On Tuesday, May 7, the Tulsa Fire Dept. was honored as the recipient of the Heart Safe Community Award for large communities, those that serve a population of more than 100,000 people.
Presented at the 2013 Fire Rescue MED Conference at the Orleans Hotel Convention Center in Las Vegas, the award, sponsored by Physio-Control and the IAFC EMS Section is presented to fire service-based EMS agencies and other EMS systems that have played a key role in improving the quality of out-of-hospital resuscitation efforts.
The Tulsa Fire Dept. serves a population of 396,466 across a 196.8 square mile area with 45 pieces of fire apparatus, 16 of which are ALS First Response Fire Companies. The department consists of 680 members, 108 of which are deployed as EMS System credentialed paramedics that work in concert with the Emergency Medical Services Authority (EMSA), the region’s contracted BLS/ALS transportation provider.
As a recipient of the prestigious award, Tulsa Fire Dept. demonstrated multiple creative approaches to improving therapies for patients with Acute Coronary Syndromes and its life-threatening complication - Sudden Cardiac Arrest through:
- Bystander CPR;
- AED deployment (i.e., PAD programs, First Response);
- Out-of-hospital 12-lead ECGs, including research on 12-Lead acquisition and transmission by BLS personnel;
- Advanced 12-lead ECG notification to receiving hospitals;
- A partnership with local hospitals to improve outcomes from ACS and sudden cardiac arrest; and
- Communication programs to increase awareness and prevention of sudden cardiac arrest and heart attacks.
- An EMS provider for more than 20 years, TFD’s EMS response had most often been guided by programs initiated by EMSA. The majority of community EMS education programs were initiated, or managed, by EMSA, and the TFD tended to focus on fire safety related public education and support of community CPR. TFD’s approach to the management of cardiac arrest victims in the field used to involve sending as many resources as possible to participate in an uncoordinated resuscitation.
2012 Projects, Programs, and Innovations
In 2012, the Tulsa Fire Department’s EMS mission gained significant momentum in the ability to effectively respond to the person suffering from an Acute Coronary Event and deliver an effective resuscitation of the cardiac arrest victim. Throughout 2012, the TFD honed skills, implemented new processes, and became proficient in working under groundbreaking EMS system cardiac arrest protocols.
Faced with numerous challenges, the department managed to make significant progress in the area of cardiac health through new programs, technology upgrades, and increased community participation. The department, under the medical leadership of innovative EMS System Medical Director, Jeff Goodloe, MD, became involved in the following programs that enabled the TFD to improve their response to, and management of, cardiac events in the City of Tulsa.
Cardiac Arrest Team Dynamics
In 2011, the Medical Control Board and Office of the Medical Director (OMD), Dr. Jeffrey Goodloe, initiated training on a new Cardiac Arrest Team Dynamics protocol to be implemented on February 1, 2012. The new, state-of-the-science, Tulsa EMS system protocols coordinated the resuscitation team in a more efficient manner to improve the effectiveness of cardiac arrest resuscitation.
This new effort focused on coordinating the often chaotic cardiac arrest scene though the application of incident management concepts, a new emphasis on the importance of teamwork, and reinforcement of the need for both the fire and EMS transport crews to work effectively together in cardiac arrest management, were emphasized. This enabled Tulsa Fire personnel to make an impressive transition to this new concept of coordinated patient care.
On New Year’s Eve 2012, Tulsa Firefighter
An increase in oversight by fire company officers related to the delivery of CPR has proven to be one of the most significant enhances in the TFD system. This is reflected in their success at ensuring quality and reducing provider fatigue during resuscitations. Although the results of the new system protocol are pending data collection and review by the Office of the Medical Director, it is anticipated that through better system provider coordination and other system improvements, the cardiac arrest survival in the communities served by TFD will exceed the 2010 Tulsa system rate of 42%.
STEMI Notification and Data Transmission
Like many public safety agencies, the Tulsa Fire Department was not immune to the financial issues that impacted the nation over the past few years. The potential layoff of 147 members, including 36 paramedics, was narrowly avoided. The ability of the department to continue its EMS mission was in jeopardy and the impact to the community would be significant.
Fortunately, the department was able to avoid the loss of staffing, but equipment and training budgets were significantly impacted and have only now been able to return to what would be considered normal.
One of the greatest concerns of the TFD EMS Branch during the time of financial crisis was the aging inventory of Physio Control LifePak 12 cardiac monitor/defibrillators and the ability to fund their replacement. Many of the devices had been in service for almost ten years, lacked the latest cardiac monitoring technology, and were inconsistent with the monitoring capabilities of the EMSA ambulances.
Fortunately, the staff planner at the Tulsa Fire Department recognized the availability of EMS equipment funding through the 2010 Assistance to Fire Fighters Grant (AFG) program. Not only did he apply for cardiac monitor equipment, but also include enhanced data transmission capabilities.
In the fall of 2011, the department was awarded a grant that allowed for the purchase of ten LifePak 15 Cardiac Monitor Defibrillators. The AFG monies were combined with other EMS equipment funding sources, and in February of 2012, the TFD was able to equip all paramedic fire companies with new monitors and wireless modems capable of transmitting information directly to receiving hospitals.
As a result of the deployment of new LP15 devices, the department has improved its patient monitoring, fire ground rehab medical operations, and ability to truly work as a critical notification in the healthcare system’s STEMI notification.
In the Tulsa community, all patients are now monitored via the same device, equipment and supplies are completely integrated, and the ability to transmit data to the CodeStat system allows for improved and standardized data collection and research, regardless of which EMS system provider arrives on scene first.
City of Tulsa AED Coordination
Early in 2011, the Tulsa Fire Department began working with the City of Tulsa to coordinate the purchase, support, and quality assurance of the AED’s located throughout municipal government facilities. The project was initiated in an integrated approach involving the Tulsa Fire Dept., City of Tulsa Safety and Health personnel, the City Physician, Dr. Phillip Berry, and the EMS system medical director, Dr. Jeffrey Goodloe, after it was noted that there was an inconsistent practice of AED purchasing, random distribution of devices without regard for location, and the inability to gather patient information from defibrillators applied to patients in public buildings.
The Tulsa Fire Dept. EMS Branch initiated a coordinated effort to ensure that when possible, all City of Tulsa facilities were equipped with Physio Control CR Plus or LP1000 AED’s. The program goals included:
- Immediate transition from bystander applied AED to ALS monitoring via the use of a common defibrillator pad;
- Ability of TFD EMS staff to download public access AED information into the CodeStat review software to enhance EMS system research and clinical quality; and
- Equipment support of City AED’s in the form of defibrillator pad replacement to ensure that expired or damaged pads were not used.
Enhanced teamwork and improved communications among City departments allowed the program to become the standard for City of Tulsa AED purchasing. Tulsa Fire EMS is now directly consulted on the purchase of AED products and recently assisted with the purchase of nine additional CR Plus AED’s to increase coverage throughout the City Hall complex.
ReadyLink Research Study
In January 2012, the Tulsa Fire Department partnered with the Department of Emergency Medicine, University of Oklahoma School of Community Medicine, Tulsa, Oklahoma to complete a research study involving the acquisition of 12-Lead EKG’s by EMT-Basic personnel. The study, “EMT Basic Acquisition and Transmission of 12-Lead ECG Using a Novel Device (ReadyLink)”, involved Tulsa Fire EMT personnel receiving an update to their ongoing 12-Lead EKG training and then completing a series of random skill testing events over a 6-month period.
The specifics objectives of the research project were to evaluate if EMT-Basics without prior 12-lead ECG acquisition and telemetry transmission training could attain and maintain those skills using the ReadyLink 12-lead ECG device designed for BLS personnel.
During the 6 month study period, the EMT-Basics involved acquired and telemetry-transmitted 132 12-lead ECGs. 130 (98.5%) 12-lead ECGs were determined through emergency physician oversight to be clinically useable for determining activation of emergency interventional cardiology services. Extreme motion artifact prevented clinically useable data in the remaining 2 (1.5%) 12-lead ECGs.
This project was accepted for presentation at the American College of Cardiology Annual Meeting in San Francisco, CA. in March 2013, Society of Academic Emergency Medicine Annual Meeting. Atlanta, GA, May 2013, and the Canadian Association of Emergency Physicians Annual Conference in Vancouver, BC, June 2013.
The ReadyLink research project was the first significant medical research project conducted by the Tulsa Fire Department and as a result, the department’s EMS Branch is currently evaluating the outcomes associated with the additional training.
Patient Care Reports, CodeStat Cardiac Arrest Annotation, and Hospital Information Exchange
The Tulsa Fire Department deployed a new version of electronic patient care record (ePCR) in July of 2012. After reviewing several ePCR options, the department chose ESO Solutions as its medical record software. With the new ePCR, fire personnel are now able to fully integrate cardiac monitor information directly into the patient care report allowing for a significant improvement in cardiac quality improvement.
In a feature unique to ESO, the software allows for hospital ER personnel to select and review Tulsa Fire patient care reports; this new process finally links the fire EMS response to the hospital care. Previously, only the EMSA ePCR was available to hospital staff. Early EKG’s, pre-hospital treatment, and other critical information obtained by fire personnel were often missed in the transfer of care between transport and ER staff.
Now the ability to trend EKG changes, record true interventions such as Aspirin administration, and record accurate on-scene arrival times are possible providing a true continuum of care in the EMS system.
In addition to enhanced patient reporting, the Tulsa Fire Department currently reviews cardiac events for quality via the CodeStat 9.0 software. The department’s 2012 upgrade in data transmission capability also allows Lifenet System participation as well. Prior to 2012, coordination with the Office of the Medical Director (OMD) on cardiac cases, and the associated research, was a significant burden on staff from both agencies and often delayed the review process.
After receiving initial training in October of 2012, the Tulsa Fire EMS Branch expanded its annotation of cardiac events as a member of the EMS system’s cardiac arrest feedback and quality improvement efforts.
A coordinated effort between the OMD, Tulsa Fire, and the Physio-Control Lifenet System, has resulted in EKG data from fire responses that is now readily accessed directly by the OMD via a central database and no longer requires separate processes to exchange critical research information.
Community Cardiac Health and CPR Programs
The Tulsa Fire Dept. also expanded its community cardiac health and CPR education programs over 2012. The following programs reflect the prevention activity of the Tulsa Fire Department personnel:
The Tulsa community suffers from a significant disparity in life expectancy among its residents with northern sections of the City living as much as 14 years less than residents in the south. The TFD Public Education Branch has increased its integration of cardiac health awareness into the overall fire Tulsa Fire Department safety message in an effort to improve the community’s cardiac health.
During 2012, Tulsa Fire personnel provided community blood pressure screenings not only at all fire station locations, but also at the following public events: Tulsa State Fair, Tulsa Boat, Sport and Travel Show, Tulsa Home and Garden Show, and Akdar Shrine Circus.
In addition to fire based community education, the TFD is an active member of the Citizen CPR program (http://www.tulsacpr.com). Formed in 1987, Citizen CPR Tulsa was designed to provide lifesaving education to the lay public and to promote the recognition of cardiac arrest, choking, and other cardiac health emergencies.
The Tulsa Fire Department provides fire personnel at “Save a Life Summer” CPR events held in the community parks, to assist community volunteers with CPR education and EMS response awareness. Additionally, the Director of EMS for Tulsa Fire Department, Michael Baker, is currently serving his second term as the President of the Board for Citizen CPR.
Although Citizen CPR is primarily funded by the Emergency Medical Services Authority, the increase in overall participation and board membership in the program has been a significant step in the presence of Tulsa Fire in the presentation of public CPR education.