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Relationships are key ingredients in the success of any EMS or fire department. Making connections and building rapport within and outside of the department can go a long way to enhancing the care EMTs and paramedics deliver to the community.
Members of the Aurora Fire Department (AFD) in Aurora, CO, have worked diligently in recent years to develop dynamic and collaborative relationships with several members of the EMS system, including dispatchers, police officers, health department officials, air medical helicopter personnel, physicians, nurses and other professionals in addition to EMS and fire personnel.
"The Aurora Fire Department recognizes the role we play is just one element in the emergency response system that protects our community," says Floyd Salazar, a paramedic supervisor in the department's EMS Bureau. "We realize that in order for the system to be at its best, each link must be at its best. To that end, we've embraced a collaborative, data-driven philosophy that encourages coordination and communication between professionals from each agency."
Salazar, along with Kevin Waters, EMS Bureau Manager, describe their agency's process of building relationships to enhance EMS care and developing programs that meet the needs of their community for EMSWorld.com.
You point out that dynamic and collaborative relationships are important to your department's success. How did you create those relationships? Why are they important?
By partnering with the Medical Center of Aurora, University Hospital, The Children's Hospital, Tri-County Health Department and Rural Metro Ambulance, an emergency medical system has been developed that is delivering world class care to our community. The joint medical oversight provided by Dr. Gilbert Pineda of the Medical Center of Aurora and Dr. Fred Severyn of University Hospital ensures the care being delivered by AFD firefighters is safe, effective, and in keeping with the most current scientific evidence available.
Realizing that no one element of the system can do everything well, we came to the conclusion that if every element is not only operating at its peak but is operating is such a way that it supports the efforts and processes of all the other partners, the system as a whole would be much more effective.
Initially, AFD brought the representatives of these various organizations together to meet on a regular basis. The goal was to build a collegial relationship between all those involved and to grow that relationship to a point where we could pool our collective talents and experience to improve EMS in Aurora.
What department programs have been instituted to meet emergent and non-emergent needs of your community?
In 2008, AFD, Rural/Metro Ambulance, the Medical Center of Aurora, University of Colorado Hospital and The Children's Hospital worked together to develop a process termed resuscitation choreography. This refinement of existing practices streamlines the way cardiac arrest patients are managed and represents a multi disciplined, coordinated approach to taking care of people who suffer sudden cardiac arrest. The resulting coordination and communication between professionals from each agency has created a synergy that is saving more lives than ever before.
The importance of early access to 9-1-1, early CPR, early defibrillation and access to post resuscitation care, have been emphasized by the American Heart Association for decades and many communities have each of these elements in place. But survival rates for people who experience sudden cardiac arrest remain extremely low. Historically, each agency involved in treating the sudden cardiac arrest victim approached this challenge from their singular perspective. While this enabled them to perfect their specific areas of responsibility, it lacked a unified approach to providing patient care. Surviving sudden cardiac arrest not only requires that dispatchers, firefighters, paramedics, nurses and physicians excel in their individual fields, but they must also excel in supporting each other's efforts.
Resuscitation choreography begins the moment someone calls 911 with a medical emergency. Public safety communications operators facilitate AFD and Rural/Metro Ambulance's response and coach the caller to perform CPR. Rescuers arrive within eight minutes of the 911 call, continue patient care and transport the patient to one of the three hospitals in Aurora where physicians and nurses in the emergency room continue advanced life saving therapies.
Employing this technique, AFD saved more people from sudden cardiac arrest in 2009 that in the previous three years combined. Resuscitation choreography is being recognized as a best practice model for managing a cardiac arrest and AFD has been asked to present this technique to area operating rooms and emergency departments. We are excited to be able to share our success with our colleagues to improve the care they provide their patients.
The Children's Hospital relocated to the Fitzsimmons campus in Aurora in 2007. AFD is proud to partner with this regional Level I pediatric trauma center and we have redoubled our commitment to our littlest patients. With hospital's guidance, AFD is one of the first agencies in the area to develop a protocol for children who suffer an Apparent Life Threatening Event (ALTE). This new program has been extremely successful at identifying some of our most at-risk pediatric patients and is fast becoming the standard of care for other prehospital providers in the region.
Shots for Tots Program
The Shots-for-Tots program provides low-/no-cost vaccinations to children. In partnership with the Aurora Rotary Club, Colorado Children’s Immunization Coalition and Tri-County Health Department, Shots-for-Tots is a monthly immunization clinic held at AFD's Station 2 in the Hoffman Heights neighborhood. Tri-County Health Department's nursing and support staff screen the kids and provide necessary vaccines. Aurora Rotarians volunteer their time to help organize and advertise the event, while Aurora fire medics administer the vaccines. Since the inception of the Shots-for-Tots program in 2002, Aurora fire medics have immunized over 7,500 children and administered over 18,000 vaccines.
Please describe the STEMI program you put in place a few years ago. How does this system improve patient care?
Cardiac Alert Program
Originally conceived of and pioneered by the Medical Center of Aurora, the Colorado Heart Institute, AFD and Rural/Metro Ambulance, the Cardiac Alert program has made a profound impact on the management of heart attack patients. Implemented in 2002, the program is a cooperative effort to ensure that patients suffering heart attacks are treated aggressively and efficiently. By creating a system where emergency responders, nurses, emergency department physicians and cardiologists come together and work with a level of cooperation and trust never before achieved, heart attack victims receive definitive treatment 25% faster than the accepted national standard.
For people experiencing a heart attack, time is muscle, and survival depends on rapid treatment. Utilizing training and techniques developed in Aurora, fire medics now function as a part of the cardiac catheterization team and are empowered to activate the cath lab based upon their clinical impression of the patient. By creating a standardized approach to the cardiac patient, maximizing drug administration, accurately identifying infarctions, limiting on-scene time and integrating smoothly with hospital processes, we have been able to routinely provide definitive treatment (door to balloon time) to the patient within 60 minutes of arrival at the emergency department, well below the national goal of 90 minutes.
At its inception, the Cardiac Alert program was only being utilized in Aurora. Within a very short time, the proven success of the program became well known and has since been implemented on a grand scale throughout the Denver-metropolitan area as well as across the United States.
Please describe the adult and pediatric stroke program. Why did you add these programs?
Stroke Alert Program
As the state of Colorado continues to work towards a comprehensive program to identify and treat stroke victims, AFD is leading the way with the Stroke Alert Program. By collaborating with our healthcare partners, a comprehensive, system-based program has been developed to provide unmatched care to adult and pediatric stroke patients.
Upon identification of a patient experiencing a cerebrovascular accident (stroke), fire medics notify the receiving emergency department and activate a stroke alert. Hospital neurologists are immediately contacted and respond to the emergency department. These patients are aggressively evaluated and may receive thrombolytic therapy in the emergency department. This collaborative process has resulted in the average door-to-CT time being reduced from greater than 90 minutes prior to implementation of the stroke alert, to less than 30 minutes upon activation of a stroke alert.
According to the National Stroke Association, it takes from 48 to 72 hours on average for a pediatric patient to get to the hospital after recognizing the first symptoms of a stroke. Recognizing the catastrophic outcomes of such late recognition and subsequent interventions, AFD, in cooperation with our healthcare partners, expanded the Stroke Alert Program to include pediatric patients and introduced one of the first, if not the only, prehospital Pediatric Stroke Alert Program in the country. This system builds on the success of our adult Stroke Alert Program and allows pediatric stroke alert patients to be transported directly to The Children's Hospital where pediatric neurologists meet the patient in the emergency department.
How does the Tactical EMS program work? What are the benefits to your department and the community?
TEM (Tactical EMS) Program
"Active shooter" incidents, terrorist threats and other complex law enforcement operations pose an increased risk to the community and the SWAT team is designed to minimize these risks. Inclusion of medical personnel on the SWAT team further minimizes the risk of disability and loss of life in these high risk environments and enhances the capability of the SWAT team's tactical operations.
EMS agencies have historically been hesitant to provide immediate medical assistance because they have been trained to remain outside of the target location until the scene is secured. Only after all threats have been eliminated, do they enter the scene and initiate medical treatment. The removal of these threats can be time consuming and a delay in medical treatment can be catastrophic. By integrating specially trained paramedics into the SWAT team, an injured officer, civilian or suspect now has immediate access to the highest level of prehospital emergency medical treatment available.
Type of department: Fire-based, career
Number of employees: Operations: 280 uniformed. Administration: 25 uniformed, 18 civilian
Service area: 154.3 square miles; population 314,326
Call volume: 30,648 (2009)
Number of vehicles: 14 paramedic engines, 14 paramedic trucks, 3 battalion chiefs, 1 Haz Mat, 1 technical rescue unit
Annual operating budget: $34,680,616 (FY 2009)
What makes your service different or unique: We are a collaborative, data-driven system. By partnering with our hospitals, AFD Medical Directors Dr. Fred Severyn and Dr. Gilbert Pineda, and by utilizing technology that allows us to critically evaluate our performance, equipment, and protocols, we are continually striving to ensure the care we provide is effective, safe and grounded in evidenced-based medical science.
Recent technology or equipment upgrades: Phillips MRx with NiBP, CO2 and 12-lead aquisition
New or unusual protocols: Shots-for-Tots, Cardiac Alert, adult and pediatric Stroke Alert, TEMS (Tactical EMS)
Special projects or programs you conduct or participate in: Shots-for-Tots, Cardiac Alert, adult and pediatric Stroke Alert, TEMS
How do you reduce costs or maximize limited funding: Recognizing the role we play is just one element in the emergency response system that protects our community has allowed us to work more closely with other agencies and maximize opportunities to support each other's efforts. As an example, our monthly Shots-for-Tots flyers are included in the discharge paperwork of all pediatric patients who are seen in our partner hospital’s emergency rooms. In turn, parents and family members receive information on how to access services provided by our partner hospitals at our Shots-for-Tots clinics.
Plans for the future: We are very excited to be exploring research opportunities with our hospital partners. We hope that, given our size and call volume and the academic expertise of our partners, we will be able to contribute to the conversation that will help shape the future of prehospital EMS. To that end, we are currently working to equip all of our cardiac monitors with the ability to upload every patient encounter where a cardiac monitor has been deployed to a central location.
Our current monitors have the ability to store 11 hours of data from every single patient encounter. If we have a complex case, we now go out and pull the case from the monitor and store it on portable media. This is a labor-intensive, time-consuming process that misses more data than it gathers. In the near future, our monitors will have the ability to upload every patient encounter to a central server that is accessible to field providers and medical supervisors. We hope that by analyzing this information we will be able to refine our clinical skills, better identify the EMS needs of our communities and evaluate the effectiveness of our training, equipment and protocols in meeting those needs.
While this type of comprehensive data review may not be very exciting for most emergency services agencies, we think it is part of what distinguishes us from many of our peers. We recognize the incredible contribution EMS makes to our individual patients as well as the larger healthcare system. As our profession evolves we need to recognize the role we play in that system. We are not researchers or physicians--we are emergency medical technicians. Our calling is based on our desire to serve, and our interventions must be based on evidence. It is in that spirit that we enthusiastically join with our healthcare partners in providing exceptional medical care to our community.