Basic Ambulance Assistants (BAA)

37 Pages·2015·2.5 MB·English

Basic Ambulance Assistants (BAA) Activity for 2015

Activity: EE2 (15)

General Theme: Training

Topics:

Using Checklists to Minimize Mistakes in the Field
If you don’t have a checklist you probably should
Wake County EMS Clinical checklist
Prevent Medical Errors in the Field with Cognitive Strategies

Approved for (3) Clinical Continuing Educational Units
EE2 (15)

Use Checklists to Minimize Mistakes in the Field

Shaughn Maxwell, EMT-P | From the June 2014 Issue | Tuesday, June 3, 2014

In Washington State, I worked on a committee that developed a statewide system for cardiac and
stroke care. We drilled down to the vital key items we should never miss on these patients—
specifically key interventions and legal requirements every provider should know on every call for
every patient.
The process begged the question: How could we ensure EMS personnel applied these critically
important interventions every time?
My medical director, Richard Campbell, MD, and I were coincidentally reading Atul Gawande’s
book The Checklist Manifesto at the same time. Gawande, a Harvard professor and surgeon, was
appointed by the World Health Organization to reduce errors and avoidable death in operating
rooms (ORs) and improve surgical safety worldwide.
One of the first concepts he presented was using simple checklists in the OR to ensure simple key
steps weren’t missed. These checklists were developed and piloted in eight hospitals around the
world. The results were expected to be modest, but these checklists reduced surgery
complications by one third and lowered the incidence of surgery-related deaths by nearly half.
Similar to surgery, the field of EMS is expanding and increasing in complexity. The parallels in what
both healthcare fields seek—consistently safe, effective care for patients—are striking. Campbell
and I felt that if hospitals and surgeons were finding ways to deliver safer, more effective care,
EMS might be able to utilize some of the same principles.
I’ve worked in fire and EMS for 25 years, and have always used checklists to ensure fire apparatus
and ambulances were ready for the next response. During my tenure as a flight medic and wildland
firefighter, we lived by checklists. During initial wildland firefighter training, each firefighter was
given a checklist for 10 standard firefighting orders and 18 watch out situations, each developed by
the United States Forest Service in the 1950s following 16 tragic fires.
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It would be unthinkable to arrive on scene and have a medication or piece of equipment missing. It
would be equally catastrophic to run out of fuel on an emergency incident. When evaluation of
vehicle checks uncovers problems, it’s often tracked back to someone not checking the equipment
or supplies.
Gawande’s book inspired us. If checklists could leverage high-consequence industries like surgical
medicine, air travel and nuclear power to a higher level of success, certainly we could take them
beyond vehicle checks.
Checklist Development
Even with thousands of hours of training and thousands of calls, EMTs and paramedics can still
forget simple, key things. Who hasn’t arrived on the ramp at the hospital and realized they forgot
to put oxygen on the patient or administer aspirin to a chest pain patient?
Campbell and I set out to develop checklists for our high acuity 9-1-1 calls. To start our list, we
used a consensus paper published in Prehospital Emergency Care titled, “Evidence-based
performance measures for emergency medical services systems: A model for expanded EMS
benchmarking.”
The paper studied the best available evidence to determine which conditions are most influenced
by EMS interventions. The review also evaluated which interventions had the highest potential to
impact outcomes.
One specific way to measure the impact of a procedure that stood out to us was the NNT, or
number needed to treat. According to its website, www.thennt.com, “The NNT offers a
measurement of the impact of a medicine or therapy by estimating the number of patients that
need to be treated in order to have an impact on one person. The concept is statistical, but
intuitive, for we know that not everyone is helped by a medicine or intervention—some benefit,
some are harmed, and some are unaffected. The NNT tells us how many of each.”
Our initial list of conditions that needed a checklist included trauma, congestive heart failure,
chronic obstructive pulmonary disease, stroke, chest pain/ST-segment elevated myocardial
infarction, seizures, asthma, anaphylaxis and cardiac arrest. Although these represent only 20% of
our calls, they’re some of our most critical interventions.
We then determined other emerging conditions where studies or complexity indicated checklists
could enhance EMS performance. Sepsis and post-resuscitation care are two examples. For
example: ACLS has simplified the resuscitation process. However, post-resuscitation care has
increased in complexity. So we developed a checklist for return of spontaneous circulation (ROSC).
We tested this checklist in our ACLS courses. Starting in the classroom setting, Campbell asked our
paramedics to write down every action that should be performed after ROSC. Very few people
could quickly list all 11 action items on our ROSC checklist.
“If this were my family member, I would expect the paramedics to remember 100% of the actions
that would contribute to the best possible outcome, right?” Campbell asked the students. We then
gave the class the ROSC checklist and found it created an effective, organized approach for the
team and provided instant confidence for the team leader.
Checklists for high-acuity EMS situations were sent to our crews, and we later had the opportunity
to share some of our success with Gawande. He was incredibly encouraging and connected me
with other experts in his field to support our efforts. I felt like I was walking among giants.
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We were also able to review Gawande’s checklists developed for use in OR crisis situations, and his
results showed that checklists not only enhanced teamwork in medical crisis situations, but also
reduced errors and/or missed steps by 75%. We were convinced that this must become an EMS
best practice.
Confident that we were on the right path, Campbell and our team of medical services officers
spent hours developing and publishing a checklist each month. This may not seem very fast, but
with some checklists requiring up to 50 revisions, I realized the enormity of our mission. Good
checklists require extensive knowledge, persistence and focus to develop.

(see Appendix A for a larger version of these checklists)

Conclusion
Utilizing checklists is a huge paradigm shift; I describe it as giving someone the answers during the
most important test: saving a life.
A few years ago, I and many colleagues were called to a once-in-a-career event. It involved an
explosion, two structure fires, a wildland fire and a 50-person mass casualty incident (MCI). As
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soon as I arrived, I was assigned to serve as the medical group supervisor and was handed the MCI
board, called “the MCI checklist.” That day, everything went right and I’ll always be confident that I
remembered everything—because I used a checklist.
Not every call is a once-in-career event. However, for the patient it’s potentially a once-in-a-
lifetime event. The patient requires the very best care. Even if seems routine to us, checklists make
sure we don’t miss anything.
Don’t get discouraged; it’s important to realize that checklists will take time to become an EMS
best practice. They’re still gaining acceptance in ORs so it may take time to have EMS and fire
crews accept and adopt them. It’s easy to get discouraged trying to implement something new,
especially when it’s something that makes you have to accept that your memory is fallible.
Professional EMS providers pride themselves in having all their information in their heads.
However, I believe that, in the future, we’ll look back and won’t be able to imagine running even a
routine EMS call without one.
Finally, remember that cognitive aids like checklists are a strength, not a weakness. We endeavour
to support others who aspire to increase the performance capability of their organization.

References
(Available on request)

If You Don't Have a Checklist, You Probably Should

BY BY RAPHAEL M. BARISHANSKY, MPH ON OCT 31, 2010
"If something so simple can transform intensive care, what else can it do?"--Atul Gawande, 2010
Checklists seem to be all the rage these days. There are checklists for managers, checklists that are
industry-specific, and even a book titled The Checklist Manifesto: How to Get Things Done Right by
Atul Gawande, MD, MPH, which states that every profession could be more effective if checklists
were used for various tasks.
As proof to Gawande's thesis, the book offers examples from several industries where safety is
paramount--specifically surgery and air travel--and there is heavy reliance on checklists to ensure
that everything is covered and covered correctly. So, do checklists have a place in EMS? Can our
operations, safety and perhaps even managerial processes benefit from this approach?
Overview
Checklists can be small or large, with varying degrees of complication depending on the specific
situation they are being developed to cover. According to Gawande, a comprehensive checklist
should be:

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 Precise
 To the point
 Easy to use
 Only a reminder of critical steps
 Practical
The essence of a checklist is taking all of the actions that go into a larger scheme-- actions that
have the potential to vary due to time, person performing the actions, day of the week, the
weather and a host of other variables--and putting them in written order so the same essential
actions happen in the same format independent of all of those aforementioned variables.
Sometimes a checklist may be essential for an event that is important but not frequently seen,
such as your EMS agency's response to a pandemic.
Examples
A good example of checklist utilization comes from Wake County (NC) EMS. Chief Skip Kirkwood
says that his EMS agency utilizes checklists to ensure that EMS providers "dot their I's and cross
their T's" in a number of clinical scenarios, including cardiac arrest management, CHF patients and
asthmatics, as well as for determining legal capacity, mental capacity and/or medical or situational
capacity. Another example of clinical checklists with a quality assurance bent comes from
the Eastern Pennsylvania EMS Council and covers a host of clinical interventions like airway
management, CHF patients, seizure management, OB/GYN emergencies, etc.
An extremely applicable checklist comes from the Monmouth-Ocean Hospital Service Corporation
(MONOC), a CAAS-accredited EMS agency in New Jersey that utilizes a comprehensive checklist to
assist supervisory personnel in investigating motor vehicle accidents in which departmental
vehicles are involved. Their checklist specifically prompts the supervisor to address various critical
points, such as seatbelt utilization, whether a traffic light was involved, whether the unit was en
route to a call or hospital at the time of the accident and weather conditions at the time, and also
reminds supervisors to take pictures of the scene.
Another checklist, developed and utilized by Lancaster County EMS providing EMS services in the
Charlotte, NC, area, specifically addresses myriad issues that field supervisors can and will face
over the course of a shift, where to funnel complaints and where in the agency personnel manual
to find information. This list is clearly specific to various supervisory responsibilities and includes
both day-to-day realities, such as location of spare equipment, checking the supervisor's unit and
overall system status, as well as more out-of-the-ordinary issues like communicating with the
media or contacting a PIO to handle media situations, coordinating mutual aid requests, and
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knowing when to contact administration for major incidents (i.e. bomb threats, major employee
injury etc.).
Conclusion
One of the underlying elements that is recurrent throughout Gawande's book is that by looking for
the answers to simple, often overlooked questions, we can avoid potentially large mistakes.
Gawande counsels agencies to get employees to embrace checklists by assuring they are easy and
quick to use, adaptable to a variety of settings and of obvious benefit.
The use of applicable checklists in EMS agencies has the potential to take some of the risk out of
what we do. They worked for Sully Sullenberger, the pilot who landed his plane successfully on the
Hudson River. I think they can work for your EMS agency as well.
Raphael M. Barishansky, MPH, is program chief of public health preparedness for the Prince
George's County (MD) Health Department and a member of EMS World Magazine's editorial
advisory board. [email protected].

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Wake County EMS System

www.wakeems.com 
Clinical Checklist  
Cardiac Arrest Checklist:

____ Code Commander is identified

____ Monitor is visible and a dedicated provider is viewing the rhythm with all leads attached

____ Continuous compressions are on-going

____ O2 cylinder with oxygen in it is attached to BVM

____ Mask travels with bag, regardless of what airway is in place

____ EtCO2 waveform is present and value is being monitored

____ ITD is in place if appropriate

____ Access has been obtained (IV or IO)

____ Gastric distention is not a factor

____ Esophageal temperature probe is in place and temperature is visible

____ D50 and sodium bicarbonate have been considered and/or administered

____ Tension PTX has been considered

____ Family is receiving care and is at the patient’s side
Version 1.1 January 2009

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Wake County EMS System

www.wakeems.com 
Clinical Checklist  
Considerations for termination of resuscitation outside of
procedure:

___ Desires of family members

___ Initial rhythm and witnessed status
Asystole ~1% survival, PEA ~10% survival, VF/VT ~40% survival

___ Current EtCO2 level (<20 mmHg with good waveform – low survival)

___ Refer to Discontinuation Form for criteria

PEARLS/Considerations

___ Unwitnessed arrest: 2 minutes of CPR prior to shock

___ Renal Failure consider Bicarb and Calcium early

___ Dig Toxic = NO Calcium

___ NO Calcium with Magnesium

___ Consider Procainamide for refractory v-fib

___ Consider H’s & T’s in PEA/Asystole arrest
Version 1.1 January 2009

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Wake County EMS System

www.wakeems.com 
Clinical Checklist  
ICE Protocol
ROSC
Postresuscitation Criteria for Induced Hypothermia
NO
protocol and initial temp >34C
Unsuccessful
Airway Management Advanced airway in place with
NO
Protocols ETCO > 20 mmHg?
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Successful Perform Neuro Exam Per IH Job Aide
Expose Patient
Apply Ice Packs to Axilla and Groin
Cold Saline Bolus 30 mL/kg
I I
to max 2 liters
Dopamine 10-20 mcg/kg/min
P P
taregt MAP 90-100
Continue to
Monitor
Discontinue Cooling >33 C, Temperature and
<33 C Reassess Temperature
Measures No Shivering Go to
Postresuscitation
>33 C and Pt Shivering Protocol
Postresuscitation A Etomidate 20 mg IV/IO A Shivering Stops
protocol
Still Shivering
Consider Vecuronium
A A
0.15 mg/kg to max 10 mg
Pearls:
(cid:121) Criteria for Induced Hypothermia
(cid:121) ROSC not related to blunt/penetrating trauma or hemorrhage
(cid:121) Age 12 or older with adult body habitus
(cid:121) Temperature after ROSC gretaer than 34 C degrees
(cid:121) Advanced airway in place with no purposeful response to pain
(cid:121) If no advanced airway can be obtained, cooling may only be initiated on order from online medical control
(cid:121) Take care to protect patient modesty. Undergarments may remain in place during cooling
(cid:121) Do not delay transport to cool
(cid:121) Frequently monitor airway, especially after each patient move
(cid:121) Patients may develop metabolic alkalosis with cooling. Do not hyperventilate

Version 1.1 January 2009

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