Physician Orientation for Base Hospital Services in Ontario EMS

1. Base Hospital Physician Orientation: PCP Services Only The Patch Phone and You!

2. Why am I watching this? • You work at a site where the ER MDs answer the patch phone as Base Hospital Physicians (BHPs) • Orientation to how/why to answer that ring • Requirement of the MOHLTC: • Orientation • Annual update • Proof (the online form)

3. Objectives

4. Southwest ontario regional base hospital program

5. SWORBHP Office

6. SWORBHP 1400 paramedics 11 Services 1.65 million population 240,000 patient contacts/year 4 BHP sites

7. Structure of EMS in Ontario

8. Care Structure of EMS

9. Delegation

10. EMS in Ontario - Delegation • Regulated Health Professions Act (RHPA) sets out 14 "controlled acts" which may only be performed by certain of the regulated health professionals • Examples include: performing a procedure below the dermis, injecting medications etc. • Paramedics are not regulated health professionals under the RHPA • In appropriate circumstances physicians may delegate the performance of acts to other individuals who may or may not be members of a RHP.

11. EMS in Ontario - Delegation • There are 2 forms of “medical control” in order to delegate medically controlled acts: • Offline Medical Control = pre-set protocols for paramedics to perform • The Medical Directors at Base Hospitals across the province provide offline medical control/delegation via the ALS Patient Care Standards (ALS-PCS) • Online Medical Control = paramedics patch into a physician in real-time • As a physician answering the patch phone you become involved in on-line medical control or direct delegation** • Mandatory patch-points (ie. Needle thoracostomy) • Unique situations

12. EMS in Ontario - Delegation • The College of Physicians and Surgeons of Ontario (CPSO) policy on delegation requires certain tenets of delegation to be followed: • Delegating acts that you regularly do as part of your practice • Appropriate education for the person being delegated to • Maintenance of competence to perform the act • Quality assurance of the act performed http://www.cpso.on.ca/policies/policies/default.aspx?ID=1554

13. EMS in Ontario - Delegation • The BH structure provides the support system necessary to delegate: • 1) Education – initial + continuing • 2) Quality Assurance – Call audits + investigations End goal = support for medically controlled acts + best possible prehospital care provision

14. Paramedic scope of practice

15. Paramedic Scope of Practice

16. Paramedic Scope of Practice • Medical Directives • Auxiliary • Core

17. PCP – Primary Care Paramedic

18. The Patch Phone

19. Types of Patches • When the phone rings, who is calling? • Notification Patches • BHP Patches “Can I have a physician for a paramedic patch”

20. Patching: WHY • What do they want from me? A paramedic shall patch to the Base Hospital when: • Mandatory Patch Point built in to a Medical Directive • Uncertainty of appropriateness of Medical Directive • For situations that fall outside of a Medical Directive • What is in it for me? • SWORBHP contributes financially to the patch MD group • Earlier awareness of cases in the field to mobilize resources

21. Patching: WHAT • What do they want from me on the phone? • Termination Of Resuscitation (TOR) or Field Pronouncement • Medication Orders • Procedure Orders • Direction in dynamic arrest / very sick patient • Unusual circumstances • medical knowledge vs operational advice • Often the medic has a PLAN- Ask what it is! • They may not be seeking the orders you are giving

22. Patching: HOW • Official Order sheet • Sign + CPSO # • Only for the MD to fill-in • Critical information: • Run # • Date/time/service • Orders granted • Pronouncement: Don’t forget the Date & Time

23. Patching: PEARLS • Consider transport time • IVF bolus, medication administration • Pronouncement/TOR • Consider paramedic scope of practice • Resources to help • Paramedic Handbooks • App • ALS-PCS Online(SWORBHP website)

24. Patching: PEARLS Continued • Radio communication • Only one person can talk at a time • Introduce yourself • Repeat important information back for confirmation • Ask directed questions • “Is he in asystole?” • vs • “He is in asystole?” • Research by our own Dr Don Eby

25. Specific patch points

26. Mandatory Patch Points (PCP & ACP)

27. PCP Medical Cardiac Arrest TOR • Reduces the rate of transport by 37%-60% • Decreases risk to public paramedics associated with Lights and Siren transport for patients with <1% chance of survival

28. Termination of Resuscitation/Pronouncements: Words to live by… • Common sense approach: • Is arrest management to your standard? • When to think twice: 1) Still shockable 2) Pulseless Electical Activity (PEA) • especially young and PEA:could it be profound hypotension and just not able to feel a pulse? 3) Public Place 4) Paramedic/ family overwhelmed • Remember – it is always okay to transport the patient

29. What if the patient is in the ambulance? • If the ambulance is NOT moving, it becomes the place of death • Medics and ambulance will be out of service until coroner comes to allow the body to be released • This can be a significant logistics issue • Should consider transporting or “rolling TOR”

30. The “Rolling” TOR • New Deceased Patient Standard from the coroners office allow for a “rolling” TOR • Medics can patch for a TOR DURING transport • If given can continue on to the planned receiving hospital • If it happens • Please call the receiving ED and make them aware of the TOR/Pronouncement • Recommended practice is: • Register the patient in the ED • Confirm and document the time of TOR by the BHP (available from the medic) • Contact the Coroner

31. Trauma Arrest TOR (PCP & ACP)

32. IV Fluid Therapy (PCP-IV & ACP) • Keep in mind transport times when considering approving fluid boluses • Does the patient NEED a fluid bolus initiated in a short transport?

33. Opioid Toxicity (PCP & ACP) • NOT a mandatory patch • BUT you may get a patch for: • <12 years-old • Larger doses • Fentanyl, carfentanil • Cardiac arrest with suspected opiate OD*

34. Patching – Outside the directives • Please be aware of the directives – occasionally paramedics will ask for medications that do not meet their protocols ie. • IVF for hyperglycemia • Acetaminophen for fever • In these cases, SWORBHP recommends that you not provide orders outside the parameters unless there is considerable extenuating circumstances

35. Patching – Unusual circumstances • Essence of off line (protocol based) control is that it is impossible to have protocol for every circumstance • Psychosocial • Refusal of care/transport • DNR validity • Medic trained to patch for direction • Often will identify options for you • Usually answer is clear, just need your OK • Use common sense

36. OTHER EMS Interactions: Non-BHP Role

37. Non-BHP Interactions with EMS • Dispatch • Destination Policies • On-scene Medical Bystanders • Transportation Between Facilities

38. EMS Dispatch & Destination • Ambulance Communication Centre • Owned and Operated by MOHLTC* • Controls the movement of the medics • Destinations dictated by • Patient status • Local destination policies (ie. Acute Stroke bypass) *some exceptions

39. EMS On-Scene Medical Bystanders • If healthcare provider stops to assist • Paramedics may only treat a patient within their authorized level of certification and under their SWORBHP approved Medical Directives • If bystander renders care beyond this scope and this continued care is required for transport, the bystander should accompany the patient Under no circumstances are Paramedics to treat a patient outside of their medical directives or provide care ordered by an on-scene physician or other healthcare provider • Destinations dictated by • Patient status • Local destination policies (eg. STEMI bypass)

40. EMS Between Facility Transfer • The same rules apply: • Paramedics may only treat a patient within their authorized level of certification and under their SWORBHP approved Medical Directives • If care required is beyond this scope, another provider capable of providing this care should accompany the paramedics during transport Under no circumstances are Paramedics to treat a patient outside of their medical directives or provide care ordered by an on-scene physician or other healthcare provider • Destinations dictated by • Patient status • Local destination policies (eg. STEMI bypass)

41. EMS Between Facility Transfer: Pearls • Be Prepared for potential decompensation: • Medications • Equipment • Providers • Transport Code • Weigh risks and benefits of lights-and-sirens transport

42. SWORBHP: Opportunities and outreach

43. Opportunities • Education • Grand Rounds • Webinars • Research • Evidence of Practice • Ride-outs • Contact your local BHP • Innovation and Ideas?

44. I have a question, who do I contact? • North Region (Bruce, Grey, Huron, Perth) • Dr. Don Eby • Don.Eby@lhsc.on.ca • Central Region (Elgin, Lambton, Middlesex, Oneida, Oxford) • Dr. Sean Doran • Sean.Doran@lhsc.on.ca • South Region (Chatham-Kent, Essex) • Dr. Paul Bradford • paul.bradford@sympatico.ca • Education-Related or Overall Program Related • Dr. Lauren Leggatt • Lauren.Leggatt@lhsc.on.ca • Research or Overall Program Related • Dr. Matthew Davis • Matthew.Davis@lhsc.on.ca

45. Resources: SWORBHP Website • SWORBHP Website • App • Medical Directives • ALS-PCS • BLS-PCS • Destination Policies • Healthcare Provider on scene Policy www.lhsc.on.ca/About_Us/Base_Hospital_Program Thank You!