Sean Kivlehan, MD, MPH, NREMT-P September 2013

2. PUBLIC HEALTH & EMS Sean Kivlehan, MD, MPH, NREMT-P September 2013

3. EDUCATION ACCESS Source: CDC/Gindi, 2012

4. Source: CDC/Gindi, 2012

5. RETHINK EMS At what point does "abuse of the system" become failure of the "system" to adapt?

6. Things Change…. Re: Safety

7. Safer…(at least this thing had seat belts)

8. 2009: Safest (so far)

9. Things Change…. Re: Communication

10. …a little easier….(although the other thing still makes a great step stool)

11. 21st Century

12. Things Change…. Re: EDUCATION • 1966: NAS/NRC • Accidental Death and Disability: The Neglected Disease of Modern Society • 1967: AAOS “Orange Book” • Emergency Care for the Sick & Injured

14. Things Change…. Re: THOUGHT PROCESS

15. OBJECTIVES • How We Got Here • Current Problems • How to Fix Them

16. How We Got Here PART ONE

17. Young & Developing 1970 NREMT Formed 1973 Emergency Medical Services Systems Act 1975 AMA recognizes EMT-P 1977 National Standard Curriculum (NHTSA) 1984 NCSEMSTC reorganizes (and tries to standardize) EMS Education

18. Still Evolving… 1990 Consensus Workshop on Emergency Medical Services Training Programs 1993National EMS Education and Practice Blueprint 1994 EMT-Basic 1998 National Standard Curriculum for EMT-P

19. Emergency Medical Services (EMS) of the futurewill be community-based health management that is fully integrated with the overall health care system. It will have the ability toidentify and modify illness and injury risks, provide acute illness and injury care and follow-up, and contribute to treatment of chronic conditions and community health monitoring.This new entity will be developed from redistribution of existing health care resources and will be integrated with other health care providers and public health and public safety agencies. It will improve community health and result in a more appropriate use of acute health care resources. EMS will remain the public's emergency medical safety net. EMS Agenda for the Future, 1996 ~~NHTSA, NAEMSP, NASEMSD

20. 2006IOM Report: EMS at the Crossroads “At its best, EMS is a crucial link to survival in the chain of care, but within the last several years, complex problems… have emerged. Press coverage has highlighted instances of slow EMS response times, ambulance diversions, trauma center closures, and ground and air medical crashes.”

21. IOM Identified Concerns: • The evolving role of EMS as an integral component of the overall health care system. • EMS system planning, preparedness, and coordination at the federal, state, and local levels. • EMS funding and infrastructure investments. • EMS workforce trends and professional education. • EMS research priorities and funding.

24. What Are The Current Problems? PART TWO

25. What IS Public Health? “The science and art of preventing disease, prolonging life and promoting health throughthe organized efforts and informed choices of society, organizations, public and private, communities and individuals." ..blah, blah..

26. Why Us? “EMS will remain the public's emergency medical safety net.” • We see people in their home environment • Often at their worst • We can see the real needs they have • We can address their issues at home

27. Leading Health Indictors • Access to Health Services • Clinical Preventative Services • Environmental Quality • Injury & Violence • Maternal, Infant, & Child Health • Mental Health • Nutrition, Physical Activity, & Obesity • Oral Health • Reproductive and Sexual Health • Social Determinants • Substance Abuse • Tobacco

28. Access to Health Services • Adolescent Health • Arthritis, Osteoporosis and Chronic Back • Blood Disorders and Blood Safety • Cancer • Chronic Kidney Disease • Dementias, Including Alzheimer’s Disease • Diabetes • Disability and Health • Early and Middle Childhood • Educational and Community-Based Programs • Environmental Health • Family Planning • Food Safety • Genomics • Global Health • Healthcare-Associated Infections • Health Communication and Health Information Technology • Health-Related Quality of Life and Well-Being • Hearing and Other Sensory or Communication Disorders • Heart Disease and Stroke • HIV • Immunization and Infectious Disease • Injury and Violence Prevention • Lesbian, Gay, Bisexual, and Transgender Health • Maternal, Infant, and Child Health • Medical Product Safety • Mental Health and Mental Disorders • Nutrition and Weight Status • Occupational Health • Older Adults • Oral Health • Physical Activity • Preparedness • Public Health Infrastructure • Respiratory Diseases • Sexually Transmitted Diseases • Sleep Health • Social Determinants of Health • Substance Abuse • Tobacco Use • Vision

30. Defining the Problem • CDC needs report + Billings report reality • People are going to the ER for things • ER already needs to maintain 24/7 capability and overhead. • So does EMS • Why not embrace the gap instead of fighting it • So then, what are the barriers we face to fill this gap?

31. Population Age

32. Chronic Disease

33. What are they? • Heart Disease • Cancer • Asthma, COPD • Hypertension • Diabetes • Obesity • Addiction: Alcohol, Tobacco, Drugs

34. Leading Causes of Death (2010) • Heart disease: 597,689 • Cancer: 574,743 • Chronic lower respiratory diseases: 138,080 • Stroke (cerebrovascular diseases): 129,476 • Accidents (unintentional injuries): 120,859 • Alzheimer's disease: 83,494 • Diabetes: 69,071 • Nephritis, nephrotic syndrome, and nephrosis: 50,476 • Influenza and Pneumonia: 50,097 • Intentional self-harm (suicide): 38,364

36. Depending on your location • Language Diversity • Poverty Lines • Uninsured rates • Immigrant/Legal • Cultural

37. Preventable causes of death • Behavioral: Smoking, Drinking, Obesity • Unintentional Injury • Opiate OD/prescription drugs “14,800 overdose deaths in 2008, more than cocaine and heroin combined.” (CDC)

39. How Do We Fix It? PART THREE

40. Be a part of the solution Failings vs Opportunities

41. Be a part of the solution Failings are Opportunities

42. Be a part of the solution Failings are Opportunities “A new name for EMS” Teachable Moments: Say it when you see it

43. 1. What percent of patients have received a flu vaccine in the prior year? 2. What are the reasons why elderly patients don’t get a flu vaccine? 3. Offering flu vaccines to all elderly non-vaccinated patients 4. Do it, and then check it

44. Applies fundamental knowledge of principles of public health and epidemiology including: • Public health emergencies • Health promotion • Illness & injury prevention

45. Expanded Roles of EMS Personnel The American College of Emergency Physicians (ACEP) acknowledges expanded scope of practice programs are being developed in response to community needs. ACEP recognizes that EMS providers are likely to be used in the workforce for these programs. With proper design and medical oversight, potential benefits may include improved access to health care in underserved areas, improved patient care, and reduced costs.

46. Data Collection • Epidemiology NEMSIS.org “This effort will define EMS and pre-hospital care in a way never before imagined, improving patient care and EMS curriculum and defining a standard on with to measure care.” http://www.nemsis.org/theProject/thePartners/howToParticipate.html

48. Findings • 136 million ER visits in 2009 • 15.8% took a 911 ambulance there • 15% of Medicare patients could have been safely treated elsewhere • Would save $559.871 million a year

49. Why? • “Doctor or clinic not open” (60%) • “No where else to go” (40%) • Anywhere from 11-61% of EMS transports “unnecessary or avoidable” • Incentivized to transport • Overhead of 24/7 preparedness