Scope of Practice

1. Scope of Practice What you don’t know can hurt you.

2. Scope of PracticeCFEDMay 20, 2014 Mike Giannini, EMT-P EMS Battalion Chief Marin County Fire Department

3. Why are we here? • Ignorance can hurt you • Recent cases demonstrate the need for increased awareness • You may have never learned “this fun stuff” • The goal of this class is to give you all the information you need to be safe practitioners AND protect yourself

4. Objectives • Define the role of regulatory agencies • Review the history of EMS in California • Review the regulatory process • Review and define ‘Scope of Practice’ • Review the ‘Notification’ process • Define the intersection between CQI and discipline

5. Case Study - Cricothyrotomy • Recent Case • Yes, it is in the scope, but…..

6. What happened? • 57 year old female • Choked on muffin • Was in cardiac arrest upon EMS arrival • CPR/ ACLS initiated • Medics unable to clear muffin and establish BLS or ALS airway after multiple attempts • Physician consult made to the base hospital. Medics received permission to cric the patient.

7. What happened? • Initially successful - criccame out during difficult extrication to medic unit • Cric repeated by medic student successfully. • ROSC en route to ED • Report to ED

8. What can be learned from this case? • In cardiac arrest, if you do not have a stable airway in the field - Load and Go! • A physician consult does not cover you if go outside your scope of practice. • Know the facts – extremely low survival when using this procedure.

9. Case Study – LA County • Crew is dispatched to possible narcotic overdose • 62 year old male with decreased LOC • 110/90, 96, 8 • Pupils constricted • Evidence of opiate overdose • Patient managed successfully with naloxone

10. Case Study (continued) • Fast forward two weeks • Same paramedic • Same patient, slightly different presentation • Decreased LOC • 130/80, 90, 22 • Treated with naloxone (no base contact)

11. Outcome • LEMSA policy for narcotic overdose • Decreased LOC • Respiratory rate ≤ 8 • Incident reported to LEMSA • Sent to the EMSA • Recommendation for discipline • ALJ hearing

12. Outcome • Suspension of license • Probation – One year • Mandatory education – 16 hours didactic • NREMT practical skills exam COULD THIS HAPPEN TO YOU?

13. Let’s go back in time….

14. How did we get here? • The 60’s and 70’s • “Accidental Death and Disability” • EMS fragmentation • Federal support • Miami, Chicago, Seattle, Los Angeles • Wedworth – Townsend Act • Law/Statute

15. Laws, Regs, and Policies • Statute (law) gives us the authority to practice • Regulations are created based on the statute • Policies are subordinate to the regulations

16. What are the two things that you don’t want to see made? _______ and _______.

17. Getting from A to Z Idea Identify a legislator Draft language (legislative counsel)

18. Introduced on the ‘floor’ Hearings Back and forth seeking resolution MAY go to the Governor Signed into law

19. Alphabet Soup • EMSA - State Emergency Medical Services Authority (EMSA) • LEMSA - County Local EMS Agency • EMSAAC – County Administrators • EMDAC – County Medical Directors • EMS Commission • FAC – Field Advisory Committee • P and P – Policy and Procedure

20. EMSA • Overarching authority for EMS in CA • Creates regulations (including scope) • EMT, paramedic, CE, AED, first aid • Licensure, investigation and discipline for paramedics • Disaster preparedness • ‘Support and regulate’ LEMSAs

21. LEMSA • Coordinate local system • Develop policy • Certify, investigate and discipline EMTs • Manage systems of care (STEMI, stroke, trauma • Most manage RFPs for ambulance service

22. EMSAAC • Association of LEMSA administrators • Meet quarterly • Annual conference • Represented on EMS Commission

23. EMDAC • Emergency Medical Directors Association of California • Advise the EMSA on clinical matters • Scope of Practice committee • Represented on EMS Commission • Who is your medical director?

24. EMS Commission • 18 members • Multiple stakeholder groups • Cal Chiefs • CA Professional Firefighters • Cal Fire • EMDAC • EMSAAC • Meets quarterly

25. Field Advisory Committee(or similar) • Operational and clinical issues • Regular meetings

26. Policy and ProcedureCommittee • Creates and revises treatment protocols (not really guidelines) • Should have broad representation • Education follows release

27. The Evolution of Policy • 70’s and 80’s – “Mother May I?” • 90’s on – Protocol Based • Reduced the need for Base contact • Expectation of strict adherence • Need to ‘Stay in the Box’ • Consults provide for variance

28. “In an effort to provide the most optimal care for the patient, some providers make adjustments to care based on a perceived need” Don’t go it alone!

29. Physician Consults • Provide a mechanism to deviate from protocol. Allows you to ‘bend’ the box • Physicians can ‘practice medicine’ • Management of patient must still conform to EMT-P Scope of Practice • MD must be familiar with policies

30. § 100169. Paramedic Base Hospital. (7) Have a physician licensed in the State of California, experienced in emergency medical care, assigned to the emergency department, available at all times to provide immediate medical direction to the MICN or paramedic personnel. This physician shall have experience in and knowledge of base hospital radio operations and LEMSA policies, procedures, and protocols.

31. Which of the following can paramedics do? • Apply “Soothe a Sting” to an insect bite? • Apply antibiotic ointment to a small cut? • Cleanse a wound with hydrogen peroxide? • Provide Advil on the fire line? • Provide decongestant on the fire line? • Administer a steroid when provided by the parent of a small child? • Allow an EMT to check blood sugar? • Provide aspirin for a headache?

32. None of the Above!

33. EMT-P Scope - examples • (1) Basic Scope of Practice: • (A) Utilize electrocardiographic devices and monitor electrocardiograms, including 12-lead electrocardiograms (ECG). • (B) Perform defibrillation, synchronized cardioversion, and external cardiac pacing. • (C) Visualize the airway by use of the laryngoscope and remove foreign body(‑ies) with Magill forceps. • (D) Perform pulmonary ventilation by use of lower airway multi-lumen adjuncts, the esophageal airway, perilaryngeal airways, stomal intubation, and adult oral endotracheal intubation.

34. Case Study • Dispatched for a seizure patient at a rehab facility • Patient is post-ictal with stable VS • Patient has in IV in place with a phenobarbital drip • Staff requests transfer to closest hospital

35. Case Study • Patient seizes during the transport • Family meets you at ED • Father of patient is a physician • Father questions PB dosing

36. What happens next?

37. Who might initiate a “notification”? • Patient • Family • Bystander • Nurse • MD • Someone who sees the video • Involved paramedic or EMT

38. Culture of Self-Reporting • Transparency • Other industries • Policy of ‘no fault’ or discipline • Increases awareness, education • Ultimately reduces errors • Better for patients

39. Notifications • What are they? • How do they relate to CQI? • Good or bad?

40. Step 1: Where does the notification start?

42. Types of Notifications Good calls : Positive Events • Good calls, exceptional care, good transport decisions • Saves, diagnostic coups, other Example This notification is being written to commend the medics involved with this case for their excellent patient care and decision making. Their accurate clinical assessment and interventions, rapid transfer, and thorough documentation was appreciated by the Emergency Department physician and staff.

43. Types of Notifications Not so good calls : Unusual Occurrence without patient harm • Protocol violation, documentation issue, • MCI >10 patients • Interagency/Interdepartmental issues • Radio communication issues • Tx outside of scope of practice

44. Step 2: Types of Notifications Serious calls : Unusual Occurrence with Patient Harm (or potential for harm) • Patient treatment violation • Harm to a patient: unanticipated death • Inappropriate tx decision/diversion • Reported misconduct in line of duty: • Personnel unfit for duty • Alleged criminal behavior • Negligence • Patient abuse • Patient abandonment • Any event actionable pursuant to Health and Safety Code Section 1798.200

45. Level 3 example: “Combative patient was brought to the ED secured to the ambulance cot with restraints. Patient was transported in a prone position with the scoop stretcher ‘sandwiched’ over the patient”

46. Response to EMS Notification After careful review of the notification, the CQI Coordinator will prepare and submit a response • 30 day time frame • Reviewed by LEMSA medical director and staff • EMT – stays at this level • Paramedic – MAY be sent to the EMSA with recommended actions

47. Case Study - Notification • 64 year old male at home – un-witnessed fall • Wife found husband, called 911 • Patient states only had “about 2 or 3 drinks” • 1 cm hematoma noted at R side of head, R wrist pain with + csm • BP 110/80, HR 98, RR 14, o2 sat 96%, GCS 15 • FS 122 • Pain scale 5/10 near R thumb

48. Case Study - Notification • EMS arrives clears patient using State of Maine criteria • Splint placed to R wrist • Pt refusing transport but finally agrees • Pt denies meds/allergies/hx • Transport

49. Case Study - Notification • Upon ED arrival pt continues to deny head, neck or back pain • Pt placed in C-collar by Emergency room physician secondary to ETOH on board and un-witnessed fall • HR 104, BP 112/74, RR 16 o2 sat 95%, GCS 15

50. Case Study - Notification • IV placed • Patient head CT ordered with c-spine and R wrist x-ray • IV Morphine 2 mg administered • Ice pack placed to R wrist