As an ED nurse, I rely heavily on the EMS provider’s documentation.  I believe the current and proposed EMS regulations regarding Patient Care Documents (12VAC5-31-1140) underestimates the importance of this document.  This record can assist with crucial decisions regarding the care of that patient.  It is part of the whole picture of the care and or treatment given to a patient prior to arrival at the hospital.  It helps with estimating time of onset of symptoms with suspected stroke, the time that trauma occurred, and the medications/treatments administered just to mention a few things.  Many times a quick patient report is given hitting the highlights but leaving out important details that may be crucial when deciding the patient's plan of care.  EMS is an essential part member of the health care team and their documentation is invaluable.  They are the first set of eyes to see a patient and their condition/environment.  To arrive 24 hours after the fact is a great disservice to the patient and, frankly, is after the fact.  The lack of a patient care document upon arrival to the hospital appears of unprofessional and I know EMS providers deserve far more credit than that!

As a member of the Medevac Committee, I participated in the development of the proposed regulations 3-4 years ago.  Given that time span and reviewing them in the present, I have two areas that appear to need more detail.  Thank you for your time and consideration.

12VAC5-31-880 Air Medical service personnel classifications

Section 4 a Prehospital Scene:

Reading this regulation, it would allow a medevac to have only one flight trained EMTP and the other "attendant" as defined in #1 could be a ground EMTP without flight training.  Given the specialized nature of air medicine and the focus on safety, both members in a medevac helicopter should be, at the minimum, EMTP with specialized air medical training (#1b, #3) . It is not acceptable to have only one member with specific flight training.  Safety is the primary concern and flight trained personnel have specific training to:  assist with communications in the cockpit, identify hazards (both air to air and LZ), crash or event actions, and general aviation and air medical safety culture training.  I request that consideration be made so that the minimum crew make up be two flight trained EMTP.  This should also extend to #1b, #1 which would require a physician (if he/she were the second crew member) to have air medical training. 

12VAC5-31-890 Equipment

#3 Should include language that clearly states that the design and dimensions of the interior cabin eliminate or address head strike areas.  Areas that could be a head strike concern, should be padded and other eliminated (if possible).  The proposed regulation begins to address the issue but misses the key point that these areas should not be in cabin. 

We have a duty to ensure that the design specifications clearly guard our air medical services not to have unsafe design.  Though helmets are worn, they to not fully protect the air medical team from significant injury due to poorly addressed or designed head strike areas.  Head strike areas are usually items such as:  additional equipment (that could be mounted in other areas), radio heads (padding), O2 regulators (flush mount regulators could reduce risk), etc. 

I, again, than you for your time and appreciate all of the hard work that the Regulation Division places in the development and maturing of our EMS regulations. 

In the definitions, an Advanced EMT is listed as a "medic".  The scope of practice of an AEMT per the NASEMSD definitions is very similar to our current Enhanced EMT, which is not considered a medic.  For instance, the AEMT does not have the ability to use a manual heart monitor, which to me seems one of the defining skills of a medic.

In 12VAC5-31-880, part 2.b.3, it looks like the attendant-in-charge for a fixed-wing transport can be any level of EMT, not specifically an EMT-Paramedic -- but the assistant attendant must be a paramedic.

The patient care document is a critical piece of information for the care of our patients. This information is vital to the emergency department's function, and while we get a "down and dirty" report at the bedside, we frequently return to the EMS run sheet to gleen further information later in the patient's visit. To wait up to 24 hours to get this information is a disservice to our community and is not quality patient care.  

I am writing to support changing the documentation requirements of EMS providers. Currently, patients can be taken to a level one trauma center and no documentation is required for up to 24 hours. As a neurosurgeon that is called upon to evaluate critical patients when they arrive, the lack of any field documentation hinders patient care. The verbal report is inadequate for the evaluation of complex patients and field assessment of neurological function and condition as well as treatment which has been rendered is needed for the trauma team to make the best care decisions as quickly as possible. I strongly urge that a full EMS field report needs to be provided in writing at the time of patient delivery to help facilitate patient care and decision making.

Since the implementation of the computerized PPCR's, our Emergency Department has experienced a significant decrease in written documentation from the pre-hospital providers when they deliver the patient to the hospital. Any medication delivered to the patient or procedures done prior to arrival is often given in a brief verbal report, but no written documentation is left behind. Often questions regarding amount of medication, time medication given, amount of fluid given, ect. goes unanswered because the EMS agency has left the hospital. This is a patient safety issue, but with the current regulations there is no enforcement to leave written documentation at the time of patient delivery because the provider has 24 hours to get that information to the hospital. 24 hours may be too late for many patients. 

Page 12, under "Medic" - what about EMT-Enhanced?

Page 17, under "Registered Nurse" - strike the words "an individual" after the word "means"

Page 42, 12VAC5-31-390 - The sentence "EMS agencies shall have a component of their OMD approved patient care reports; a triage component consistent with Code of Virginia mandated state specialty care hospital triage plans." does not read right.  Perhaps missing a word or two?

Page 50, 12VAC5-31-540 - Why is it necessary to have a driving record transcript if the person does not operate vehicles?

Page 54, 12VAC5-31-610 - the term "responding interval" should be changed to "responding time" as this was changed in the definitions.  This occurs in various places throughout the regs.

Page 55, A.2.a - unit mobilization interval standard should be stricken from the rules as it was deleted  from the definitions.

Pages 76,78,79 and 80 - strike the number "4" as was done for all other numbers.

Page 87, 4.g - the term "medical protocols" was deleted from the definitions.  I suggest that the term "Prehospital Treatment Protocols" be used in order to cover all treatments, regardless of the nature of the injury/illness.  This is also on Page 92.

Page 99, D - Why is the EMT-enhanced (lower case?) package different from the AEMT when the two are essentially the same?

Pages 101 4.7 and 102 5.e - Can "End Tidal CO2" be added to the wording to emphasize the importance of this as a standard of care?

Page 104 C.2 - last sentence "per the agency's policy required in 3.a"  There is no 3.a that I can find.

Page 105, 12VAC5-31-885 - "The air medical agency shall have a planned and structured program that  all medical transport personnel must participate in."  What kind of a planned and structured program?

Page 106, B.6 - EMT-B should read just EMT.  This should be corrected throughout the book if we are going to follow the national levels. 

Page 116, 12 VAC5-31-900, 2. "Be clean and neat in appearance;"  Who is going to define this?  Hair length, color? Tattoos? Piercings? All the time? On a single incident?

Page 132, 12 VAC5-31-1230, 1. - The operator of the vehicle needs to have some medical training if they are going to be a part of a two person crew.  I would prefer to see EMT required.  My experience is that it is a terrible thing to be on an ambulance with a driver who does not know what a suction unit is, or a bag-valve-mask, or a non-rebreather mask.  Or, try teaching a non-trained person how to backboard a patient on the scene with an injured patient.  Or, arrive on the scene of a motor vehicle crash with two injuries and one person has no idea how to treat the second patient.  This is 2010 and the standard of care should be that there are at least two trained people on an ambulance. Certainly most of the ambulances in the state operate with just two people and it is not fair or safe for one of them to be untrained.  Doing this could eliminate the need for item 3 in 12 VAC5-31-1250.

Page 133, item 4, last sentence - "Based on extenuating circumstances and documentation, the EMS agency and/or the EMS provider may be subject to enforcement action."  What does this mean?  You do what is right for the patient and then might be cited for it because you didn't have an EMT on the ambulance?  This fully supports my position stated above.

Page 145, Why do EMT instructors and ALS Coordinators have a two year certification period, yet the EMS Education Coordinator has a three year certification period?

Generally speaking, there needs to be more cross referencing of the new levels with the existing levels.  For example, where the level First Responder is written there needs to be a reference to Emergency Medical Responder.  Same goes for EMT-Enhanced and Advanced EMT.  There needs to be a better way to talk about the new levels and the existing levels in the regs that makes sense.  Take away all references to EMT-B if the new level is just EMT.  Take away all references to EMT-P if the new term is just Paramedic.

Thanks for the opportunity to provide input. 

Twenty-four hours is an unacceptable time frame to go without any documentation by EMS providers.  Poor communication is often cited as a contributing factor to medical errors, leading JCAHO to include patient handoff communication as a national patient safety goal.  Although EMS providers provide a brief verbal report, the written document frequently provides additional details that are important in the development of the plan of care for the individual patient.  The EMS report is a vital part of the medical record and should be regarded as such, by changing the regulations to require EMS agencies provide written documentation before they leave the facility.

The proposed change to 12VAC5-31-390 “Destination to specialty care hospitals” currently states “An EMS agency shall follow specialty care hospital triage plans for trauma, stroke, and others as recognized by OEMS…” 

The system of care for STEMI (ST-elevation myocardial infarction) often works, but too often it does not.  I have heard many stories first-hand from family members and survivors who could have experienced a better outcome if more standardized triage plans for STEMI had been in place and acted upon.  There is much documentation available demonstrating that having defined plans of care in place leads to better and more consistent patient care, and it would be fair to provide those for EMS personnel in the field trying to respond appropriately to these urgent life-threatening events. 

STEMI is a critically time-sensitive condition, and should be specifically named on the list of required triage plans.  The language should read:  “An EMS agency shall follow specialty care hospital triage plans for trauma, stroke, STEMI, and others as recognized by OEMS…” 

Please consider this simple change to help elevate awareness of the need to provide consistent STEMI care based upon evidence-based standards.

Thank you.

This proposal is seriously flawed.  Putting asside the absence of a clear explanation of the of what the proposal is seeking to accomplish and the poor draftsmanship of many provisions which will raise a host of problems and issues, this proposal contains two major shifts in policy that will dramtically impact most, in not all, EMS agencies.

The first of these is contained in Section 940 which addresses impaired EMS personnel.  The section addresses 2 concepts: prohibiting personnel impaired by drug or alcohol from administering patient care or operating a motor vehicle; and requiring every EMS agency to have a substance abuse program.  Both are laudable goals

The regulatory language chosen is the problem.  What constitues impairment?  For alcohol is it the same as the standard for blood and breath levels when operating a motor vehicle or is it lower?  If it is lower, how is the threshold being set and what method is used to determine who exceeds the threshold?  What consequence flows for violating whatever the criteria is?  What is the consequence of refusing to participate in a testing regimine desinged to ferret out impairment? 

When you switch to "drugs" the issue gets even worse.  What drugs are we talking about?  Assuming that the staring point is Federally prohibited substances, that is a shifting target.  The way to define the forbiden substances in that context is to use the Federal rules by cross referencing them.  Then there are the legally available drugs.  Any number of presciption and over the counter drugs come with warnings about potential adverse side effects.  If cold remedies make a person drowsy, does that constitue "impairment" under this rule?  What about use of a muscle relaxant taken by virtue of  a doctor's prescription?   What test is going to be employed to determine whether an EMT is "impaired"?

Next look at issue of the agency policy and the same types of issues are just below the surface.  The policy must have a testing process to screen for use drugs and alcohol.  Most, if not all, substance abuse professionals will say that for a screening process to be effective it must include unannounced, random, mandatory testing under closely supervised conditions.  I seriously doubt most people are aware of the implications from this section.  Just think about the employment and liability  implications for some organizations and the complince burden for small organizations. If an EMS agency tries to avoid some of these pitfalls with a loosely worded policy they run a whole different set of risks.  For example, what consequences flow from non-compliance is hard to determine.

Section 610 is another policy shift that seems loaded with potential for posing difficulty.  It does three things:  establishes a timeframe for responding to calls, imposes a recordkeeping burden; and requires an annual review to determine if 90% of the agencies calls are responded to within the established timeframe.  Look first at the process for establishing the time frame.  Initially the OMD is excluded from the process.  Then, instead of using the County Director of Emergency Service who by law should be the Chair of the Board of Supervisors as decision maker, it tasks the local government which it defines as the whole Board of Supervisors as the decision maker.  It is hard to envision a better way to ensure making this issue a political football.  Assuming that obstacle can be overcome, no ageny can avoid the need to keep a new set of records and many agencies will get to struggle with liability issues relating to timelyness.   Ignoring those matters, look at the need to meet the standard 90% of the time.  Ther are no clear answers to what conseqences flow form the failure to accomplish that goal.  

There are any number of other problems with the draft.  Some have been mentioned by other commenters.  Try asking somebody to read this and tell you in their words what training a person needs to become a basic EMT.  The rule says the person must attend 85% of the course.  That can mean  we talking 85% of a set number of hours, or 85% of the classes or s85% of the subject matters covered.  The clarity with which the proposal defines which equipment must be present on an ALS ambulance is another delight.  I wonder if everyone knows what an EMT enhanced package is and I'd be curious to know if they recognize that it does not include an EKG monitor.

I plan to submit written comments to the Board of Health that will cover a range of other concerns.  I thought it would be helpful to share these thoughts now,

As the Cardiovascular Service Line Director I am involved in reviewing and evaluating all the STEMI cases that we receive in our ED.  I am also a member of the ODEMSA Regional STEMI Committee and a guest to VHAC.  It is imperative that we include STEMI to the language of of 12VAC5-31-390 to include STEMI.

The American College of Cardiology has changed the time frame of door to balloon time based on extensive research stating that the quicker the culprit vessell is opened, the decrease in mortality rate for the patient.  The time of coronary flow establishment is now calculated from the first medical encounter to balloon time which raises the standards in meeting 90 minutes from the time EMS encounters the patient.  The change in language would emphasize this goal and allow for standardized care for the patient. 

Please consider and allow this change in verbage so that we can have the consistent care for our patients and reduce the effects of an MI according to evidence base practice.

Thank you.

I agree with consolidating definitions down to one unified "Responding Time" definition, as the true system quality attribute to measure and evaluate is the elapsed time between notification and arrival.

The terminology has not been completely updated to reflect this. Specifically, under 12VAC5-31-10 - definitions "Local EMS response plan" still refers to the old "interval" terminology. Also 12VAC5-31-610 Designated emergency response agency standards still refers to the old "interval" terminology.

Recommend ensuring that the updated rules and regulations accurately reflect the unified terminology of "responding time" to avoid any misunderstanding of the systemwide quality attribute that OEMS is promoting.

Regarding the proposed change to 12VAC5-31-390 "Destination to specialty care hospitals."  

The proposed change currently states "An EMS agency shall follow specialty care hospital triage plans for trauma, stroke, and others as recognized by OEMS..."  The Change should specifically add the diagnosis of STEMI to trauma and stroke and read "An EMS agency shall follow specialty care hospital triage plans for trauma, stroke, STEMI, and others as recognized by OEMS..."

STEMI, or ST elevation myocardial infarction, is a life threatening disease that requires rapid and highly specialized care.  Numerous studies have shown that rapid treatment, in particular, treatment to open the occluded coronary artery with percutaneous coronary intervention, can save lives.  National campaigns by the American College of Cardiology and the American Heart Association and other organizations have focused attention on these life-saving measures.  Now, portable 12-lead EKG devices with radio transmission capabilities have created an opportunity to diagnose a STEMI in the field at an earlier stage, enabling transport of the patient to the most appropriate hospital where specialized care is available.  Like trauma and stroke, STEMI patients will be best served through proper triage to the appropriate facility.

In the definitions, an Advanced EMT is listed as a "medic".  The scope of practice of an AEMT per the NASEMSD definitions is very similar to our current Enhanced EMT, which is not considered a medic.  For instance, the AEMT does not have the ability to use a manual heart monitor, which to me seems one of the defining skills of a medic.

Many Thanks,
Programas de Afiliação

As the Director of Emergency Services at Southside Regional Medical Center, I would also like to recommend that "STEMI" be added to the list of critical,time sensitive conditions that would require EMS agencies to follow specialty care hospital triage plans.

There is significant evidence presented by the American Heart Association/American College of Cardiology that states that patients with evidence of an ST-Segment elevation MI (STEMI) are best served by immediate treatment in facilities that are equipped to perform interventional cardiology. There have been significant strides by these types of facilities to improve their door to balloon times as well as their first medical encounter to balloon times. They work hand in hand with EMS to ensure that the patients get the best possible care.

I have a serious concern with the following section in quotes:

I have a concern with the 24 hour time period for EMS providers to provide patient care documentation to the receiving hospital as noted in the section below.

“12VAC5-31-1140 12VAC5-31-1140. Provision of patient care documentation.

It is imperative that written patient documentation is provided to the receiving hospital at the time the patient is delivered to the emergency department.  Although providers do deliver a verbal report, there is still vital information from the prehospital care that must be on the chart.  This includes times and rhythms in cardiac arrest, onset of symptoms in stroke care, and treatment/medications delivered by EMS that must be available to the health care team at the receiving hospital.  This is especially important in critical patients who may have to go to the operating room, or receive vital life-saving care in other departments.  In these situations, there must be written EMS documentation on the patient's chart to help consultants and facilitate the transfer of care.

I am an emergency room physician and former paramedic.  As a physician, EMS documentation is vital in caring for patients as it allows me to know how the patient initially presented, and gives information such as the initial physical exam and vital signs.  The lack of a written prehospital care report or a short-report form leaves out a large portion of the patient's medical presentation.  As a former paramedic, I could never imagine leaving a patient at a hospital without some form of written documentation.  This is a form of abandonment, and results in an incomplete patient transfer.  Although a verbal report is given, not all the vital information can be covered, nor remembered by the health care team, to allow for excellant patient care.  Therefore, written documentation should be left with the patient at the time of arrival at the receiving facility, NOT within 24 hours.

I am a trauma surgeon at a level I trauma Center (VCU Medical Center, Richmond).

12VAC5-31-1140 A allows the EMS personnel 24 hours to provide accurate written documentation of the pre-hospital condition and treatment of the patient. Patients with time sensitive medical conditions (trauma, stroke, STEMI etc) require life saving therapies within minutes to hours of arriving at the speciality hospital. The nature of the treatment is different depending upon what care has been provided prior to arrival to the hospital. In light of that allowing 24 hours for accurate pre-hospital documentation may complete the paper record but is completely inadequate in helping with appropriate therapy. Verbal reports may be inaccurate and incomplete. EMS personnel should be required to provide an accurate written report about the pre-hospital condition and treatment of every patient they bring to the hospital AT THE TIME OF PATIENT DELIVERY.

Patient safety and accurate documentation will continue to be imperative for providing optimal patient care. In order to provide this standard of care for all patients, both national patient safety goals and the JCAHO have focused on handing off patients between caregivers. The standard of care should be the same for any healthcare providers in that the most accurate and important information be communicated at the time of patient care delivery.  Prehospital care providers often have unique and important information regarding medications, LOC, therapeutic interventions and any difficulties they encountered enroute. A delay ofup to 24 hours to share this information is an extremely poor reflection of the value of the information that EMS providers contribute to patient care management.

The EMS report is the initial documentation of a patient's illness or injury. It paints a picture of what was found at the scene, as well as how the patient initially presented to the EMS provider. For instance, in an auto crash, was the patient restrained or not? Was there a loss of consciousness? Did the patient have to be extricated? Delaying the availability of this report up to 24 hours doesn't make sense. Why would you keep vital pieces of information from those who are trying to provide the patient with the appropriate level of care?

EMS documentation is vital in the continued treatment of patients once they arrive at the ER.  EMS providers give a brief turn over report to the receiving facility but this is only a verbal handoff of information.  By having the written report available there is additional information that can be retrieved from it that was not passed on in the verbal handoff.  Critical information is pulled off of the written report left at the receiving facility by a lot of hospital staff that did not receive the initial report from the EMS provider.  It is imperative that the report be completed and left at the facility at the time of transport.  This will only hinder or complicate the appropriate care that the patient needs to receive at the receiving facility.

Acute MI represents a life-threatening disease, similar in early death rates to that of trauma and stroke, that is best managed by early revascularization. This can be performed at many, but not all hospitals. If a patient with acute MI can be identified by EMS, as increasingly happens by more widespread use of pre-hospital ECGs, they should be taken to the hospital that can provide the best care, not the one that happens to be the closest.

I believe the language to the regulation should be changed so that acute MI patients are included, and should read "an  EMS agency shall follow specialty care hospital triage plans for trauma, stroke, STEMI, and others as recognized by OEMS..."

I am writing in support of the new language as it pertains to personnel convicted for DWI/DUI.  This language corrects the current in-accurate process of double penalizing personnel who are convicted of a DWI/DUI.  The current regulations caused many EMS providers in the Commonwealth to loose their jobs which no other profession in the Commonwealth would be prohibited from working their profession if they received a DWI/DUI while not employed.  Granted, their employer may terminate the EMS provider for the offense the Department of Health should not have the authority. 

For example; a physician who is arrested/convicted of a DWI/DUI while driving home from a party and not practicing medicine at the time of intoxication can still practice medicine as a doctor.  This example can be used for any other health care provider that the Department of Health regulates.

As the current law states, an EMS Provider convicted of a DWI/DUI would have all the normal penalties associated with the criminal offense but the Department of Health would then enact a 5 year prohibition for the EMS Provider to drive a licensed vehicle.  This was paramount more costly to the EMS Provider than what a Court of law would require.  If the person was a paid EMS Provider than typically would loose their job and not be able to gain employment in the EMS setting. 

As the only person who spoke out about this in the early Summer of 2002 during the last public hearing process (Richmond Airport Hotel) I can attest that this regulation was never intended to penalize EMS providers who were convicted off the job.  It was always designed to be a penalty for an EMS Provider who was charged/convicted while driving an EMS Vehicle.  Which the new regulations address.  Thus, I am strongly supporting the new proposed regulation 12VAC-5-31-910.

PPCR Submission

I am supporting the language in the new regulations that allow for up to 24 hours for an EMS Agency to submit the pre-hospital patient care report (PPCR).  This requirement gives EMS Agencies the flexibility during disaster situations which are both local and state declared disasters to rapidly turn ambulances around at receiving hospitals.  Our County (Roanoke County) transports close to 10,000 patients a year to local hospitals and our PPCR is almost always left at the hospital at time of turn over to the ER Staff.  On rare occasions (if almost never) the PPCR would be sent later that day but a full report to the ER Staff has been provided by the EMS Personnel who transported the patient.

Requiring more stringent reporting is burdensome and has financial implications for local governments already dealing with the worst budget recession since the Great Depression. 

EMS Education Coordinator Recertification Process

I have a concern that the language in the new regulation concerning 12VAC5-31-1552 does not clearly state that the recertification test can be waived by the OMD.  This topic has been discussed at length at the last two EMS Symposiums (ALS/EMT Instructor Updates).  As by state statue, all EMS Certifications that are up for renewal which require a test to be re-certified can be waived by the Operational Medical Director if all other recertification requirements have been met.  I recommend that 12VAC5-31-14010 GENERAL RECERTIFICATION REQUIRMENTS be referenced under 12VAC5-31-1552 so all EMS Education Coordinators realize that they do have the option to have the test waived if their medical director desires to waive their test.

12VAC5-31-1552 is very vague and based on the OEMS Committee meetings that discussed this issue it was apparent that a minority of the committee wanted to have more control over who could instruct EMS Certification Courses in Virginia and the current proposed language may lead some OEMS Officials to believe that the recertification testing wavier that an OMD can approve would not apply to the EMS Education Coordinator. 

My second suggestion is to have the term EMS Education Coordinator referred to with all of the other EMS Certifications so their will be no mistake that the EMS Education Coordinator’s re-certification test can be waived if the EMS Education Coordinator’s OMD desires to do so and the EMS Education Coordinator has met all other requirements.

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The current state regulations require EMS providers to submit their PPCR's (pre-hospital care reports) within 24 hours to the receiving hospital.  EMS patient care is vital to improving outcomes for all types of patients, many of whom are gravely ill or severely injured.   EMS providers render increasingly complex care to these patients, including defibrillation, medication administration, advanced airway procedures, etc.  Additionally, EMS providers have the advantage of observing the patient in a different setting than hospital healthcare professionals.  This observation can provide valuable insight during the course of treatment.   The absence of this information can radically alter a patient's treatment plan and outcome.  Healthcare professionals are expected to leave written documentation of their observations and treatment of patients during handoff to other healthcare providers.   EMS providers are professionals and should be expected to report as other healthcare professionals.    The state regulations should require them to leave basic, critical information (at minimum) when they treat and transport patients to hospitals.  If they are unable to leave a full PPCR, they should leave a written MIVT report, or a draft of their electronic PPCR.  I would like to add that many EMS agencies  have been working collaboratively with the various acute care facilities in the Richmond area to improve EMS reporting.  However, there is nothing in Virginia code to compel them to do it.  Therefore, some agencies/providers have done nothing to solve this very serious problem.   I commend the EMS agencies and hospitals who have been working hard to solve this issue because at the end of the day, this is about improving patient outcomes and patient safety.  Nothing is more important than that.

Type over tRecommend wording change to proposed EMS Regulations

The proposed change to 12VAC5-31-390 “Destination to specialty care hospitals” currently states “An EMS agency shall follow specialty care hospital triage plans for trauma, stroke, and others as recognized by OEMS…” 

The wording should be amended to include "STEMI", in addition to trauma and stroke.  Patients presenting with a type of heart attack called a "STEMI" (ST elevation myocardial infarction), are at high risk for both immediate and longterm complications or death.  As an interventional cardiologist, former State Chairman of the American College of Cardiology door-to-balloon project in Virginia, and a founding member of the Virginia Heart Attack Coalition, I think it is critically important to add STEMI to the list of time-critical illnesses.  Rapid reperfusion, or restoration of blood flow in a blocked coronary artery during a heart attack, has been shown in multiple studies to improve patient outcome.  For every 30 minute delay of this lifesaving treatment, the patient's risk of death increases by 7.5%!!  Numerous studies, and personal experience, have shown us that triage plans and protocols improve prehospital care and reduce "e2b" time--the time from first medical contact to reperfusion.

In reviewing the comments regarding PPCR submission, I can see the validity and support the clinical providers desiring a complete report prior to EMS providers leaving the hospital. While the Va. EMS system is moving towards an electronic format in submitting reports, arguing against a 24 hour time frame for turning-in PPCR's in pre-mature. Until all Va. EMS agencies convert to sometype of electronic PPCR submission and hospitals provide secure access points to exchange this information upon receiving a patient, it's imperative for EMS agencies to maintain flexibility in returning to service.

I support a 24 hour submittal time frame.

The proposed change to 12VAC5-31-390 "Destination to specialty care hospitals" currently states "An EMS agency shall follow specialty care hospital triage plans for trauma, stroke, and others as recognized by OEMS..."

I recommend that STEMI be included with trauma and stroke.

All 3 of these conditions can be made less severe when the appropriate interventions are performed earlier rather than later. EMS is an important key in recognizing and pre alerting the receiving facility.

These are my personal opinions and not those of the University of Virginia where I am employed.

Transport caregivers intiial findings (including date/time), interventions, responses to those interventions, and contact information for futher questions need to be presented legibly in writing to the care team prior to leaving the facility.  That information is actually used by clinicians in the care of patients.  For instance, when a neurosurgeon estimates anoxic periods - we use the EMS sheet. If they want to know how soon they can perform physical exams without paralytic interference, they use EMS info. Many more examples exist.

On a seperate note, there must be an efficient manner to assure EMS electronic documentation makes its way into patient records throughout hospitals in Va.  Hopefully there will be EMS & hospital collaborative efforts towards this end. 

In reading the language for the proposed change to 12VAC5-31-390 “Destination to specialty care hospitals” currently states “An EMS agency shall follow specialty care hospital triage plans for trauma, stroke, and others as recognized by OEMS…”  I noticed that unfortunately STEMI was not included.  As a citizen of the Commonwealth of Virginia, I believe it is imperative to include the focus of STEMI in this language.  Care for STEMI patients is very time sensitive and standards need to be put in place to ensure adequate care is provided for all STEMI patients.

I support the  proposed change: 12VAC5-31-390 “Destination to specialty care hospitals” states “An EMS agency shall follow specialty care hospital triage plans for trauma, stroke, and others as recognized by OEMS…”  As a critically time-sensitive condition, STEMI (ST-elevation myocardial infarction) should be included in the list of required triage plans.  The recommended language should read:  “An EMS agency shall follow specialty care hospital triage plans for trauma, stroke, STEMI, and others as recognized by OEMS…” 

Joseph P. Ornato, MD, of the Department of Emergency Medicine at Virginia Commonwealth University, wrote of the significant need for NATIONAL attention to "The ST-Segment-Elevaltion Myocardial Infarction Chain of Survival" in Circulation. 2007;116:6-9.  Virginia should be in the fore front of implementing needed  STEMI changes.

As a retired Federal official who helped plan and fund rehabilitation for traumatic brain injury and stroke survivors that depended upon excellence in traige, and as the father of a son who has recovered from cardiac bypass surgery, I am very aware of the need to update State policies to conform to research findings.

I look forward to learning that the Commonwealth has moved forward on this important need.

Richard P. Melia, Ph.D.

Arlington, VA

The proposed change to 12VAC5-31-390 “Destination to specialty care hospitals” states “An EMS agency shall follow specialty care hospital triage plans for trauma, stroke, and others as recognized by OEMS…”  As a critically time-sensitive condition, STEMI (ST-elevation myocardial infarction) should be included in the list of required triage plans.  The recommended language should read:  “An EMS agency shall follow specialty care hospital triage plans for trauma, stroke, STEMI, and others as recognized by OEMS.
 

ST segment elevation myocardial infarction (STEMI) is a heart attack diagnosed by looking at the EKG.  If STEMI is apparent on the EKG, the SINGLE most important thing that emergency care providers can do is insure that each STEMI patient receives timely opening of the blocked artery (reperfusion) as fast as possible.  Truly, "Time equals Muscle."  This reperfusion treatment must take place at a hospital, either by use of clot busting drugs or emergent angioplastly in a heart catheterization lab.

However, STEMI is a rare event that is often diagnosed when least expected, usually under chaotic circumstances. This points to the value of having a triage plan in place for when it does occur, allowing rapid planning and execution to occur.  Indeed, study after study has shown that the single most important factor in improving STEMI treatment (time to reperfusion) is simple: 

"Does each emergency provide have a STEMI plan (triage plan) in place for when STEMI is diagnosed?"

Thus, requiring that each agency have a STEMI ALERT plan in place is vital and essential if Virginia hopes to offer excellence in care to each Virginia resident who in the future suffers from a STEMI.  If agencies do not have these plans of execution in place, then they will be unable to guarantee rapid reperfusion based on a consistent plan.

Please note that the exact plan in place is not as important as simply having a STEMI triage plan in place.  What this implies is that the exact STEMI ALERT triage plan (though required via this change) will still be developed by the care providers in each area who will collaborate together to determine what constitute the best and most exact STEMI ALERT triage plans within their areas of service.

This type of flexible and collaborative "systems engineering" approach to optimizing STEMI care is being enacted throughout the US; by adopting this approach Virginia will be in-step with many areas and states within the US currently striving to optimize care for patients diagnosed with ST elevation heart attack.

The proposed change to 12VAC5-31-390 “Destination to specialty care hospitals” currently states “An EMS agency shall follow specialty care hospital triage plans for trauma, stroke, and others as recognized by OEMS…” 

The language should read:  “An EMS agency shall follow specialty care hospital triage plans for trauma, stroke, STEMI, and others as recognized by OEMS…” 

STEMI stands for ST Elevation Myocardial Infarction.  ST Elevation is a specific EKG change and a Myocardial Infaction is a heart attack.  A STEMI is the most life threatening form of heart attack. 

Medical research has shown conclusively that patients with STEMI have significantly less death and disability if the blocked vessel in the heart is opened up quickly.  This can only be accomplished consistantly if specific STEMI protocols are in place and utilized.

The simple change of adding the word "STEMI" to the proposed verbage of this regulation would save many lives.

12VAC5-31-1453 Part 2 Minimum ages for students-(page 164) This requires students to be 16 for BLS and 18 for ALS classes before the official start date of the class. In regards to ALS, we have students graduating High School now at 17. They are enrolling in college programs at this age. With this requirement, they are forced to delay their education because they will not be 18 at the beginning of class. I think a more reasonable age restraint would be 18 prior to beginning of clinical rotations for ALS programs. This issue appears again in 12VAC5-31-1503 Part A Sec. 2 (page 178) and again in 12VAC5-31-1521 Part B (page 180).

I am in favor of the proposed language change to EMS regulations 12VAC5-31-390

“An EMS agency shall follow specialty care hospital triage plans for trauma, stroke, STEMI, and others as recognized by OEMS…”

 STEMI is an extremely time sensitive condition and with a delay in care, the patient can experience irreversible damage to their body and delays can even cause death. It is very important that STEMI patients receive the appropriate care in a timely manner. By including this language in the EMS regulations, the Commonwealth can help to ensure that EMS personnel have a defined plan of care for STEMI patients and ensure that all STEMI patients receive appropriate care.

I'm a retired Battalion Chief Paramedic with 31 years service to Public Safety and feel I have to write on this topic. ST segment elevation myocardial infarction (STEMI) is a heart attack diagnosed by looking at the EKG.  If STEMI is apparent on the EKG, the SINGLE most important thing that emergency care providers can do is insure that each STEMI patient receives timely opening of the blocked artery (reperfusion) as fast as possible.  Truly, "TIME EQUALS MUSCLE."  This reperfusion treatment must take place at a hospital, either by use of clot busting drugs or emergent angioplastly in a heart catheterization lab.
However, STEMI is a rare event that is often diagnosed when least expected, usually under chaotic circumstances. This points to the value of having a triage plan in place for when it does occur, allowing rapid planning and execution to occur.  Indeed, study after study has shown that the single most important factor in improving STEMI treatment (time to reperfusion) is simple:

"Does each emergency provider have a STEMI plan (triage plan) in place for when a STEMI is diagnosed?"

Thus, requiring that each agency have a STEMI ALERT plan in place is vital and essential if Virginia hopes to offer excellence in care to each Virginia resident who in the future suffers from a STEMI.  If agencies do not have these plans of execution in place, then they will be unable to guarantee rapid reperfusion based on a consistent plan.

Please note that the exact plan in place is not as important as simply having a STEMI triage plan in place.  What this implies is that the exact STEMI ALERT triage plan (though required via this change) will still be developed by the care providers in each area who will collaborate together to determine what constitute the best and most exact STEMI ALERT triage plans within their areas of service.

This type of flexible and collaborative "systems engineering" approach to optimizing STEMI care is being enacted throughout the US; by adopting this approach Virginia will be in-step with many areas and states within the US currently striving to optimize care for patients diagnosed with ST elevation heart attack.

More lives will be saved by a simple change of words and policies about STEMI care and education.

I thoroughly understand the reason for leaving a written report at the ED at the time the patient is brought in.   In our system it is standard practice to leave a printed PCR with the staff.  But even with this, reports are lost in the hospital, requiring the trauma registrar and Chest Pain staff to contact our agency on a regular basis because they cannot find the PCR in the patient's chart.  As the state moves to electronic reporting there will be many issues to arise.  One we have experienced is when the EMS printer (multi-agency partnership) at the hospital breaks leaving no way to print the report.  Reports have to be printed somewhere else and brought back to the hospital.  Printing issues will become more frequent  as more agencies use electronic reporting.  Keep in mind that , the agencies are providing the printers, not the hospitals.  This is an expensive, complex, and time consuming program to maintain. The ultimate goal would be to have a way for everyone to send the PCR to a website or offsite server where the information would be automatically sent back to the hospital in an electronic format.  This is going to be very challenging as there are different EMS PCR programs and each Hospital IT Dept. and Agency IT Dept. have their own security rules and measures.   The 24 hr time period is essential when printers are down or the computer will not connect with the printer.  Leaving a PCR with the patient is "Best Practice" and should be  encouraged until electronic data can be sent quickly to the ED. It will take much more than changing the regulation to truely fix the problem. 

In regards to the ruling that allows agencies 24 hours to submit PCRs, I am in favor of keeping the 24 hour time period in place.  I completely agree with previous comments made about the importance of proper documentation and the need for agencies to leave a copy of the PCR with the receiving facility on departure.  However, a ruling against the 24-hour time period would tie the hands of agencies and could negatively impact patient care in the long run.  Our agency runs approximately 80% of the EMS calls in our jurisdiction  and we only have 3 front line/staffed medic units.  There are times when it is necessary for our units to clear from the hospital (before finishing the PCR) in order to run another EMS call because our other medic units are on other calls and it would be detrimental to wait for mutual aid to arrive.  This would also be the case if we were to have a disaster/MCI in our region/jurisdiction where it would be beneficial to have quick turn-around times for our medic units in order to treat/transport more victims.  Being that we are a Fire and EMS department, all of our full-time personnel are cross-trained in both fire and EMS.  When a structure fire occurs in our area, we rely heavily on all of our personnel, even those staffing the medic units in order to get enough fire/EMS personnel on scene to operate safely and effectively.  Our department leaves PCRs at the hospital upon departure 98% of the time.  The only time we do not leave a copy of the PCR on departure is when the printer is malfunctioning, in which case we go back to the station and print off the PCR and are usually able to provide a copy to the ER within a couple of hours.  We also allow our medic units to clear EDs before finishing a PCR in cases where all other medic units are tied up on calls and it would be detrimental to the patient to wait for another EMS service and/or for structure fires/major emergencies in which we need their manpower (however, our personnel are instructed to notify the receiving RN that they are leaving without leaving a copy of the PCR, but will return as soon as possible to do so).   I would ask that the regulation stay in place to allow for the 24 hour time frame, with the understanding that agencies will leave a copy of the PCR upon departure except under extenuating circumstances (such as those listed above). 

The proposed change to 12VAC5-31-390 “Destination to specialty care hospitals” states “An EMS agency shall follow specialty care hospital triage plans for trauma, stroke, and others as recognized by OEMS…”  leaves out a very important disease process.

It is important to note that cardiovascular disease including heart attack and stroke is the number one killer of Virginians yet there is no mandate to require an EMS plan for heart attack.  It is commendable that stroke is now included in addition to trauma but this still leaves out heart attack and particularly a very serious heart attack condition called STEMI (ST-elevation myocardial infarction).  Effective treatment options including primary angioplasty and stenting to open blocked arteries now exist at many Virginia hospitals Including STEMI in the list of required triage plans could have a dramatic impact on survivability and outcomes for patients with this condition.  The recommended language should read:  “An EMS agency shall follow specialty care hospital triage plans for trauma, stroke, STEMI, and others as recognized by OEMS…”

Does this regulation on its own contribute to the improvement or decline of mortality rate versus contributing to the improvement or decline in EMS responder safety.  Does it make sense to apply this same requirement to both a PSAP call for service of a Blood Pressure Check  and one for Uncontrolled Bleeding, or Cardiac Arrest?

The decision to run lights and siren ("hot") to a call for service is a calculated risk based on information obtained and supplied during each individual call.  That calculation should not be unduly influenced by a single arbitrary response threshold.

Instead, OEMS should be promoting an EMS Quality Management System that supports continuous process improvement with respect to delivery of patient care.  This should include measuring and assessing  all facets of delivering EMS care, such as:

·         Proper triaging of PSAP calls for service to determine resources required (EMS response, Nurse referral, etc.)

·         Properly prioritizing EMS response via an EMD system

·         Measuring and reviewing EMS response against thresholds established for each priority, not a single catch-all threshold

·         Measuring and reviewing delivery of care and patient outcome for EMS responses.

This regulation as written is designed to reward systems that set an arbitrary high number and punish those systems that try to be more aggressive, and should be withdrawn unless a prioritization scheme is also enforced to properly categorize PSAP calls for service.  Only then should enforcement of thresholds  for each priority be considered.

It does not make sense to enforce a single attribute outside of a coordinated management system.

I recommend STEMI be specifically included on the list of conditions warranting field triage to specialty centers, as we require for Trauma, Stroke, and other conditions identified the OEMS.

Thank you, James Dudley