July/ August/ September 2001

1 OCEMS Program Manager Appointed

1 A Word from the EMS Program Manager by Darlene Isbell

2 A Fond Farewell

3 EMS Staff

Darlene Isbell, RN, MPA
Bruce E. Haynes, MD
Ken Miller, MD
Jane Elder, RN
David Johnson, RN
Paul Russell, RN
Mary Jo Vincent, RN

Orange County Emergency Medical Services

405 W. Fifth Street, Suite 301A 

Santa Ana , CA 92701 

(714) 834-3500

Volume 2, Issue 4 Editor: Barb Andrade, RN

Inside this Issue 

1. Appointment of a New Manager Program Manager Column

2. A Fond Farewell New Asthma Medication Updated Guidelines for the Treatment of Exposures to Hepatitis

3. No Contact Calls EMS Staff 

4. Diversion

5. Coming Events "Happiness is not a station you arrive at, but a manner of   travelling." -Margaret Lee Runbeck

 

 

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OCEMS Program Manager Appointed The County of Orange Health Care Agency is excited to announce the appointment of the new Emergency Medical Services (EMS) Manager, Darlene Isbell, RN, MPA. Darlene has been working as the Assistant Director of the Los Angeles County EMS since 1994. Her responsibilities there included the prehospital care program, as well as disaster planning and response. Prior to this Darlene served as a nursing instructor at the LA County Paramedic Training Institute and as a critical care nurse.

Ask anyone in LA County and they will tell you that Darlene is widely respected and held in high regard by EMS constituent groups throughout the LA area.

We here at OCEMS are looking forward to working with Darlene. She is a welcome addition to our team of professionals.

A Word from the EMS Program Manager by Darlene Isbell 

It is with great pride and pleasure that I have the opportunity to become a part of Orange County's Emergency Medical Services as the new Program Manager. I am joining a team of professionals who are dedicated to ensuring and continuously improving the delivery of prehospital care to the public. I am fortunate to be entering a system that has had the benefit of the leadership of both Dr. Bruce Haynes, EMS Medical Director, and CeCe Waite, the recently retired EMS Program Manager.

It is evident to me that there is an atmosphere of cooperation and respect among the various stakeholders; EMS providers, hospitals, ambulance companies and the EMS Agency. This reputation goes beyond County borders and is something to be proud of.

Over the next several months, it is my goal to be meeting many of you— learning more about Orange County's successes and what you perceive as the challenges and opportunities for EMS in the future.

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A Fond Farewell Along with welcoming Darlene Isbell to OCEMS, we find that we are also saying good bye to one of our EMS Coordinators. Barb Andrade, RN will be resigning the first week of August. She has accepted a position closer to her home and family. Barb has been the Trauma, Pediatric and Hospital Coordinator since she began working for OCEMS in September 1998. For a brief time she also assisted as the ALS Coordinator. Within the County, Barb has been actively involved as a Performance Incentive Program trainer for the managers and supervisors. She has also been involved in teaching CPR to county employees and participating on the OC Fair Planning Committee for the Health Care Agency. We will miss her, but wish her the best in her new ventures.

NEW ASTHMA MEDICINE By Bruce E. Haynes, MD 

Formoterol (Foradil®) is a new long-acting beta-2 adrenergic agonist for maintenance, treatment of asthma and prevention of exercise induced bronchospasm. The medication is similar to Serevent that has been available in the United States for some time. As a long-acting beta agent, similar to the albuterol, Formoterol can be used for maintenance treatment to add to inhaled steroids for patients with moderately severe asthma. Typical uses might be for overnight use or to reduce the use of rescue albuterol. It may also be beneficial in preventing exercise induced bronchospasm among asthmatics. Formoterol has expert consultation is recommended for clinicians prescribing post exposure prophylaxis in a number of cases including delayed (i. e., later than 24-36 hours) exposure reports, unknown sources (e. g., needle and sharp disposal container and laundry), known or suspected pregnancy in the exposed person, resistance of the source virus to anti-retroviral agents, and toxicity of the initial Expert

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UPDATED GUIDELINES FOR MANAGEMENT OF EXPOSURES TO HEPATITIS B, C AND HIV by Bruce E. Haynes, MD 

The United States Public Health Service just issued updated guidelines for management of occupational exposures to hepatitis B, hepatitis C, and HIV with recommendations for post exposure prophylaxis. The document summarizes the current state of the art on the evaluation of health care workers exposed to these three viruses, as well as recommendations for post exposure prophylaxis and management. Those who are interested in reviewing the full report can find it at the CDC website www. cdc. gov/ mmwr under MMWR Recommendations and Reports for June 29, 2001. OCEMS will make sure that all hospitals are aware of the updates. A few selected highlights follow; however, the information is consistent with current practice and should not result in any major changes to evaluation and treatment. The recommendations point out that hepatitis C is transmitted in about 1.8% of virus-positive needle sticks and that no prophylactic therapy is effective or recommended. On the other hand, early testing followed by early treatment if the health care worker contracts hepatitis C is considered beneficial, so diagnosis and evaluation are important. Immune globulin which has been used in the past following hepatitis C is not effective and there have been no clinical trials conducted to assess post exposure use of anti-viral agents, (e. g. interferon with or without ribavirin) to prevent hepatitis C infection. The guidelines point out that hepatitis B, in particular, is persistent for extended periods of up to one week in dried blood even in small amounts, and that appropriate personal protection should be employed for cleaning dried blood on equipment even well after use. For pregnant individuals, prophylactic treatment for hepatitis B is recommended under the usual protocols. For HIV exposure, post exposure prophylaxis is generally warranted after discussion between the woman and her physician, with avoidance of certain drugs. There is some viral resistance to HIV medications, and while the initial post exposure prophylaxis may not be affected by this, in some cases clinicians will want to tailor the drugs used to known resistance in the community, or based on the source patient's clinical profile. The new guidelines outline newer medications now available for post exposure prophylaxis of HIV along with their advantages and disadvantages as well as recommendations for current protocols. These are similar to protocols used in the past. One new recommendation is the rapid HIV antibody kits be used more frequently for evaluation of source patients. The existing post exposure recommendations based on the severity and volume of exposures are contained in this draft as well. An issue seen in the past is the testing of needles or other sharps if a source patient is not available. The document recommends against testing needles or other sharps. One issue is the potential danger to laboratory personnel and transporting personnel in carrying these needles and sharps. Healthcare personnel exposed to hepatitis B or hepatitis C infected blood do not need to take any special precautions to prevent secondary transmission during the follow-up period, such as modification of sexual practices and refraining from becoming pregnant. If an exposed woman is breast-feeding, she does not need to discontinue. On the other hand, they should refrain from donating blood, plasma, organs, tissue, or semen. For HIV exposure, on the other hand, it is recommended healthcare personnel commit to behavioral measures such sexual abstinence or condom use to prevent secondary transmission during the follow-up period. If an exposed woman is breast-feeding, she should be counseled about the risk of HIV transmission in breast milk and discontinuation of breast-feeding should be considered, especially for high-risk exposures. This is also true if anti-retroviral drugs are employed.

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Health Care Agency's Emergency Medical Services ........................ 3

New Asthma Medicine continued from page 2 

the same adverse effects that would be seen with other inhaled beta agents, such as albuterol. It can be used in adults and children at least 5 years of age. Like Serevent, Foradil is not indicated for immediate relief. "Brand" or "trade" names include Oxis Turbuhaler and Oxeze Turbuhaler.

MDI? What is a metered dose inhaler? A metered dose inhaler, or MDI, is a device used to deliver asthma medication directly to the lungs.

UPDATED GUIDELINES continued from page 2 

Expert consultation is recommended for clinicians prescribing post exposure prophylaxis in a number of cases including delayed (i. e., later than 24-36 hours) exposure reports, unknown sources (e. g., needle and sharp disposal container and laundry), known or suspected pregnancy in the exposed person, resistance of the source virus to anti-retroviral agents, and toxicity of the initial post exposure regimen. A number of the current resources for assistance with post exposure prophylaxis and needle stick evaluation and management are available in the document. If you have any questions about the document or infectious disease issues, please contact Jane Elder in our office.

EMS Staff If you have questions for someone in OCEMS, the general office number is (714) 834-3500. The fax number is (714) 834-3125. Individual telephone numbers and e-mail addresses are listed below. Darlene Isbell, RN, MPA EMS Program Manager (714) 834-2791 disbell@ hca. co. orange. ca. us

Bruce E. Haynes, MD EMS Medical Director (714) 834-6712 bhaynes@ hca. co. orange. ca. us

Ken Miller, MD Assistant Medical Director (714) 834-3500 kmiller129@ aol. com

Jane Elder, RN ALS Coordinator (714) 834-2926 jelder@ hca. co. orange. ca. us

David Johnson, RN QI Coordinator (714) 834-6233 djohnson@ hca. co. orange. ca. us

Paul Russell, RN Medical Disaster Coordinator (714) 834-3124 prussell@ hca. co. orange. ca. us

Mary Jo Vincent, RN BLS Coordinator (714) 834-2964 mvincent@ hca. co. orange. ca. us

Trauma/ Pediatric/ Hospital Coordinator (714) 834-3500

"No-contact" Calls -Jane Elder RN; ALS Coordinator June 18 th , 2001, paramedics throughout Orange County began performing some advanced life support interventions to a select group of patients without contacting their assigned base hospital.

Stable ALS patients over the age of 6 years who do not require a specialty center are candidates for "no-contact" even if their condition requires any of the following ALS interventions: IV access, dextrostick, or cardiac monitoring. Base contact continues to be required for ALS patients with conditions in which medication or IV fluid bolus is indicated, or if the patient may need to be evaluated at a specialty center.

It was anticipated that the number of base-contacted calls would drop by 20-25% using the above criteria. Although the actual percentage varies by provider agency and base region, numbers reported to date indicate a "no-contact" rate of 14-35%. The PreHospital Care Coordinators are carefully monitoring all "no-contact" calls to ensure compliance with criteria and are providing one-to-one education for any fall-outs; however, the PCCs report very few deviations and of those, the situations were minor.

Under "no-contact", paramedics are responsible to contact the intended receiving hospital to provide a limited report to ED staff. In some areas, the transporting agency (ambulance company) has agreed to contact the hospital in lieu of the paramedic. Receiving hospital staff should refrain from suggesting medical interventions; by state law, paramedics can only accept medical direction from the base hospital/ base physician. Likewise, unless the ED is reporting "Closed: ED Saturation" on the ReddiNet system, staff should not ask paramedics or ambulance contiued on Page 4 

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July/ August/ September 2001 

4 ........................ "No-contact" CALLS continued from page 3 personnel to divert to another hospital. Hospital staff or others with questions regarding "no-contact" are encouraged to contact their assigned base hospital prehospital care coordinator.

DIVERSION by Bruce E. Haynes, MD 

Emergency department patient bypass or diversion hours have unexpectedly stayed high this year, again focusing attention on what can be done to reduce it. In December and January, we saw the typical increase in bypass for that time of year, although not as severe as in some of the bad "flu" years we have seen. What was different this year is that after January, diversion never fell back to normal levels as it typically does. Diversion hours for emergency departments remained high through May when they began to decrease a little, but we are still at much higher levels than the same month last year. The reasons for the continued elevation of diversion numbers are unclear.

Possible reasons might be higher ED volumes, longer stays due to more prolonged work-ups for managed care reasons, less hospital excess capacity, and shortage of critical care beds. Obviously, there are many other possible contributing factors. Efforts are being made in a number of areas to deal with this. First, there is increasing recognition that diversion is the result of a hospital-wide problem. It is not really an emergency department problem, and certainly not a field problem. OCEMS and the Healthcare Association of Southern California Orange County Division have invited hospital personnel from Scripps

Mercy Hospital in San Diego to an August 16th meeting to discuss their experiment with a week without going on diversion. They will discuss the preparation, the actual week itself and their follow-up of this interesting trial. The intended audience is hospital administrative and clinical personnel. A similar educational meeting focused on sharing information among hospitals from Orange County is tentatively scheduled for September. OCEMS is attempting to collect additional information regarding ED volumes, length of stay, and other data that may help us understand the current problem. Ideas vary and we hope to be able to eventually identify the role that volume increases play in this, although many people believe that increased patient lengths of stay due to more prolonged work-ups under managed care may be an additional cause. Specific information will be sent out in the diversion newsletter from OCEMS.

One idea that has been suggested by constituent groups several times in the past is that OCEMS personnel should perform hospital site visits during diversion hours to better understand the hospital situation, and in some cases to assure that the hospitals understand the diversion rules. We do plan on instituting selected site visits to hospitals while they are on diversion in the near future. Other policy changes that have been suggested is limiting the amount of time on diversion, such as a limit of two hours on diversion followed by a minimum of one hour open before the emergency department can be closed again. In addition, some believe that only basic life support patients should be diverted and that advanced life support patients should not be subject to diversion. Both these ideas will probably be put into draft form for committees and constituents to debate at some point in the near future to ascertain whether or not they have value.

The diversion problem is a symptom of deeper issues in the healthcare system, its financing and management, and it is unclear whether EMS-based solutions will truly be helpful. However, we will continue to work hard at managing this.

Hospital Diversion – ER Sat Hours Comparison Report PRC May99 May 00 May 01 AGH 9: 23: 00 14: 05: 00 90: 51: 00 AMMC 7: 54: 00 0: 46: 00 94: 39: 00 AM-West 5: 18: 00 Closed Closed Brea 19: 24: 00 45: 52: 00 138: 56: 00 Chapman 29: 19: 00 2: 06: 00 20: 21: 00 Coastal 40: 56: 00 16: 06: 00 64: 35: 00 FVHMC 71: 50: 00 104: 12: 00 80: 59: 00 GGMC 3: 52: 00 24: 23: 00 56: 02: 00 Hoag 8: 46: 00 No hrs 14: 02: 00 H. Beach 47: 01: 00 75: 08: 00 102: 29: 00 IMC 46: 16: 00 57: 14: 00 207: 42: 00 Kaiser 8: 44: 00 3: 36: 00 9: 35: 00 LaPalma 8: 41: 00 21: 14: 00 53: 52: 00 Los Al 67: 42: 00 41: 57: 00 107: 41: 00 Mission 107: 08: 00 170: 33: 00 96: 05: 00 OCMMC No hrs 5: 30: 00 3: 58: 00 PLH 26: 21: 00 25: 09: 00 33: 53: 00 San Clem No hrs 5: 30: 00 3: 58: 00 SMMC 39: 31: 00 102: 12: 00 141: 17: 00 S. Coast No hrs 34: 46: 00 45: 20: 00 St. Joe's 1: 43: 00 No hrs 4: 40: 00 St. Jude 87: 58: 00 54: 49: 00 46: 22: 00 UCIMC 8: 10: 00 17: 24: 00 45: 09: 00 WAMC 46: 45: 00 89: 08: 00 164: 17: 00 WMCAna 7: 44: 00 12: 35: 00 48: 56: 00 WMCSA 89: 13: 00 90: 38: 00 92: 01: 00 TOTAL 789: 39: 00 1020: 46: 00 1819: 55: 0 Median 22: 52: 30 25: 09: 00 56: 13: 00 Mean 31: 50: 16 44: 22: 52 72: 47: 48 

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Health Care Agency's Emergency Medical Services 

Coming Events August 2001

2 Trauma Ops 11: 00 10 Mission RPAC 09: 00 13 QAB 12: 00 16 AMMC RPAC 08: 30 DEAG 09: 00

17 St. Jude RPAC 08: 30 24 EMCC 09: 00

September 3 Labor Day OCEMS closed 6 Fire Chiefs 09: 00 Trauma Coord. 1: 00 PCC 1: 00 7 Hoag RPAC 08: 30 11 FAC 09: 00 12 BHPD 11: 00 CPAC 1: 00

13 WMCSA RPAC 08: 30 "Yesterday is but today's memory, and tomorrow is today's dream." -Kahlil Gibran

Disastrous News… By Paul Russell, RN 

Schedule of Upcoming Mass Casualty Exercises... San Onofre Nuclear Generation Station (SONGS) Aug. 8, '01 & Sept. 12, '01 Operational Area (Orange County) Power plant incident

John Wayne Airport Exercise Oct. 3, '01 JW Airport Aircraft accident Metro/ Blue/ North Green Nets Exercise Oct. 24, '01 City of La Habra Natural gas explosion at a charity breakfast

Statewide Hospital Exercise Nov. 15 '01 All Hospitals Terrorist release of a hazardous material

SONGS and O. C. Hospitals / BLS Transportation Providers The annual test of the San Onofre Nuclear Generating Station emergency response plan will be rehearsed on August 8 th and tested for FEMA on September 12 th . Your facility or agency is very likely to get a ReddiNet message, a telephone call or fax regarding resource availability related to a SONGS event. The Health Care Agency official calling will identify themselves and announce clearly that "this is a drill." As in past years, this is only a paper and communications exercise. There will be NO actual movement of people or resources.

An MMRS Opportunity… The Metropolitan Medical Response System (MMRS) is well underway in the production of the documents that will bring this county-inclusive response plan to life. In the upcoming months you will have the opportunity to help shape an Operational Area (county) wide system with the primary purpose of responding to a weapon of mass destruction incident. Some of the first documents for review are draft copies of model policies dealing with hospital credentialing of staff in an emergency and mass patient decontamination. Also out for comment is a draft of a suggested equipment list for hospital personal protective equipment and decontamination equipment. You are encouraged to get a copy and make comments during this 50-day comment period. Call (714) 834-3500 to have copies mailed to you. Or e-mail Paul Russell at: prussell@ hca. co. orange. ca. us

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