies to address specific issues concerning the prevention and prehospital treatment of cardiac disease and stroke. • Organize statewide EMS efforts in the areas of prevention and public education, public access defibrillation and prehospital treatment of cardiac/stroke patients in order to measurably reduce mortality and morbidity associated with these disease processes. Automatic Defibrillator and CardioPulmonary Resusciation Program (AED/CPR) The Delaware Office of Emergency Medical Services (OEMS) is charged with "coordinating a statewide effort to promote and implement widespread use of semi-automatic external defibrillators and cardio-pulmonary resuscitation…" (DelCode Title 16, Chap 97). In fiscal year 2001 The OEMS with funding and support from the Health Fund Advisory Committee developed the First State, First Shock! Early Defibrillation Program. What are the goals of this program? • Decrease death and disability in Delaware by decreasing the time to defibrillation in cardiac arrest patients. • Strengthen the Chain of Survival in Delaware by: • Supporting heart health promotion and early recognition of heart attack activities. • Increasing the accessibility to AEDs within our state. • Increasing the number of Delawareans trained in CPR/AED. • Tracking outcome to guide future efforts. PROGRAM PERFORMANCE AEDs Purchased FY 2001 375 FY 2002 230 FY 2003 100 FY 2004 97 FY 2005 90 FY 2006 325 Fiscal Year 2001 (July 1, 2000 – June 30, 2001): • First year of funding from the Health Fund Advisory Committee (HFAC). • Initial plan was for 3 years of funding from the state’s HFAC Fiscal Year 2002 (July 1, 2001 – June 30, 2002): • The state’s high schools received AEDs • The OEMS applied for and was awarded 1-year of funding through the Rural Access to Emergency Devices grant program (federal funding). Fiscal Year 2003 (July 1, 2002 – June 30, 2003): • Instructor training courses began. • The Office of EMS applied for and was awarded a 3-year non competitive grant through the Rural Access to Emergency Devices Program. o This funding is to provide AEDs and support to federally designated rural areas and surrounding agencies which provide mutual aid. o Fiscal year 2005 will be the final year of the grant. Fiscal Year 2004 (July 1, 2003 – June 30, 2004): • The train-the-trainer program initiated under the 2003 Rural Access grant has been expanded. • Additional funds will be utilized to purchased batteries and other equipment to assure sustainability of the initiative. Fiscal Year 2005 (July 1, 2004 – June 30, 2005) • Expanded 1st responder definition • Any person who has a “duty to act” or “duty to respond” • Includes school nurses, safety teams, lifeguards etc… • Second “tier” responders • Those individuals by nature of there job would respond to an incident • Store/Business manager etc… Fiscal Year 2006 (July 1, 2005 – June 30, 2006) • New challenges identified o Manufacturer slow to produce units o Changes in AHA guidelines • Retraining of individuals • Replace “old” equipment (subject to appropriations) • AHA guideline changes o Recommends bi-phasic units o New CPR and AED protocols AED Usage Prior to ALS arrival FY 2003 56% Actual FY 2004 65% Actual FY 2005 70% Actual FY 2006 72% Projected FY 2007 75% Goal FY 2008 80% Goal FY 2009 85% Goal *EMS Cardiac arrest, BLS or First Responder arrival prior to ALS CPR / AED Training FY 2001 2650 FY 2002 1400 FY 2003 630 22 Instructors FY 2004 300 35 Instructors FY 2005 100 15 Instructors • Number of persons trained in CPR/AED through this program First State, First Shock Program Facts Where Delaware Stands 1999 • 360 AEDs registered with the Office of EMS. • 580 reported cardiac arrests. 2002 • 1,365 AEDs registered with the Office of EMS. • 506 reported cardiac arrests. 2003 • 1,965 AEDs registered with the Office of EMS. • 790 reported cardiac arrest 2004 • 2110 AEDs registered with the Office of EMS • 780 reported cardiac arrests 2005 • 2328 AEDs registered with the Office of EMS • 770 reported cardiac arrests Number Patients Patients Patients that of Pronounced Tranported Experienced a Cardiac Dead by to Return of Year Arrest Paramedics Hospital Circulation 2004 780 170 610 158 (26%) 2005 770 185 585 170 (29%) Cardiac Arrest by Location 1. Home / Residence 2. Public Place 3. Care Facility 4. Street 5. Other 6. Work EMS Implications of the 2005 AHA Guidelines In November, 2005 the American Heart Association modified their recommended cardiovascular care guidelines. This change in guidelines will make an enormous impact on the Delaware First State/ First Shock program as well as cardiovascular care in our state. The AHA guideline changes affect all levels of care from bystander CPR through hospital treatment. The most significant change in regards to CPR is a uniform number of compressions versus ventilations in all age groups with the exception of the newborn. The new ratio is 30 compressions to 2 ventilations. Another significant change that affects the program is the change in AED usage. Past guidelines recommended up to a three shock series to treat cardiac arrest. New guidelines state a single shock followed immediately by two minutes of CPR. This change was made to decrease delays in CPR. There are two different types of AEDs based on the type of energy waveform that they utilize monphasic and biphasic. OEMS with funding from the Health Fund Advisory Committee, Emergency Tech Fund and the Rural Access to Emergency devices grant program have purchased and placed over 1100 AEDs within the state. Of those placed, 835 are monophasic AEDs which are not reprogrammable and do not meet new AHA guidelines. The remainder of the AEDs are biphasic which can and will be reprogrammed. In a publication by the American Heart Association promulgating their new ECC Guidelines it states, “No specific waveform (either monophasic or biphasic) is consistently associated with a higher rate of return of spontaneous circulation (ROSC) or rates of survival to hospital discharge after cardiac arrest”. In response to the AHA changes the Office of Emergency Medical Services has taken the following position: The original LP 500 monophasic AEDs should continue to be used with the pre-November 2005 guidelines. These units are still functional and there have been many successful uses of these devices. The Office of Emergency Medical Services will replace these models subject to appropriations. Until all units have been exchanged, the State will have 2 distinct protocols for AED usage. This will have ramifications throughout the Emergency Responder community. There have also been significant changes in CPR protocols. AHA goal is to update training during an individual’s recertification course. Certification is every 2 years, it is estimated that it will take approximately 3 years to “roll out” new guidelines. Heart-related Disease Stroke Programs In 2005, Delaware Paramedics treated over 5200 patients with cardiovascular related complaints. Future direction includes further development of EMS system capacity for treating cardiac and cardiovascular complaints. The goal of such a system is to “Decrease death and disability, improve the quality of life, and to maximize patient outcome by delivering evidence-based effective, efficient and safe care from pre-hospital management through transport in a timely fashion to the most appropriate care facility”. There has been a movement within state’s hospitals to expand their capability to provide timely access to cardiac catheterization to patients. Some of our state’s hospitals are developing cardiac specialty centers. Nationwide there is a push to identify “stroke centers” with the goal of providing optimal treatment for stroke patients. EMS resources must be integrated with the hospitals to ensure seamless care of patients as they are brought from the field into the hospital. Cardiac Care Real time data to the current capabilities of the various cardiac centers should be readily available, as is done with our state’s trauma centers. It is imperative that EMS providers know where to take each type of patient based on their condition, and that the receiving facility is capable of properly treating patients as they are brought in, or transferring them to a facility that can care for them in a timely fashion. The Statewide Standard Treatment Protocols for paramedics within our state have begun to address this issue. Currently any patient who presents with signs and symptoms of Acute Myocardial Infarction (AMI) are to have a 12 lead EKG performed. Any patient who is deemed to have an EKG that is suspicious of an AMI should be transported to an emergent Percutaneous Coronary Intervention (PCI) capable facility. In the 2nd half of 2005, 5200 patients had a 12 lead EKG performed, 320 patients were “diagnosed” with an AMI and another 125 patients (approximately) where identified as potential candidates for PCI. Instituting a Cardiac Alert/Cardiac Code , is a strategy to identify the AMI in the field, notify the hospital immediately and then transport emergent to a specialized care hospital that utilizes cardiac catheterization for the treatment of AMI. Studies have shown that this strategy may reduce the diagnostic time about 30 minutes and is significant in bringing the vital hospital "door to balloon" time below 90 minutes, the national gold standard for this procedure. A recent study conducted by Christiana Care evaluated the effect of a systematic response to AMI and found that the patients reviewed had a lower mortality rate as well as a shorter hospital stay when identification and treatment followed a systematic response model. This rapid treatment has a tremendously beneficial effect on the patient because during a heart attack "time is muscle”. Stroke Programs The American Heart Association emphasizes the importance of rapid appropriate care and transportation. Studies on acute stroke management have shown that there is a narrow therapeutic window that mandates rapid identification, transport, diagnosis, and treatment; any delay undermines the system and the quality of care available to the acute stroke patient. EMS plays an important role in the management of stroke patients. EMTs and paramedics are responsible for transport decisions regarding level of transport, speed of transport, and destination of transport. There is strong evidence to support improved outcomes of stroke patients who are managed in established stroke centers. EMS training curricula needs to place more emphasis in the areas of stroke. If possible, EMS providers should attempt to identify the time of onset of symptoms. In addition, AHA recommends consideration of transporting a witness (family member, co-worker etc) with the patient to assist with the gathering of time-sensitive information. Dispatchers and EMTs have limited instruction on stroke diagnosis and management which can contribute to a small number of acute stroke patients arriving in the ED within the therapeutic window. Statewide integration and development of a cardiovascular system will make Delaware a leader in the treatment of cardiovascular complaints. It will further integrate Emergency Medical Services into the general healthcare system of the state. SECTION XII VI. EMERGENCY MEDICAL SERVICES FOR CHILDREN (EMSC) In 1997 Delaware was awarded a federal grant through the Maternal Child Health Bureau to improve Emergency Medical Services for Children (EMSC). In 2005 we are still dependent upon yearly federal grant funding for EMSC to meet children’s needs in our ever-changing EMS System. Most recently, enhanced pediatric training was provided to prehospital personnel through delivery of the 16 hour Pediatric Education for Prehospital Professionals (PEPP Course). Delaware is using the information system to better address pediatric EMS issues and reduce child mortality and morbidity sustained from severe illness and/or trauma. We are identifying Children with Special Healthcare Needs (CSHCN), through implementation of the Special Needs Alert Program (SNAP) and we are working towards improving EMSC by meeting objectives that institutionalize EMSC in Delaware. EMSC objectives for 2004-2007 are to: Objective #1: Develop the EMSC System: 1A. Throughout the grant cycle 2004-2007, Delaware will continue to pursue an effective strategy to institutionalize EMSC in the state EMS System. 2005 Progress – DEMSOC is considering the inclusion of EMSC in proposed legislation for 2006. Objective #2: Prevent childhood injuries: 2A. Conduct a one-day annual children’s injury prevention conference (three conferences by March of 2007) with the Delaware SAFE KIDS Coalition or other community organization targeting emergency personnel and others as participants. 2005 Progress-two conferences were held, one in 2004 and one in 2005. The last SAFE KIDS/EMSC conference is planned for June 21, 2006. 2B. Introduce the Risk Watch injury prevention program into 200 more classrooms in Delaware each year of the funding period for a total of 600 new Risk Watch classrooms by March of 2007. 2005 Progress – Risk Watch is in 66 Delaware schools, 797 classrooms serving 18,200 students as of December 31, 2005. The Risk Watch program was physically moved over to the Delaware State Fire School in July of 2005 to facilitate delivery of the program. Objective #3: Provide pediatric training: 3A. Provide Pediatric Education for Prehospital Providers (PEPP) training to 50 paramedics and 100 BLS providers in Delaware, by March of 2007. 2005 Progress- All ALS providers in the three counties and the State Police Aviation Section completed the PEPP Course in February 2006 (approximately 250 paramedics). 3B. Disseminate the “Triaging Kids During a Disaster” training CD-ROM developed for Delaware by the Critical Illness and Trauma Foundation to the state’s five ALS agencies and to 100 percent of the BLS agencies. Goal is 50 percent participation, evidenced by completion of learning activities and a printed out post-test on the CD-ROM, submitted to the OEMS by ALS and BLS providers (100 paramedics and 500 BLS) by March of 2007. 2005 Progress-the CD will be used for ALS distance learning continuing education in May of 2006 and was shared with Delaware State Fire School for BLS dissemination. Objective #4: Disseminate pediatric data: 4A. Include a pediatric data section in the annual Delaware Emergency Medical Services Oversight Council Report to the Governor and EMS leaders. 2005 Progress-objective was met in 2005 and will continue as a section of this report. Objective #5: Implement the Special Needs Alert Program (SNAP) for children with special health care needs. 5A. Coordinate with state Maternal Child Health (MCH) staff to promote awareness of and enroll a minimum of 15 children per year in SNAP in 2004 and 2005 (30 children by the end of the project period). 2005 Progress-60 families are enrolled in the program statewide. 5B. By March of 2005, evaluate the effectiveness of SNAP with families and EMS providers through phone and written surveys. 2005 Progress-The evaluation will be completed and data will be analyzed by the University of Delaware Center for Disabilities Studies by August of 2006. EMSC Data This is the second year the OEMS is using EDIN to determine where pediatric calls are occurring in Delaware, what the most frequent primary impressions are recorded on pediatric calls and which procedures ALS and BLS providers most frequently perform on pediatric calls. Table E-1 Number of Pediatric Incidents by Age Age ALS BLS Total Ages 0 to 1 27 60 87 Ages 1 to 2 367 746 1,113 Ages 2 to 4 520 1,167 1,687 Ages 5 to 9 516 1,304 1,820 Ages 10 to 14 598 1,633 2,231 Ages 15 to 19 1,470 4,139 5,609 Total 3,498 9,049 12,547 Table E-1 and Graph G-1 The number of pediatric emergency calls is on the increase. Particularly in the 0-1 (newborn-24 months) age group. There was a 21% increase in the number of calls in this age group. This finding warrants further investigation as Delaware has the 7th highest infant mortality rate in the country. In the 2-4 year age group the number of EMS calls increased from 2004 by nine percent. This is concerning because overall increase in calls was only five percent. EMSC staff will examine more closely the alarming increase in the 2 to 4 year old age group. Graph G-1 (Not shown) Total Number of Pediatric Reports (Ages 0-19) According to Patient Age Above in table E-1 and Graph G-1 it is clear that the highest number of incidents for BLS providers is in the 15-19 year old age group. Upon further investigation 20% of those BLS runs are due to motor vehicle crashes, while 31% of the ALS runs in the 15-19 year old group are due to motor vehicle crashes. Table E-2 Total Number of Pediatric Service (Ages 0-19) Reports by Ambulance Service in the EDIN System 2003 2004 2005 Aetna Hose Hook and Ladder 741 635 754 Ambulance Service Incorporated 427 197 0 Bethany Beach Fire Company 1 0 0 Blades Fire Company 70 69 79 Bowers Fire Company 15 31 26 Brandywine Hundred Fire Company 226 202 201 Bridgeville Volunteer Fire Company 57 91 100 Camden - Wyoming Fire Company 201 171 216 Carlisle Fire Company (Milford) 80 103 159 Cheswold Fire Company 88 179 157 Christiana Care LifeNet 1 4 1 Christiana Fire Company 713 651 661 Claymont Fire Company 216 241 257 Cranston Heights Fire Company 122 136 161 Dagsboro Fire Company 45 61 43 Delaware City Fire Company 169 145 203 Delaware State Police 73 95 109 Delmar Fire Company 8 5 3 Ellendale Fire Company 0 0 7 Elsmere Fire Company 137 156 148 Felton Fire Company 85 84 136 First State Quality Transport 1,194 1,102 1,180 Five Points Fire Company 89 127 123 Frankford Fire Company 46 45 43 Frederica Fire Company 16 28 24 Georgetown American Legion Ambulance 191 205 229 Goodwill Fire Company 69 118 103 Greenwood Fire Company 42 50 59 Gumboro Fire Company 41 26 34 Harrington Fire Company 114 139 117 Hockessin Fire Company 162 143 116 Holloway Terrace Fire Company 126 103 94 Indian River Fire Company 1 0 0 Kent County EMS 643 690 683 Laurel Fire Company 186 187 198 Leipsic Fire Company 2 17 17 Lewes Fire Dept. 152 110 131 Little Creek Fire Dept. 2 1 2 Magnolia Fire Company 47 72 37 Mid-Sussex Rescue Squad 77 98 101 Millcreek Fire Company 295 281 245 Millsboro Fire Dept 144 173 156 Millville Fire Company 175 195 157 Milton Fire Company 1 5 50 Minquadale Fire Company 100 170 120 Minquas Fire Company 14 127 146 New Castle County EMS 1,695 1,630 1,840 Odessa Fire Company 52 58 90 Port Penn Fire Company 3 17 15 Primecare Medical Transport (PMT) 0 201 465 Rehoboth Beach Fire Company 159 134 127 Roxana Fire Company 63 67 57 Seaford Fire Company 107 251 201 Selbyville Fire Company 38 27 49 Shore Emergency Educators, Inc. 0 1 0 Slaughter Beach Fire Company 2 10 3 Smyrna American Legion Ambulance 137 158 167 Sussex County EMS 849 876 865 Talleyville Fire Company 151 170 196 Townsend Fire Dept 1 0 56 University of Delaware- UD1 166 219 189 Volunteer Hose (Middletown) 245 254 252 Wilmington Fire Department 0 173 190 Wilmington Manor Fire Company 121 197 199 In table E-2 above, as expected, the ambulance services with the highest volumes of calls also see the highest number of children. For the BLS agencies - First State Quality Transport, Aetna Fire Company, and Christiana Fire Company saw the highest volumes of children in the state respectively. Aetna had the largest percentage increase in pediatric calls going from 635 calls to 754 calls for an almost 19% increase in the number of pediatric calls. For the ALS agencies; New Castle County saw 1,840 (1,630 in 2004), Sussex saw 865 (down from 876 in 2004) and Kent saw 683 (down from 690 in 2004) pediatric patients during 2005. This is a 13% increase in pediatric calls for New Castle County EMS. This information on where pediatric calls are located can be used to identify local training needs. Table E-3 Types of Pediatric Patients (Ages 0-19) Seen by EMS Providers Medical Trauma Medical/Trauma OB/GYN Total Advanced Life Support 2,417 950 130 1 3,498 Basic Life Support 4,872 3,596 573 8 9,049 Total 7,289 4,546 703 9 12,547 New Out Kent Castle Sussex of County County County State Total Medical Advanced Life Support 461 1,362 592 2 2,417 Basic Life Support 736 3,193 925 18 4,872 OB/GYN Advanced Life Support 0 1 0 0 1 Basic Life Support 4 4 0 0 8 Trauma/Medical Advanced Life Support 30 61 38 1 130 Basic Life Support 92 312 165 4 573 Trauma Advanced Life Support 225 448 267 10 950 Basic Life Support 577 2,161 836 22 3,596 Graph G-2 ALS/BLS Patient Classification 2005 ALS 69% Medical 27% Trauma 4% Trauma/Medical BLS 54% Medical 40% Trauma 6% Trauma/Medical Table E-3 and Graph G-2 The majority of pediatric ALS emergency calls are for medical reasons (69%). A little over half of all pediatric BLS calls are medical in nature (54%). Overall ALS medical calls were up 16% in 2005 compared to 2004, while BLS medical calls were only up 11%. ALS trauma calls were down 5% and BLS trauma calls were only up 3% over last year. Graph G-3 Pediatric Patients Ages 0-19-Pediatric Ages 0-19-Top 10 Primary Impressions by Prehospital Providers (Not shown) Graph G-4 Pediatric Patients Ages 0-19-Top 10 Pediatric Procedures by Prehospital Providers (Not shown) As in 2004 the most frequent procedure performed for pediatric patients in 2005 by ALS and BLS is assessment of vital signs. It is noted that BLS agencies very infrequently contact medical control for assistance in the field. Of the top ten procedures performed in the field three of the procedures are related to spinal stabilization and OEMS will look at this field to assess if it can be consolidated into one procedure. ALS providers most frequently start intravenous lines and monitor blood glucose in children. Documenting what procedures are most frequently performed with children helps OEMS identify training needs. SECTION XIII XIII. DOMESTIC PREPAREDNESS EMS provider agencies throughout the state continue to work with local, state and federal government to ensure that our providers are prepared to respond to any type of disaster, whether it is naturally occurring or a terrorist event. This preparation falls into several key areas: Planning, Training, Exercises, and Equipment. Efforts have been ongoing throughout the year to ensure that EMS is incorporated into preparedness plans at all levels. Each paramedic services in the state and a large number of BLS services have received National Incident Management System (NIMS) training. All providers at all levels must receive this training to comply with federal mandates. Various EMS capabilities have been tested during numerous exercises in 2005, with more training and exercises scheduled throughout 2006. Toxmedic Protocols These protocols were developed to delineate the requirements and responsibilities of various agencies when providers or patients are exposed to hazardous substances. Patients who have been exposed to chemicals and weapons of mass destruction often require procedures, medication and treatments that are not in the scope of a normal field paramedic. Participation in the Toxmedic program by Delaware paramedic agencies is elective. Currently each ALS agency has participated in training. Each paramedic identified as a “Toxmedic” has successfully completed the Advanced Hazmat Life Support Course (AHLS). AHLS program is a 2-day, 16 hour course. The AHLS program focuses is on medical management of people exposed to hazardous materials, including nuclear, biological and chemical terrorism. Participants are trained to provide rapid assessment of hazmat patients, recognize toxic syndromes, provide medical management for hazmat patients, apply the poisoning treatment paradigm and administer specific antidotes. Nerve agent antidote protocols for BLS and Public Safety The protocol was designed to outline the process by which BLS and Public Safety agencies may train, acquire, maintain, use and discard of MARK I kits. It is recognized that during an act of chemical terrorism or hazardous materials incident that Emergency Responders may be exposed to harmful, even fatal doses of nerve agents. In these situations, responder’s may need to administer life saving medications to themselves or fellow responders in a rapid time frame. The decision to participate in the MARK I program is voluntary however; those agencies wishing to participate must comply with the Nerve Agent Antidote protocol which outlines training and QA/QI requirements. Cooperative Train-the-Trainer Effort In 2005, OEMS participated in a program sponsored by The National Association of State EMS Directors, the National Highway Traffic Safety Administration and the National Fire Academy to provide NIMS training and incident command training to EMS providers in each state. Delaware sent 2 individuals to participate in Train the Trainer programs for: • Introduction to Unified Command for Multi-agency and Catastrophic Incidents • NIMS/Incident Command for • Fire Service • EMS • The National Response Plan Pandemics Our EMS providers throughout the state are preparing to meet the challenges that would be presented through the effects of a pandemic incident. Several exercises and training sessions have been completed concerning Avian Flu, smallpox and other diseases that could infect Delaware. Provisions are being made to ensure that our provider workforce is adequately protected during such an event so that EMS field care can remain intact. Trauma The majority of potential terrorist events involve some sort of blast or traumatic injury inflicted upon the victims. Emphasis on our statewide trauma system and the EMS care of patients injured by blast or trauma has become more important than ever. EMS agencies throughout the state are working together to develop plans that ensure trauma patients in mass casualty situations get to proper care as quickly as possible. APPENDICES Appendix A HOUSE OF REPRESENTATIVES 140th GENERAL ASSEMBLY HOUSE BILL NO. 332 AS AMENDED BY HOUSE AMENDMENT NOS. 2,4,5, 6, 7 & 8 AN ACT TO AMEND TITLE 16 OF THE DELAWARE CODE RELATING TO PARAMEDIC AND OTHER EMERGENCY MEDICAL SERVICE SYSTEMS. BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF DELAWARE: WHEREAS, the Delaware Emergency Medical Services (EMS) system is made up of over 1700 emergency care providers including paramedics, emergency medical technicians, volunteers, dispatchers and first responders; WHEREAS, the dedication of the emergency care providers has helped thousands of Delawareans in times of need and crisis; WHEREAS, these individuals have a long history of dedication and commitment to improving and protecting the health and safety of all Delawareans; WHEREAS, notwithstanding the dedication and commitment of these emergency care providers, the current EMS system has several weaknesses that must be addressed in order for the system to achieve optimal performance for the citizens of our State; WHEREAS, Delaware’s EMS system must focus on achieving specific goals for an optimal system that, if attained, will result in an improved system for the people of Delaware; WHEREAS, specific goals for response times and other performance measures do not currently exist; WHEREAS, the General Assembly hereby establishes a goal that the Delaware EMS system provide cardio-pulmonary resuscitation (CPR) within 4 minutes of the receipt of Delta calls on at least 90 % of the times in urban areas and 70 % of the times in rural areas. WHEREAS, the General Assembly hereby establishes a goal that the Delaware EMS system provide Automatic External Defibrillation (AED) within 6 minutes of Delta calls on at least 90 % of the times in urban areas and 70 % of the times in rural areas. WHEREAS, the General Assembly hereby establishes a goal that each Advanced Life Support (ALS) paramedic agency within the Delaware EMS system provide an ALS paramedic unit, as defined by recognized state standard, on the scene within 8 minutes of the receipt of Delta calls on at least 90 % of the times. WHEREAS, the General Assembly hereby establishes a goal that each Basic Life Support (BLS) ambulance agency within the Delaware EMS system provide a BLS ambulance unit on the scene within 10 minutes of the receipt of Delta calls on at least 90 % of the times in urban areas and 70 % of the times in rural areas. WHEREAS, the General Assembly hereby establishes a goal that each ALS paramedic agency within the Delaware EMS system provide an ALS paramedic unit, as defined by recognized state standard, on the scene within 8 minutes of the receipt of Charlie calls on at least 90 % of the times. WHEREAS, the General Assembly hereby establishes a goal that each BLS ambulance agency within the Delaware EMS system provide a BLS ambulance unit on the scene within 12 minutes of the receipt of Charlie calls on at least 90 % of the times in urban areas and 70 % of the times in rural areas. WHEREAS, the General Assembly hereby establishes a goal that each BLS ambulance agency within the Delaware EMS system provide a BLS ambulance unit on the scene within 12 minutes of the receipt of all Bravo calls on at least 90 % of the times in urban areas and 70 % of the times in rural areas. WHEREAS, the General Assembly hereby establishes a goal that each BLS ambulance agency within the Delaware EMS system provide a BLS ambulance unit on the scene within 18 minutes of the receipt of all Alpha calls on at least 90 % of the times in urban areas and 70 % of the times in rural areas. WHEREAS, the General Assembly hereby establishes a goal that in cases involving cardiac arrest, each EMD center within the Delaware EMS system process all calls for assistance within 45 seconds in at least 90 % of such cases. WHEREAS, timely pre-hospital and inter-facility air medical transport should be available in 95% of cases where helicopter transport is appropriate; WHEREAS, the General Assembly hereby establishes a goal that in all other cases, each EMD center within the Delaware EMS system process all calls for assistance within 72 seconds in at least 90 % of such cases. WHEREAS, all components of the system should uniformly and electronically collect the data necessary to measure performance against the previously stated goals; WHEREAS, the performance of each component of the system against the above stated goals should be routinely made available to the public; WHEREAS, attainment of these goals will require changes to the current EMS system; WHEREAS, the availability of CPR and AED within medically required time frames will require utilization of BLS as first responders, law enforcement officers on patrol and increased public awareness and access to AED; WHEREAS, for the Delaware EMS system to meet its response time goals, the public must be active participants especially in providing CPR and the use of AEDs; WHEREAS, current law overly restricts the ability of ALS managers to deploy their resources effectively and efficiently thus hampering performance; WHEREAS, ALS managers need flexibility to deploy ALS resources, subject to appropriate medical oversight; WHEREAS, the State Fire Commission lacks the statutory authority to manage BLS in terms of response times and performance; WHEREAS, the regulatory authority of the State Fire Prevention Commission over BLS services should be significantly broadened and strengthened; WHEREAS, the Delaware EMS system is a medical system that requires comprehensive medical involvement and oversight; WHEREAS, medical oversight should be increased and restructured to ensure that all components of the system are performing according to generally accepted medical protocols; WHEREAS, members of the General Assembly, the Governor, the public and other policy makers should know the costs of Delaware’s EMS system in order to measure its effectiveness; WHEREAS, all components of the EMS system should report revenues and expenses so that the system can be continually evaluated for its cost effectiveness; WHEREAS, emergency medical services is a system with several providers and proper oversight of that system is necessary to ensure effectiveness and to reduce fragmentation; WHEREAS, an EMS Oversight Council charged with the on-going responsibility of monitoring the system and making recommendations for system is necessary; and WHEREAS, the General Assembly, the Governor and the public and other policy makers should recognize that in order to meet the goals of this legislation a commitment of money and other resources may have to be provided by the State of Delaware or other sources. NOW, THEREFORE: BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF DELAWARE: Section 1. This Act shall be known as the Delaware Emergency Medical Services System Improvement Act of 1999. Section 2. Amend § 9703, Title 16, Delaware Code by deleting said section in its entirety and inserting in lieu thereof the following: "§ 9703. Delaware Emergency Medical Services Oversight Council. a. There is established the Delaware Emergency Medical Services Oversight Council (DEMSOC). The Council shall consist of the following members: 1. A representative of the Office of the Governor appointed by the Governor: 2. The Secretary of the Department of Public Safety; 3. The Secretary of the Department of Health and Social Services; 4. The Chair of the Delaware State Fire Prevention Commission or another Commissioner selected by the Chair; 5. The President of the Delaware Volunteer Fireman’s Association; 6. The Colonel of the New Castle County Police Department or, at the Colonel's discretion, the Director of New Castle County Emergency Medical Services; 7. The Kent County Administrator or, at the Administrator’s discretion, the Kent County EMS Chief; 8. The Sussex County Administrator, or at the Administrator’s discretion, the Sussex County EMS Director; 9. The President of the Delaware Chapter of the American College of Emergency Physicians; 10. The State EMS Medical Director; 11. The Chair of the Trauma Systems Committee; 12. A practicing paramedic, certified and employed in the State of Delaware, appointed by the Governor; 13. The Chair of the DVFA Ambulance Advisory Committee; 14. Two (2) additional at-large members appointed by the Governor; and 15. The President of the Delaware Healthcare Association or, at the President’s discretion, a representative of the Delaware Healthcare Association. 16. The Executive Director of the Medical Society of Delaware or, at the Executive Director’s discretion, a representative of the Medical Society of Delaware; and 17. The Chair of the Delaware Police Chiefs’ Council or, at the Chair’s discretion, a representative of the Delaware’s Police Chief’s Council. On July 1, 2003, the Pre-Hospital Advanced Care Directives (PACD) were published in the Delaware Register of Regulations, and became effective July 10, 2003. For a complete copy of the PACD Regulations, refer to the July 1, 2003 Delaware Register of Regulations, pages 85-94. The following two (2) pages contain the physician Pre-Hospital Advanced Care Directive (PACD) form developed by the Office of Emergency Medical Services. Although the form has the word “Sample” written across it, this is only for unauthorized duplication protection, and is an example of the actual form currently in use by licensed, practicing physicians within the State of Delaware. DELAWARE HEALTH & SOCIAL SERVICES DIVISION OF PUBLIC HEALTH - OFFICE OF EMERGENCY MEDICAL SERVICES PRE-HOSPITAL ADVANCED CARE DIRECTIVE (PACD) FOR TERMINAL ILLNESS ONLY SCOPE OF EMERGENCY MEDICAL SERVICES CARE I, __________________________________, (please print your full name), request the following emergency medical care in the event I am incapacitated due to my terminal illness. _____ Option A: (Advanced Life Support (ALS)) – Maximal (Restorative) Care Before Arrest, Then DNR. Individual shall receive the full scope of restorative interventions permissible under the Delaware Statewide ALS treatment protocol. _____ Option B: (Basic Life Support (BLS)) – Limited (Palliative) Care Only Before Arrest, Then DNR. Individual shall receive comfort care for control of signs and symptoms. _____ Option C: (Do Not Resuscitate (DNR)) – No Care Administered Of Any Kind Individual is permitted to reject care of any kind provided there is a signed order clearly stating this course of action. Where this option is in place, no form of comfort care or life saving efforts of any kind will be administered by Emergency Medical Service personnel under any circumstances, unless the individual provides some form of communication such as verbally, eye blink, finger tap, or some other similar form of communication, to indicate the desire to revoke the existing PACD order in place. I understand that Do Not Resuscitate means that upon my rejection of any life- saving care efforts, if my heart stops beating or I stop breathing due to my present terminal illness no medical procedure to restart breathing or heart functioning will be instituted by emergency medical service personnel. _______________________________________________________________________________ Patient/Surrogate Signature Date _______________________________________________________________________________ Surrogate’s Relationship to Patient I affirm that this patient/surrogate is making an informed decision and that this Pre-Hospital Advanced Care Directive is the expressed wish of the patient. _______________________________________________________________________________ Physician Signature Date _______________________________________________________________________________ Print Name Telephone _______________________________________________________________________________ Address City State Zip _______________________________________________________________________________ Patient’s Name (Print) Telephone _______________________________________________________________________________ Address City State Zip As is cited in Section 2513(b) of the Death with Dignity Act (Code of Delaware), and in the Pre-Hospital Advanced Care Directive Regulations Section 7.0; willful concealment, destruction, falsification or forging of an advance directive, without the individual’s or authorized decision maker’s consent, is a class C felony. Record Keeping Instructions: The original live-signature copy of this document is to be kept with the patient’s permanent medical records/files at the facility providing the primary care for the patient; i.e., health care provider (physician’s office), Hospital, Nursing Home, or other health care provider facility. A copy of this document is to be kept with the patient either at the patient’s home, or the health care facility where the patient is admitted and receiving medical care/treatment. -------------------------------------------------------------------------------- Patient PACD Card Instructions: Once the information has been completed below, punch card out on the perforated lines, fold in half, and carry on your person at all times (wallet, purse, etc.). Present this card, along with the copy of your signed PACD form, to emergency medical personnel upon their response arrival. -------------------------------------------------------------------------------- Front of Card Back of Card Delaware Health & Social Services An official State of Delaware PACD Form Division of Public Health signed by the patient’s physician and Pre-Hospital Advanced Care Directive the patient/surrogate must be presented (PACD) to EMS personnel along with this wallet Wallet Identification Card identification card at the time of emergency response for this wallet This PACD wallet identification card identification to be valid and honored. has been issued to the recipient listed below. ________________________________________ Physician Name Date ____________________________________ ________________________________________ Patient Name Date Physician Signature ____________________________________ Patient Signature [Option #] -------------------------------------------------------------------------------- Appendix B: County Advanced Life Support Response Time Data Percentage When Kent County ALS Arrived On-Scene in 8 Minutes or Less On Delta-Echo Level Incidents 2000 2,566 Incidents 57.20% 2001 2,604 Incidents 57.20% 2002 2,381 Incidents 54.10% 2003 2,767 Incidents 56.30% 2004 3,865 Incidents 50.40% 2005 3,610 Incidents 52.90% Average 2,966 Incidents 54.68% Percentage When Kent County ALS Arrived On-Scene in 8 Minutes or Less On Charlie Level Incendents 2000 2,175 Incidents 55.40% 2001 2,175 Incidents 55.20% 2002 2,357 Incidents 57.20% 2003 2,424 Incidents 58.40% 2004 2,750 Incidents 53.45% 2005 2,938 Incidents 53.20% Average 2,470 Incidents 55.48% Kent County Paramedic Units are located in the three major population areas within the County. As such, response times to the majority population are actually less than eight minutes. For rural areas of Kent County, where emergency services across the board are not as abundant, specifically because of the reduced demand coupled with the logistics of deployment, responses are sometimes greater than eight minutes. The demographics of our rural areas dictate that emergency responses will be somewhat lengthier than in the high demand population concentrations where all emergency services are available in greater concentrations and in a more expeditious manner. Percentage When NCC ALS Arrived On-Scene in 8 Minutes or Less On Delta-Echo Level Incidents 2000 5,759 Incidents 74.30% 2001 8,470 Incidents 73.80% 2002 8,643 Incidents 71.80% 2003 8,828 Incidents 72.30% 2004 8,184 Incidents 70.30% 2005 12,014 Incidents 66.70% Average 8,650 Incidents 71.63% Percentage When NCC ALS Arrived On-Scene in 8 Minutes or Less On Charlie Level Incidents 2000 10,350 Incidents 69.30% 2001 12,656 Incidents 68.60% 2002 13,764 Incidents 67.40% 2003 13,294 Incidents 68.70% 2004 14,241 Incidents 65.40% 2005 12,893 Incidents 63.20% Average 12,866 Incidents 67.10% Source: New Castle County Computer Aided Dispatch System. New Castle County EMS maintains an eighth paramedic unit on a “power shift” configuration to provide increased ALS services during peak call volume. A ninth unit is operational on a part-time basis, provided sufficient personnel are available to staff the unit. Additional response time improvements are expected with deployment of additional power shift units, combined with Paramedic Sergeants. Percentage When Sussex County ALS Arrive On Scene In 8 Minutes Or Less On Delta-Echo Level Incidents 2000 3,943 Incidents 50.40% 2001 4,392 Incidents 50.40% 2002 6,616 Incidents 50.80% 2003 4,974 Incidents 55.70% 2004 5,902 Incidents 46.81% 2005 5,786 Incidents 47.40% Average 5,269 Incidents 50.25% Percentage When Sussex County ALS Arrived On-Scene in 8 Minutes or Less On Charlie Level Incendents 2000 3,829 Incidents 47.30% 2001 4,392 Incidents 49.30% 2002 3,892 Incidents 50.50% 2003 4,190 Incidents 49.70% 2004 4,478 Incidents 49.82% 2005 4,633 Incidents 49.10% Average 4,236 Incidents 49.29% The population of Sussex County, both year-round and seasonal, continued to increase steadily during 2005. Meanwhile, five areas in western Sussex County (Greenwood, Bridgeville, Seaford/Blades, Laurel and Delmar) have been identified by the Delaware Office of State Planning Coordination as communities and developing areas targeted for growth over the next five years. Appendix C: Medical Director Report and Clinical Performance Report Data in the below columns represent available data from the EDIN patient care report database. This data is displayed in accordance to geographic location rather than individual agencies. This data is for patients transported and excludes cancellations, patient refusals and DOPA data. New Out Total PATIENT TYPE Kent Castle Sussex Of For Data County County County State Collected MEDICAL Advanced Life Support 5,731 18,556 9,280 35 33,602 Basic Life Support 7,664 33,246 11,690 179 52,779 OB/GYN Advanced Life Support 2 10 0 0 12 Basic Life Support 9 26 2 0 37 TRAUMA/MEDICAL Advanced Life Support 199 515 329 3 1,046 Basic Life Support 543 1,830 936 13 3,322 TRAUMA Advanced Life Support 982 2,030 1,317 35 4,364 Basic Life Support 2,440 9,800 3,641 67 15,948 ALS/BLS PATIENT CLASSIFICATION 2005 ALS 86% Medical 11% Trauma 3% Trauma/Medical BLS 73% Medical 22% Trauma 5% Trauma/Medical New Out PATIENT GENDER Kent Castle Sussex Of County County County State Total FEMALE PATIENTS Advanced Life Support 3,626 10,940 5,567 30 20,163 Basic Life Support 6,013 24,540 8,610 145 39,308 MALE PATIENTS Advanced Life Support 3,281 10,161 5,353 43 18,838 Basic Life Support 4,639 20,333 7,647 112 32,731 SEX UNKNOWN Advanced Life Support 0 11 3 0 14 Basic Life Support 12 35 2 1 50 Gender of ALS/BLS Patients ALS 52% Female 48% Male 0% Unknown BLS 55% Female 45% Male 0% Unknown Patient's New Out Ethnic Kent Castle Sussex Of Origin County County County State Total ALS BLS ALs BLS ALS BLS ALS BLS Als BLS White 4.952 7,346 13,754 27,898 8,684 12,640 59 184 27,449 28,068 Black, Non- Hispanic 1,704 2,831 5,850 13,825 1,774 2,745 9 49 9,337 19,450 Indian/Alaska Native 9 27 12 105 1 19 0 0 22 151 Hispanic, White 139 245 835 2,176 373 642 5 19 1,352 3,082 Hispanic, Black 16 32 44 102 20 54 0 0 80 188 Asian/Pacific Islander 39 56 131 318 20 34 0 2 190 410 Other 22 72 213 333 38 92 0 1 273 498 N/A 1 9 14 33 0 1 0 2 15 45 Unknown 32 38 258 113 16 42 2 2 306 195 New Kent Castle Sussex Total Patient Age County County County Reports ALS BLS ALS BLS ALS BLS ALS BLS < 12 Years Old 312 555 963 2,517 381 795 1,656 3,867 12 to 20 Years Old 499 1,028 1,088 3,829 618 1,332 2,205 6,189 21 to 30 Years Old 634 1,183 1,718 5,341 796 1,491 3,148 7,985 31 to 40 Years Old 701 1,131 2,087 5,359 867 1,379 3,655 7,869 41 to 50 Years Old 911 1,385 3,078 6,837 1,352 1,935 5,341 10,157 51 to 60 Years Old 823 1,209 2,812 5,309 1,354 1,785 4,989 8,303 61 to 70 Years Old 886 1,170 2,746 4,311 1,515 1,987 5,147 7,468 71 to 80 Years Old 1,179 1,545 3,219 5,232 2,058 2,805 6,456 9,582 81 to 90 Years Old 790 1,194 2,828 4,975 1,648 2,260 5,266 8,429 > 90 Years Old 179 286 572 1,191 337 500 1,088 1,977 ALS and BLS Patient Age Comparison 2005 Graph (Not shown) New Top 20 Primary Castle Kent Sussex Impression County County County Total ALS BLS ALS BLS ALS BLS ALS BLS Pain 550 2,137 1,416 10,700 975 3,044 2,941 15,881 Difficulty Breathing 928 1,146 3,419 4,489 1,592 1,835 5,939 7,470 General Malaise (Sick) 850 846 1,753 3,868 1,189 1,330 3,792 6,044 Other (Document in Narrative) 172 828 1,013 3,237 344 1,241 1,529 5,306 No complaint 272 569 678 2,446 425 1,378 1,375 4,376 Cardiac Problems 320 350 1,133 1,677 511 710 1,954 2,737 Cardiac Problems (Angina/MI) 433 173 1,660 640 877 350 2,970 1,163 Abdominal Pain 234 430 408 1,929 328 685 970 3,044 Aletred Mental Status 253 339 1,037 1,279 396 376 1,686 1,994 Chest Pain (Non-cardiac) 182 322 720 1,223 270 450 1,172 1,995 Syncope 194 282 706 996 333 407 1,233 1,685 Seizures 218 276 718 1,078 268 311 1,204 1,665 CVA/TIA 207 137 583 617 370 279 1,160 1,033 Laceration(s) 68 221 131 1,126 94 447 293 1,794 Dizziness 104 244 279 854 145 287 528 1,385 Bleeding 75 268 113 899 99 362 287 1,529 Altered Mental Status (Diabetic) 98 163 514 610 170 221 782 994 Multi-System Trauma 202 147 491 363 229 261 922 771 Hypoglycemia 177 77 610 316 307 106 1,094 499 Head Injury 172 204 294 518 192 194 6,453 916 New Kent Castle Sussex Patient Location County County County Total ALS BLS ALS BLS ALS BLS ALS BLS Aggregate Care Facility 140 142 613 1,048 197 144 950 1,367 Doctor's Office 236 354 1,659 2,182 496 464 2,391 3,000 Educational Institution 145 232 318 657 118 156 581 1,045 Farm 25 12 2 5 19 31 46 48 Home/Residence 6,094 8,130 19,032 29,784 9,209 10,841 34,335 48,755 Industrial Place 43 31 74 122 45 76 162 229 Nursing Home 666 873 2,034 2,867 850 958 3,658 4,590 Other 228 251 611 939 238 345 1,077 1,535 Public Places 1,055 1,434 2,593 4,342 1,391 1,804 5,039 7,580 Sports Field or Complex 58 95 77 224 39 72 174 391 Street or Highway 2,513 2,222 3,191 9,674 1,656 3,108 7,360 15,004 Unknown 84 12 107 159 54 24 245 195 Work 190 334 1,180 1,784 356 394 1,726 2,512 ALS BLS Patients Patients Alfred I. duPont Institute 454 1,177 Atlantic General Hospital 239 476 Beebe Hospital 4,100 6,394 CER-Christiana Hospital 10,767 24,117 Chester Crozier Medical Center 88 200 DHCI (DE Hospital for Chronically Ill) 3 2 Easton Memorial Hospital 1 6 Elkton (Union) Hospital 64 220 Glasgow Medical Center 0 1 Kent General Hospital 4,539 7,909 Milford Memorial Hospital 2,090 3,462 Millville Emergency Center 6 135 Nanticoke Hospital 2,255 4,069 Newark Emergency Center 0 8 Peninsula Regional Medical Center 520 631 Queen Annes & Kent Hospital 0 2 Riddle Hospital 4 10 Salem Hospital 3 30 Shock Trauma (Baltimore) 1 1 Southern Chester County Medical Center 3 14 St. Francis Hospital 1,925 4,983 Union (Baltimore) Hospital 7 13 Univeristy of Del-Student Health Services 0 20 VA Medical Center 120 325 Wilmington Hospital 3,088 10,663 ALS Receiving Hospital Comparison 2003-2005 2003 2004 2005 Alfred I. duPont Institute 404 383 454 Beebe Hospital 3,762 4,098 4,100 CER-Christiana Hospital 9,593 9,505 10,767 Kent General Hospital 4,468 4,478 4,539 Milford Memorial Hospital 1,893 1,992 2,090 Nanticoke Hospital 2,027 2,205 2,255 St. Francis Hospital 1,688 1,843 1,925 Wilmington Hospital 3,128 2,875 3,088 BLS Receiving Hospital Comparison 2003-2005 2003 2004 2005 Alfred I. duPont Institute 1,021 1,071 1,177 Beebe Hospital 5,701 6,135 6,394 CER-Christiana Hospital 19,396 22,282 24,114 Kent General Hospital 7,036 7,482 7,909 Milford Memorial Hospital 2,381 2,723 3,462 Nanticoke Hospital 2,647 3,911 4,069 St. Francis Hospital 3,918 4,427 4,683 Wilmington Hospital 9,081 9,875 10,663 Time of Day When EMS Incidents Occur Time of Day Incident ALS BLS Occurred Incidents Incidents 12am to 12:59am 1,521 2,349 1am to 1:59am 1,446 2,164 2am to 2:59am 1,274 1,945 3am to 3:59am 1,131 1,633 4am to 4:59am 943 1,416 5am to 5:59am 1,124 1,617 6am to 6:59am 1,491 2,180 7am to 7:59am 1,886 2,958 8am to 8:59am 2,600 3,923 9am to 9:59am 3,298 4,577 10am to 10:59am 3,579 5,015 11am to 11:59am 3,506 5,015 12pm to 12:59pm 3,458 5,037 1pm to 1:59pm 3,295 4,743 2pm tp 2:59pm 3,228 4,928 3pm to 3:59pm 3,100 4,821 4pm to 4:59pm 2,952 4,819 5pm to 5:59pm 2,856 4,658 6pm to 6:59pm 2,802 4,437 7pm tp 7:59pm 2,906 4,249 8pm to 8:59pm 2,698 3,982 9pm to 9:59pm 2,439 3,668 10pm to 10:59pm 2,250 3,274 11pm to 11:59pm 1,961 2,843 Month When Incident Occurred ALS BLS Total January 4,720 7,218 11,938 February 4,749 6,924 11,673 March 4,813 7,199 12,012 April 4,485 6,819 11,304 May 4,854 7,291 12,145 June 4,666 7,047 11,713 July 5,118 7,579 12,697 August 5,196 7,608 12,804 September 4,862 7,266 12,128 October 4,758 7,306 12,064 November 4,602 6,768 11,370 December 4,921 7,226 12,147 Appendix D: EXTRAMURAL FUNDED PROJECTS and MULTI-CENTER TRIALS PUBLICATIONS: Articles (Peer Reviewed) Lerner EB, Billittier AJ, O’Connor RE, Allswede MP, Blackwell TH, Wang HE, White LJ: Linkages of Acute Care and EMS to State and Local Public Health Programs: Application to Public Health Programs. Journal of Public Health Practice and Management. 2005; 11:291-297. Nichol G, Steen P, Herlitz J, Morrison LJ, Jacobs I, Ornato JP, O'Connor RE, Nadkarni V; The International Resuscitation Network Investigators. International Resuscitation Network Registry: design, rationale and preliminary results. Resuscitation. 2005 Jun;65(3):265-77. Cone DC, O’Connor RE. Are US informed consent requirements driving resuscitation research overseas? Resuscitation 2005; 66 141–14. Eckstein M, Isaacs SM, Slovis CM, Kaufman BJ, Loflin JR, O'Connor RE, Pepe PE on behalf of the U.S. Metropolitan Municipalities' EMS Medical Directors Consortium. Facilitating EMS Turnaround Intervals at Hospitals in the Face of Receiving Facility Overcrowding. Prehosp Emerg Care 2005; 9:267-275. International Liaison Committee on Resuscitation. 2005 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care with Treatment Recommendations. Circulation. 2005;112(suppl III):III-1-III-136. Emergency Cardiovascular Care Committee and Subcommittees of the American Heart Association. 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2005;112:IV-1-IV- 211. Hazinski MF, Nadkarni V, Hickey R, O’Connor RE, Becker L, ZaritskyA. Major Changes in the 2005 AHA Guidelines for CPR and ECC: Reaching the “Tipping Point” for Change. 2005; 112: IV-206 – IV-211. Selbst, SM, Friedman M, Singh S. Epidemiology and etiology of malpractice suits involving children in US emergency departments and urgent care centers. Ped Emerg Care, 21:165-169, 2005. Taylor B, Selbst SM, Clark Shah A: Prescription writing errors in a pediatric emergency department. Pediatric Emergency Care, 21: 822-827, 2005. Bradford KK, Kost S, Selbst SM, Renwick AE, Pratt A. Family Member Presence for Procedures: The Resident's Perspective. Amb Pediatr 2005;5(5):294-7. Abstracts Megargel RE, McGinnis-Hainsworth D, O’Connor RE. Does Neuromuscular Blockade Offer an Advantage over the use of Deep Sedation Alone When Performing Endotracheal Intubation on Patients with a GCS < 8. Prehosp Emerg Care; 2005; 9:114. Megargel RE, O’Connor RE. The impact of mode of arrival to the hospital on time interval from symptom onset to treatment for patients with acute coronary syndrome. Prehosp Emerg Care; 2005; 9:121. Aswegen A, Megargel RE, McGinnis-Hainsworth D, O’Connor RE. Degree of clinical improvement following prehospital treatment of suspected pulmonary edema. Prehosp Emerg Care; 2005; 9:122-123. Megargel RE, McGinnis-Hainsworth D, O’Connor RE. Comparing the effectiveness of treating hypotension in the prehospital setting using intravenous saline boluses versus placing the patient in a flat and supine position. Prehosp Emerg Care; 2005; 9:123-124. Megargel RE, O’Connor RE. Association between change in patient condition and paramedic response interval in a two-tiered EMS system. Prehosp Emerg Care; 2005; 9:131-132. Moseley MG, Patel SG, Coletti CM, Augustine J, Davidson SJ, Fisher AS, Hoxhaj S, O'Connor RE, Reese CL on behalf of the Emergency Department Benchmarking Alliance. Patients per Day and Admission Rate Predict Average Length of Stay in the Emergency Department Benchmarking Alliance. Acad Emerg Med 2005 12:26. Hoxhaj S, Carroll JM, O'Connor RE. Does Emergency Department Crowding Prolong Door-to-balloon Times for Patients with Acute Myocardial Infarction? Acad Emerg Med 2005 12: 29. O'Connor RE, Reese CL, Stillman PL, Mahoney DD. The Use of an Express Admit Unit to Reduce Overcrowding in the Emergency Department and Reduce Hospital Length of Stay. Acad Emerg Med 2005 12:105. O'Connor RE, Tinkoff GH, Miller K, Jones MS, Megargel RE. Implementation of a Statewide Trauma System Results in a Reduction in Trauma Deaths. Acad Emerg Med 2005 12:115-116. O'Connor RE, Lin L, Tinkoff GH, Megargel RE. Effect of a Graduated Driver Licensing System on the Proportion of Crashes and Injuries Involving Drivers under Age 18. Acad Emerg Med 2005 12:130. Farley H, Khan M, Fisher AS, Hoxhaj S, Davidson SJ, Augustine J, O'Connor RE, Reese CL, IV on behalf of the Emergency Department Benchmarking Alliance. The Percentage of Patients Who Leave before Treatment Is Complete Is Related to the Average Length of Stay and Patients Seen per Day. Acad Emerg Med 2005 12:151. Moseley MG, Megargel RE, McGinnis-Hainsworth D, O'Connor RE. The Effectiveness of Parenterally Administered Promethazine in Relieving Nausea and Vomiting in the Prehospital Setting. Acad Emerg Med 2005 12:167. Fisher AS, Hoxhaj S, Patel SG, Augustine J, Davidson SJ, O'Connor RE, Reese IV CL. Predicting Patient Volume Per Hour. Ann Emerg Med 2005; 46:6-7. 194) Megargel RE, McGinnis-Hainsworth D, O'Connor RE. Survival Following Penetrating Trauma and Response Time Delays. Ann Emerg Med 2005; 46:36. Michalke JA, Patel SG, Fisher AS, Hoxhaj S, Augustine J, Davidson SJ, O'Connor RE, Reese CL. Emergency Department Size Determines the Demographics of Emergency Department Patients. Ann Emerg Med 2005; 46:39. Price AS, Faller A, O'Connor RE. Length of Stay of Critically Ill Patients in the Emergency Department. Ann Emerg Med 2005; 46:40. Hoxhaj S, DiSabatino A, Bittner L, Fisher AS, Carroll J, Reese IV CL, O'Connor RE. Using Non-Interventional Cardiologists As First Call Does Not Affect the Door-to-Balloon Time or Decision to Use Angioplasty for AMI Patients Presenting to the Emergency Department. Ann Emerg Med 2005; 46:42-43. Bollinger G, Bollinger ME, O'Connor RE. Does the Patient's Age Play a Role in Deciding Whether to Transport Trauma Patients to a Level One Trauma Center by Air or by Ground? Ann Emerg Med 2005; 46:46. Reed D, Birnbaum A, Brown LH, Fleg JL, O'Connor RE, Peberdy MA, Van Ottingham L, Hallstrom AP, The P.A.D. Trial Investigators. Location of Cardiac Arrests in the Public Access Defibrillation Trial. Ann Emerg Med 2005; 46:75. O'Connor RE, Bitner L, Megargel RE, ReeseCL. Performance and Interpretation of the Prehospital ECG by Paramedics is Associated with a Reduced Time to Intervention, Shorter Hospital Length of Stay, and Reduced Mortality. Circulation 2005 (in press) Research Paper Presentations NAEMSP. Naples, FL, January 2005. “Does Neuromuscular Blockade Offer an Advantage over the use of Deep Sedation Alone When Performing Endotracheal Intubation on Patients with a GCS < 8.” NAEMSP. Naples, FL, January 2005. The impact of mode of arrival to the hospital on time interval from symptom onset to treatment for patients with acute coronary syndrome. Prehosp Emerg Care; 2005; 9.121. NAEMSP. Naples, FL, January 2005. Degree of clinical improvement following prehospital treatment of suspected pulmonary edema. Prehosp Emerg Care; 2005; 9.122-123. NAEMSP. Naples, FL, January 2005. Comparing the effectiveness of treating hypotension in the prehospital setting using intravenous saline boluses versus placing the patient in a flat and supine position. Prehosp Emerg Care; 2005; 9.123-124. NAEMSP. Naples, FL, January 2005. Association between change in patient condition and paramedic response interval in a two-tiered EMS system. Prehosp Emerg Care; 2005; 9.131-132. SAEM. New York City, May 2005. “Patients Per Day and Admission Rate Predict Average Length of Stay in the Emergency Department.” SAEM. New York City, May 2005. “Does Emergency Department Crowding Prolong Door-to-Balloon Times for Patients with Acute Myocardial Infarction?” SAEM. New York City, May 2005. “The Use of an Express Admit Unit to Reduce Overcrowding in the Emergency Department and Reduce Hospital Length-of-Stay.” SAEM. New York City, May 2005. “Implementation of a State-wide Trauma System Results in a Reduction in Trauma Deaths.” SAEM. New York City, May 2005. “Effect of a Graduated Driver Licensing System on the Proportion of Crashes and Injuries Involving Drivers Under Age 18.” SAEM. New York City, May 2005. “The Percentage of Patients Who Leave Before Treatment is Complete is Related to the Average Length of Stay and Patients Seen Per Day.” SAEM. New York City, May 2005. “The Effectiveness of Parenterally Administered Promethazine in Relieving Nausea and Vomiting in the Pre-hospital Setting.” ACEP Research Forum. Washington, DC, September 2005. "Survival Following Penetrating Trauma and Response Time Delays." ACEP Research Forum. Washington, DC, September 2005. “Emergency Department Size Determines the Demographics of Emergency Department Patients.” ACEP research Forum. Washington, DC, September 2005. "Length of Stay of Critically Ill Patients in the Emergency Department." ACEP Research Forum. Washington, DC, September 2005. “Using Non-Interventional Cardiologists As First Call Does Not Affect the Door-to-Balloon Time or Decision to Use Angioplasty for AMI Patients Presenting to the Emergency Department.” ACEP Research Forum, Washington, DC, September 2005. "Does the Patient's Age Play a Role in Deciding Whether to Transport Trauma Patients to a Level One Trauma Center by Air or by Ground?" ACEP Research Forum, Wahsington, DC, September 2005. "Location of Cardiac Arrests in the Public Access Defibrillation Trial." AHA Scientific Sessions, Dallas, TX, November 2005. "Performance and Interpretation of the Prehospital ECG by Paramedics is Associated with a Reduced Time to Intervention, Shorter Hospital Length of Stay, and Reduced Mortality." Appendix E: Scratch Report Kent County: 796 scratches out of 18,004 incidents or 4.42% of the time. New Castle County: 521 scratches out of 41,607 incidents or 1.25% of the time. Sussex County: 691 scratches out of 14,223 incidents or 4.86% of the time. Rehoboth 911 Center: 144 scratches out of 1,902 incidents or 3.58% of the time. Seaford 911 Center: 94 scratches out of 1,777 incidents or 5.28% of the time. Appendix F: Kent County Dept of Public Safety 2005 Improvement Initiatives and Summary Report Radial Diagram Homeland Hazmat MCI EOD Security ToxMedic Mass Gatherings SORT KCDPS Special Operations Rehab Bikes Maritime Technical NEHC ATV Response Rescue Overview Throughout 2005 the concept of Special Operations became more solidified within the Department. Instead of having separate attention focused on hazmat, MCI, and other unusual response operations the Special Operations concept follows the more universal “all hazards” model mimicking the structure of the Homeland Security Grant Program and the National Response Plan. Within the Department this concept develops a picture of multi-tasking equipment and personnel while allowing for particular specialization by a few self-motivated staff. Special Operations encompasses the response categories of Mass Casualty Incident (MCI), Hazardous Materials Incidents (Hazmat), Technical Rescue Operations (high angle, trench, collapse), Explosive Ordnance and Tactical Support (EOD/SORT), Fire Ground Support (Rehab), All-Terrain Medical Response (Bikes & Medic-Gator), Maritime Operations, and Weapons of Mass destruction (WMD) preparedness and response. This section of the report will review the current status of each of these response categories as a result of equipment procurement, training of personnel, activity, and further will outline future needs and initiatives to move the Special Operations concept forward. Mass Casualty Incident (MCI) Response: The Department MCI Plan identifies staged levels of response based upon assessed patient populations. The key operational point identified is to activate the MCI response and to that end the plan allows for any component of the system to “make the call”. Within this Department Dispatchers, Medics, Supervisors, or Administration can all initiate the MCI Response Plan. The MCI Response Plan has been presented to and endorsed by the Kent County Fire Chiefs as to the automatic response levels. Equipment: Each Medic Unit carries Triage Kits and limited additional supplies to be used for patient care. Medic 65 is equipped with an MCI Command Kit to facilitate orderly control of the medical sectors of the incident. The Special Operations trailer is equipped to support triage and treatment of up to 50 patients, has its own electrical power supply, and has additional components of the Treatment Area Command Kit, TVI Shelter with air heater unit, Chemical Personal Protection Kits (PPE), Nerve Agent Antidotes Kits (NAAKs), and Cyanide Antidote Kits. The Decon Support trailer may also be deployed for further sheltering and electrical supply. The Mobile Command Post may be deployed for extended operations. Training: All Medics are trained in START Triage and this skill is supported by monthly “Triage Days” during which all patients are identified with appropriate triage tags. Continuing education sessions this year included the roll-out of the updates MCI Plan which gives Medics guidelines for determining the level of response necessary and emphasizes the need for the first-on-scene Medic crew to initiate the MCI response. A “Trailer Day” con-ed was conducted in which all Medics were familiarized with the response support units and completed hands-on practical evolutions with the equipment. Activity: There were no incidents requiring emergency deployment of MCI support units. Units were pre-deployed as required in support of Mass Gathering events. Needs and Initiatives: Continued refresher training through Triage Days and con-eds will maintain current training levels. Further training needs to be accomplished such that all Medics are competent in establishing a Medical Sector at an MCI (Triage, Treatment, Transport). Dedicated towing vehicles should be established such that no on-duty Medic Unit is diverted from direct response to the scene in order to transport a support unit. Mass Gatherings Response: The Department prepares for several Mass Gathering activities each year. Notably, the NASCAR races at Dover Downs, the Delaware State Fair, the Bike-to-the-Bay, and the Amish Country Bike Tour present the venues for the largest populations. There are occasionally other events (VIP appearances, DAFB Air Show, Chicken Festival, etc.) which also require Mass Gathering preparations. Operations center on pre-positioning assets and adding staff to cover the particular event. Response may be limited to assigning a Bike Team to the venue or expanded to establishing an entire communications center with dozens of support units on site. Equipment: The All-Terrain Medical Response trailer now houses the Bikes and the Medic-Gator. This trailer facilitates the transport and provides an operational base for these units. All trailer units can be pre-deployed in support of larger events. These units include the Spec Ops, Decon Support, and Medical Resource Unit (MRU) trailers. Additional ALS gear sets have been established to support each of these units. The Mobile Command Post is a self- contained communications center which can be deployed to any site as needed. Training: A number of Medics are trained to operate the Bikes and a lesser number trained to operate the Gator (the primary means of covering large venues). Activity: The Gator and/or Bikes were used to cover Spring and Fall NASCAR races, Safe Summer Day, Needs & Initiatives: Available staffing minimums should be established such that all bikes and the Gator could conceivably be manned if necessary. Maritime Response Response: Kent County’s primary response jurisdiction extends well into the Delaware Bay and includes a busy anchorage. Currently the Medics are taken to vessels via VFD Rescue Boats. Occasionally the Coast Guard assists with aviation support. Equipment: There is no specialized equipment currently in service to support maritime response. Training: There is no specialized training currently offered to support maritime response. Activity: There has been no maritime response activity during 2005. Needs & Initiatives: Investigation of specialized response concerns should be undertaken. The Coast Guard has previously expressed open willingness to conduct joint training regarding rescue lift operations. Communications exercises including EMS, Fire Service, Coast Guard, and commercial maritime vessels should be investigated. Hazardous Materials Response (Hazmat) Response: The Department’s response continues to be one component of a multi- agency response plan. Supported primarily and in depth by the Little Creek VFD, the group response is once again a first line dispatch for known non-petroleum hazmat incidents. The mission of the Hazmat Group remains primarily the provision of decontamination services. Following a request by DNREC and the support from the Department Chief, an expansion of the mission has been to develop a limited number of personnel capable of assisting DNREC in entry operations as a medical component of the entry team. Equipment: The State of Delaware Hazardous Materials Decontamination trailer remains housed at Little Creek. A custom built Hackney tow vehicle was placed in service in late spring. This truck is titled to Little Creek and improves the transport of the trailer while providing additional equipment storage, back- up electrical supply, and a new supplied air respirator (SAR) system. Training: Regular training sessions are held on the third Tuesday night each month (with few exceptions). As new equipment arrives it is introduced through these regular training sessions. Joint exercises have been conducted with DNREC and DAFB. These joint sessions have met with great approval from all concerned and more are planned for the future. Currently there are a limited number of Medics trained to the Hazmat Technician level which qualifies them to assist the entry team. Activity: There was one incident response in 2005 for a chlorine leak which had the local VFD, DAFB Hazmat, and DNREC on scene as well as our response group. The unit(s) participated in displays 6 times. The units were utilized in the Dover Downs Exercise. Needs & Initiatives: Joint training evolutions with other response agencies should be enhanced. Volunteer Fire Service personnel recruitment and training needs to take greater precedence, however this has been deferred pending establishment of uniform training curriculum through the Delaware State Fire School. To meet the Department’s previous goal of sufficient response of personnel and to achieve the new goal of assisting the DNREC entry team, a minimum of four Hazmat Technician level responders must be maintained on-call. This initiative would require additional Technician level training and on-going costs of on-call pay. This initiative would most likely be phased in over time and budgeting allows. The previous initiative to establish a Hazmat Duty Officer should be refocused towards a Special Operations Duty Officer, thus enhancing the justification for the position. Technical Rescue Response: The newly formed, yet rapidly advancing Technical Rescue Team in Kent County is spearheaded by the Dover FD with support from several Kent County FDs. From its’ inception the Team has requested active participation by Kent County Medics. Currently there are 3 Medics training with the team. Technical Rescue encompasses trench, collapse, confined space, high angle, and swift water rescue operations along with urban search & rescue (USAR). The primary response area is Kent County with assisting teams in New Castle and Sussex counties. The “Second Due” area for the Kent team extends to the Chesapeake Bay including Caroline, Talbot, and Queen Anne counties in Maryland (dual response with Anne Arundel). Equipment: The team equipment is based at Dover Station 2 and is contained in a support trailer. Dover runs an engine and a squad with the trailer. All rescue operations equipment is compatible with the other two county’s equipment. Each team member has a “go bag” with some personalized gear. Some specialized medical equipment is on order. Training: Several Operations level courses and a few Technician level courses have been completed resulting in a good core group of qualified responders. Two Medics are Trench and Confined Space Technicians and one Medic is qualified at the Operations level. On-going training sessions are conducted periodically. Activity: The team responded to one call in Maryland and was utilized to extricate a trapped worker from a grain silo. Needs & Initiatives: As the team increases in number and equipment inventory, continuing training will have to occur. Exercises testing the recovery techniques are planned and should include ALS intervention practice. The team is working towards USAR qualification. EOD/SORT Response Response: Medic Units are routinely dispatched to support EOD/SORT operations. Bomb Technicians are medically monitored before and after entry evolutions. Medics stand by in safe zones for certain law enforcement operations. Medics are dispatched to incidents involving explosions. Equipment: Currently there is little equipment in service directly related to EOD/SORT. Body armor is on order and ballistic helmets are in stock. Training: All current Kent County Paramedics received the 8 hour ODP Prevention and Response to Suicide Bombings course in October of 2005. In addition to the course Delaware State Police EOD team leader brought their specialized gear in order to familiarize Kent County Paramedics with how to safely remove the suit in the event an EOD tech is sick or injured. Operational concerns were discussed and the session resulted in greater mutual understanding of the job at hand. Medics routinely receive refresher training regarding the assessment and treatment of blast and burn injuries. Activity: Early in the year there was a peak in activity resulting from dredged oyster shells being used as driveway material. The dredging produced a large number of potentially volatile ordnance from WWII and the Korean War. Medics responded to 3 such incidents. There were also several “suspicious package” incidents. Medics responded to 2 such events. Medics also responded to 2 “bomb threats”. Needs & Initiatives: Initial response is currently accomplished by one of the three primary Medic Units. The establishment of the Spec Ops Duty Officer will allow primary units to return to available status quickly. Additionally, an agreement with EOD needs to be established in which this Department is notified of an EOD response in Kent County prior to the EOD units being on scene. This would allow the Duty Officer time to meet EOD and eliminate committing a primary unit. There are a few specialized medical equipment items that may be considered. Fire Ground Support Response: Medics are routinely dispatched to multiple alarm working fires and many “occupied high density residential” locations. Many times this response is merely a stand-by, however it is not uncommon for the Medics to assist in rehab services or conduct medical assessment and monitoring of firefighters. Equipment: Primary Medic units have no specific equipment for fire ground support operations. All of the support trailers have sheltering, heat, and lighting capability. The new truck (Express Cutaway) will have similar equipment plus an air conditioning unit for hot weather. The Spec Ops trailer has additional IV supplies and cots. Training: No specific training is indicated. Medics should be capable of deploying shelters. Activity: There were over 60 calls for Medics to stand-by fire grounds. The total time committed to stand-by exceeds 28 hours for the year. There was nearly even distribution across 8 hour time divisions with a slight majority of calls falling between 0800 and 1600 hours (20). The average duration of the calls was 33 minutes with the longest being 98 unit minutes (duration split between 2 units). As of 19 Dec 2005 the call volume by unit was: 65-25; 66-15; 67-8; 68-3. There appears to be only a few civilian patients evaluated and/or transported from these incidents. Needs & Initiatives: The establishment of a Duty Officer should alleviate the demand for primary Medic units to cover stand-by operations. While the primary units may still make initial responses (especially incidents with reported patients), the Duty Officer should be able to relieve primary units at extend incidents. The Duty Officer will be able to provide enhanced services including shelter, heat, air conditioning, and cooling fans. All-Terrain Medical Response Response: The Bikes and Medic-Gator have thus far been pre-deployed to special events. While the units are capable of emergency response, the application of these assets remains as support to in-progress incidents. The units are housed in the ATMR trailer which requires transport to the scene. Equipment: The ATMR trailer has been a tremendous improvement in storage and ease of transport of the units. All response vehicles (Crown Vics excluded) are equipped to tow the trailer. A solar battery charging system was installed for the Gator. Bike gear remains the same and Gator gear is assembled from spare equipment as needed. Training: The Bike Team continues as before with several Medics trained to ride the units. Gator training has been completed and all medics are familiar with Gator unit operation. Activity: Generally activity was reduced this year. The Bikes and Gator covered the NASCAR races. The Bikes appeared in at least 2 parades. The Gator was used at Safe Summer Day and the Dover Downs Exercise. Needs & Initiatives: An assessment needs to be conducted to determine minimal Bike Team staffing. Additional training on Gator operation should be conducted to increase the number of qualified drivers. Gator driving should be extended to all Department employees and an MOU should be established to allow VFD personnel to operate the unit under extreme circumstances. Further training on trailer operations should be conducted and extended to all Department employees to increase the number of qualified drivers. WMD / Terrorism Preparedness Response: General ideology suggests that response units will most likely not know ahead of time that an incident is an act of terrorism or involves WMD. Therefore, all responders must be capable of adapting operational modalities in response to information as it is acquired. Specialized equipment will be utilized as the situation warrants. Equipment: Personal “Escape Ensemble Kits” are available on each unit which include 3 Mark I NAAKs and PPE. Over-the-uniform body armor and ballistic helmets will be in service by the end of the first quarter of 2006. Tox-Boxes are being developed so that those medics with AHLS training can function under the ToxMedic Protocols. Four of the five support trailers in the department carry additional WMD response equipment and supplies. The First-On-Scene response guidelines include a “Bomb Response” checklist and related reference materials. Each Medic Unit will be equipped with a radiological response kit by the first quarter of 2006. Training: A “Trailer Day” con-ed was conducted in which all Medics were familiarized with the response support units and completed hands-on practical evolutions with the equipment. A hands-on training add-on for radiological response will be conducted in March 2006. AHLS courses are conducted twice each year and are available to all Medics. Activity: There was no identified activity in response to WMD / Terrorism. Needs & Initiatives: Refresher training in the use of PPE and “escape kits” needs to be conducted. Each Medic should demonstrate proper use of this equipment. Awareness and Operational level concepts and procedures for WMD response should be revisited through in-service review and printed distributions. Conclusion: Situational Assessment: Incidents involving some form of Special Operations response continue to occur at a manageable frequency, however primary Medic Units are being committed to these incidents for longer periods. Several annual event venues present significant challenges to the department’s operations. The department has continued response roles both locally and regionally. The possibility of a disaster, natural or man-made, is as present as ever. Vulnerability: Training and exercise has increased awareness and response capability as compared to previous years, thus reducing the vulnerability of the individual responder. Geographically Kent County remains central to several major metropolitan areas of national significance. Complacency as a result of low utility presents the greatest controllable risk factor. Capability: The establishment of a Duty Officer program will reduce the demand on the primary Medic Units at many Special Operation incidents. The Medics are better trained to utilize available equipment. Resources continue to expand and develop to provide flexible response modalities and increased capability. Appendix G: NEW CASTLE COUNTY EMS ACCOMPLISHMENTS AND INITIATIVES – 2005 Organizational Structure The New Castle County Government has restructured and renamed the department as the county Department of Public Safety. The restructure restores the Emergency Medical Services component to division-level status, and places the Chief of Emergency Medical Services as a direct report to the Director of Public Safety. Staffing Paramedic Sergeants: New Castle County EMS implemented a new level of front line supervision via the promotion of four (4) Paramedic Sergeants. The Paramedic Sergeants are ALS field supervisors that enable the EMS Division to have improved coordination with other agencies, improved oversight of medical operations during major or unusual incidents, improved quality improvement through direct observation of patient care in the field, and improved clinical care capability via the availability of an additional paramedic during critical cases. Paramedic Class: Members of the Paramedic Class of 2004-2005 completed their requirements for graduation from Delaware Technical and Community College and verification of their clinical capabilities during field evaluation. Eight (8) members of the Paramedic Class of 2005-2006 will start their field internship in May 2006. The Emergency Medical Services Division will enroll another group of candidates in the upcoming Paramedic Class of 2006-2007. Picture of New Castle County Paramedic Class of 2005-2006 Recruitment: New Castle County EMS has maintained the assignment of a designated recruitment coordinator to facilitate ongoing recruitment and selection of out-of-state and entry-level paramedic candidates. New Castle County EMS also participated in the EMS Today Conference and Exposition in Philadelphia, PA by staffing an information booth and providing ride-along opportunities to conference attendees. Picture of ew Castle County EMS Today Conference & Exposition display, March 2005 Employee Safety Soft Body Armor: New Castle County EMS has issued soft body armor to all paramedics. The soft body armor provides a level of personal protection against acts of violence and other forms of blunt trauma—including motor vehicle collisions. The distribution of this type of personal protective equipment protects our most valuable asset: our personnel. Weather Gear: New Castle County EMS also issued all personnel a raingear ensemble for protection from the elements. The rain jacket (with removable liner) and rain trousers provide weather protection and increased visibility through utilization of safety colors and reflective striping. Operations New Castle County EMS has maintained an eighth (“Medic 8”) on a “power shift” configuration to provide increased advanced life support resources during peak call volume period. A ninth (“Medic 9”) has been placed in service on a part- time basis, provided sufficient personnel are available to staff the unit. NCC*EMS is planning to deploy additional units on a “power shift” schedule as additional paramedics become available. Fleet Enhancements Replacement Vehicles: New Castle County EMS has elected to move from a SUV (Chevrolet Suburban) type of response vehicle to a utility-style truck. Eight (8) replacement trucks have been ordered, and will be delivered during calendar year 2006. The new vehicles provide additional, temperature-controlled storage space, four-wheel drive capability, and seating for paramedic candidates and ride-alongs. Utility Vehicle: New Castle County EMS has obtained a utility truck via federal funding for operational support of the paramedic service. The Operations Support Vehicle will be utilized to support daily service tasks, in addition to EMS operations during major or extended incidents. Special Operations ALS Bike Team: The NCC*EMS ALS Bike Team has been expanded to include additional paramedics. All new personnel were trained and certified as EMS Cyclists through the International Police Mountain Bike Association by in-house instructors. The ALS Bike Team has also obtained additional bicycles with enhancement of existing equipment to support their mission. SWAT Medic Team: The NCC*EMS Tactical Emergency Medical Support team replaced all their tactical armor through federal grant funding during 2005. The replacement armor provides additional ballistic protection, and has been specifically configured by the SWAT medics. New Castle County EMS routinely provides medical support to area law enforcement tactical teams. Public Education and Community Services New Castle County EMS maintained an active community outreach program during calendar year 2005. A summary of New Castle County EMS public education activity includes: • Inspection and installation of 501 child passenger seats at the Child Passenger Seat Fitting Station operated by New Castle County EMS. • Presentation of 17 child seat safety programs to 980 participants. • Participation in the Community Emergency Response Team (CERT) training program coordinated though the County Office of Emergency Management. NCC*EMS assisted in the instruction of 2 classes and 40 participants. • Maintenance of CPR and First Aid training as a designated Community Training Center for the American Heart Association. NCC*EMS presented 12 first aid courses to 288 participants, 5 Friends and Family CPR courses to 100 participants, and 62 Heartsaver AED courses to 1,368 participants during 2005. • Presentation of 5 “Paramedic Assist” programs to 235 fire service or industrial first aid personnel. The “Paramedic Assist” program provides an orientation to the paramedic service, and identifies methods that first responders can assist the paramedics during emergency incidents. NCC*EMS has been authorized by the state Office of EMS to provide continuing education credit for the program. • Presentation of 4 Career Day presentations to approximately 800 participants. The Career Day programs provide an opportunity to highlight the availability of paramedic careers to high school students. • Presentation of 23 Students Learn About Mortality (SLAM) presentations to 7,800 participants. The SLAM program provides a graphic illustration of the tragic effects of preventable motor vehicle crashes. • Presentation of 25 Vial of Life information sessions to 3,661 participants. The Vial of Life provides a “low tech” method of storing vital patient information for EMS personnel by senior or disabled citizens that live alone. The Wilmington Housing Authority has made enrollment in the Vial of Life program mandatory for its residents in all facilities. • Participation in a Senior Picnic, Safety Day, Bicycle Rodeo and 2 Teen Driving events that reached an estimated 10,000 participants. Employee Recognition Picture of NCC*EMS Graduation & Appointment Ceremony, May 2005 EMS Graduation & Appointment Ceremony: New Castle County EMS conducted their annual EMS Graduation and Appointment Ceremony during National EMS Week. The annual ceremony recognizes its personnel that graduated from the Delaware Technical and Community College, in addition to those appointed to the agency from out-of-state. Awards Ceremony: New Castle County EMS recognized several personnel during an awards ceremony conducted in June 2005. New Castle County EMS recognized the following personnel for their performance: S/Lt. Karl E. Hitchens Lt. Joseph J. Dudley Paramedic Corporal August H. Clagett, III Paramedic Corporal Michael A. McColley Paramedic Corporal Michael R. Nichols Paramedic Corporal William C. Wagner, III Paramedic First Class Jason E. Baxley Paramedic First Class James D. McCarnan Paramedic First Class William J. O’Leary Paramedic Francine L. Conley Paramedic Ruoy L. Koontz Appendix H: SUSSEX COUNTY EMS ACCOMPLISHMENTS AND INITIATIVES – 2005 • Adams-Ewing Public Safety Service Center: Opened Paramedic Station 107 in Bridgeville, co-located with Delaware State Police Troop 5. This new station provides service to Western Sussex County from Seaford to Greenwood. Along with the relocation of Medic 102 to Laurel and the establishment of a Western District Supervisor last year, this more than doubles our response capability to this rapidly growing area. • Medic Unit 108: Staffing and equipment for this part-time “power” unit was initiated, providing service during times of peak activity. Currently, the unit is housed in Georgetown, however is it not assigned a specific area, and may be sent wherever needed. • EZIO: We were the first in Delaware, and among the first departments in the country to obtain, train personnel, and initiate use of the “EZIO” adult intraosseous infusion device as an alternative means of gaining vascular access in critical patients. In its first day of use, the device was integral to the resuscitation of two cardiac arrest victims. Since its adoption by SCEMS, all three of the county’s hospitals have purchased the device for use in their emergency departments. • Special Operations Coordinator: We created the position of Special Events Coordinator, and appointed former District Supervisor Tim Cooper as the first to hold that position. Tim works directly under the Operations Division Manager, and is responsible for supervision of WMD, HazMed, Special Events Teams, Public Education and Public Information Officer activities. • PIER Team: Activities of the Public Information, Education and Relations team included: o “What In The World”: a program in the public schools designed to demonstrate to students the value of science education in a variety of professions. Team members discuss the operation of EKG and other equipment, how medications are measured, the study of anatomy and physiology as a part of our profession, and other appropriate topics o Displays and Demonstrations: New displays have been created for use at a wide variety of community events throughout the year, including local celebrations, health fairs and other events. o EMS Week Open House: In 2005, we held a half day open house, including CPR classes, demonstrations of advanced rescue techniques, and displays of SCEMS and fire service equipment at our headquarters in Georgetown. • Fleet Enhancements: In cooperation with the Delaware Emergency Management Agency and Delaware Department of Public Health, Office of Public Health Preparedness, we added to our fleet: o An all-terrain “Gator” vehicle, for use at special events where use of a traditional paramedic vehicle is not practical. The vehicle has been deployed to such events as the Fourth of July Fireworks celebrations in several communities and the annual Punkin’ Chunkin’ competition o A Hackney hazardous materials truck, designed to carry equipment and supplies necessary for response to a chemical, radiological or biological hazard incident, as well as to tow the decontamination trailer o A Ford Excursion response vehicle, used by the HazMed team duty officer to provide rapid response to hazardous materials incidents throughout the county, as well as to supplement paramedic unit response during times of heavy call volume o A Medical Resources Unit trailer, which holds large amounts of medical supplies, for use at a large-scale incident involving multiple casualties o A Hazardous Materials Resource trailer, which hold large amounts of haz-mat supplies, for use at a large-scale incident involving hazardous materials • Personnel Enhancements: Due to the rapidly growing needs of our County, we have expanded the number of employees in the department: o 2004-2005 Paramedic Class: Our first class of four paramedic students graduated from the Delaware Technical and Community College program, and are currently working throughout the county. o 2005-2006 Paramedic Class: We enrolled five students in the class which began in March of 2005, and which will graduate and become certified as Delaware Paramedics in the fall of 2006 o Out-of-State Paramedics: We hired paramedics from other States and, in cooperation with the Delaware Office of EMS, certified them as Delaware Paramedics. • Sussex County EMS Paramedic Competition Team: In its first year of existence, the four-person team won first place at the EMS Today “Jems Games” Competition, held as part of the EMS Today international EMS conference in Philadelphia, Pennsylvania. The group competed against 18 other teams, including those from Australia and Canada. They were each awarded gold medals in a ceremony held on the last day of the conference. Appendix I: RECOMMENDATIONS OF THE SUBCOMMITTEE • It is the subcommittee’s recommendation that a Legislative Subcommittee be established within DEMSOC to address suggestions requiring legislative action in an organized, uniform fashion. This group would also be charged with developing strategies for the development, presentation, promotion and monitoring of legislative initiatives. This should be a standing sub-committee which should periodically review and make recommendations to the full committee regarding review and update of legislation. • It is the subcommittee’s recommendation that a Finance Subcommittee be established within DEMSOC, perhaps using the current BLS Finance Committee as its nucleus, to address recommendations requiring financial resources in an organized, uniform fashion. • It is our recommendation that DEMSOC initiate a comprehensive effort to improve the health and wellbeing of our providers, beginning with development of statistical information regarding EMS and Firefighting personnel. • The Subcommittee recommends that DEMSOC support pilot projects and initiatives that explore alternative deployment models and strategies at both the ALS and BLS levels. • The subcommittee recommends the addition of the monitoring and oversight of privately owned EMS Transportation resources, and their inclusion in EMS planning, as a priority recommendation. • The subcommittee recommends that DEMSOC and its elements work with the E-911 Committee on implementation of Phase II of the wireless communications project, and that progress reports on this project become a regular agenda item for DEMSOC meetings. • The subcommittee recommends that DEMSOC and its elements work with the E-911 Committee on implementation of Phase II of the wireless communications project, and that progress reports on this project become a regular agenda item for DEMSOC meetings. • The subcommittee recommends investigation of the feasibility of developing a Public Safety cable channel within the systems currently serving Delaware. • The subcommittee recommends that the composition of the ALS Standards Committee of the Board of Medical Practice should be reviewed and revised to reflect current practice. • The subcommittee recommends establishment of a multi-disciplinary committee to revise processes and, as necessary, standards for addressing complicated issues involving certification and disciplinary actions, particularly regarding BLS practitioners. While this may seem simple on its face, the complexities of our two-tiered, multi-agency provider system, overseen by multiple agencies often render effective action impossible. Such issues actions against the certification of an ALS person who is working as an EMT-B for a BLS agency, effect of charges reduced from felony to misdemeanor on available remedies, etc. require a comprehensive and uniform approach. This will likely require legislative action, and should be referred to the agenda of that subcommittee. • The subcommittee recommends the establishment of a permanent, full-time position at the Delaware State Fire School for a Quality Improvement Officer. The growth of the BLS system, both in numbers of providers and numbers of calls for service, requires consistent oversight beyond the capabilities of the current staff. This person’s responsibilities would mirror those of the current Quality Improvement Officers within the ALS agencies, and the BLS QI person would work with that group to provide a comprehensive approach to QI on a system-wide basis.