Table of Contents Acknowledgements
03
Executive Summary
04-05
Objectives and Main Frame
06
Background
07-13
Medical Teams International
7
Trauma Secretariat
7
Current Situation of the Pre-Hospital Care System
7
Component of the Pre-Hospital Care System
8
Methodology
14-16
Physical Resources
14
EMT and EMD
14
Efficiency of Service
15
Results and Discussion
17-56
Physical Resource
17-24
EMT and EMD
25-45
Efficiency of Service
46-56
Recommendation and Conclusions
56-58
1
Acknowledgements Special thanks are due to personnel and organizations who gave their support for the Prehospital care review program from the initial stage. Required permission and guidance was given by Ministry of Health and Nutrition, Ministry of Local Government and Trauma Secretariat of Sri Lanka. Mr. Jeff Fernhout (Country Director – Medical Teams International (MTI) Sri Lanka), Ms. Kecia Bertermann (Asia Health Advisor -MTI), Mr. Paul Bollinger (EMS SeniorAdvisor- MTI), Mr. Dilanga Manuweera (Volunteer EMS Technical Advisor – MTI) and Mr. Raman Nominathan (Northern Province Program Manager – MTI Sri Lanka) for providing guidance and technical support on launching the Pre-hospital care review program and for the support provided in editing the review report. Mayors, Hospital Directors and others government officials of the cities that participated in the review program for providing the required facilities and permission to conduct the program and for fire Chiefs, Officer in-charges, Pre-hospital care providers, hospital staffs, public workers and public for sharing the information and for supporting by participating in the review. We also would like to thanks Dr. Edwin Salvador (Technical Officer – Emergency and Humanitarian Action) from World Health Organization – Sri Lanka for encouraging us to conduct this program, Ms. Shiwanthika Chathurangi for the support given in the data entering process, Medical Teams International Sri Lanka and Head office staff that have given support to make the review program a success.
Authors, E.A.D. Nuwan Chamara Deputy Program Manager Emergency Medical Service Program Medical Teams International
Dr. Sanooz Raheem Medical Consultant Medical Teams International
2
Executive Summary Medical Teams International (MTI) has been working with the Trauma Secretariat of the Ministry of Health Care and Nutrition (MOH) towards the development of pre-hospitalcare in Sri Lanka since 2005. During the past half decade, MTI and the Trauma Secretariat trained 2,836 Emergency Medical Technicians (EMTs) both at Level-1 and Level-2, and established seven pre-hospital care systems throughout the country. Medical Teams International launched a Pre-hospital Care Systems Review Program during the time period between November1, 2010 and January 31, 2011 with the permission of the Trauma Secretariat of Ministry of Health. The review project focused mainly on auditing the pre-hospital care system in Sri Lanka. The main objectives were to assess the current situation, to verify the achievements in pre-hospital care during past the reporting period to determine the areas needing further improvements. Fourteen assessment tools were applied to assess the above objectives. These tools assessedthe Emergency Medical Technicians and Emergency Medical Dispatchers (EMTs and EMDs), physical resources, and efficiency of the service. Seven cities with functioning pre-hospital care systems (Anuradhapura, Badulla, Colombo, Galle, Jaffna, Kandy, and Kurunagla) and two cities without pre-hospital care systems (Tangalle and Kaluthara) were selected to launch the program. Tangalle and Kaluth ara were selected for the review because they had the physical resources and trained personal to establish a pre-hospital care system. After the review began, Anuradhapura and Colombo elected not to participate. During the review, the review team visited each city. The cities that participated in the review supported the process by sharing information and data and by granting permission to include their systems in the report. In Sri Lanka, established pre-hospital care systems are known as 1-1-0 systems. “1-1-0” is the national (non-centralized) three-digit number that the public uses to contact pre-hospital care services. During the review it was found that each and every pre-hospital care system was functional to varying degreesand even the two cities (Tangalle and Kaluthara) that did not have established systems were using their Emergency Medical Technicians to provide ambulance services using their local 10 digit number in a small scale. The main gaps identified by this review were: lack of public awareness, communication lapse and a lack of opportunity to continue education for pre-hospital care providers. Most of the pre-hospital care systems had not conducted any public awareness campaigns after the launch of 1-1-0 system, and the fire brigade-centered pre-hospital care systems were a bit reluctant to expand their service through public awareness campaigns due to minimum resources. The Jaffna Pre-hospitalCare System was able to overcome most of these issues through special funding provided by the World Health Organization, AmeriCares and UMCOR to establish and to expand the services. During expansion of the Jaffna PrehospitalCare System, Medical Teams International trained more than 11,000 personnel in basic life support skills. The communication gap was most evident when people dial 1-1-0 and the call is transferred to the wrong dispatch center. Theseoccurrences were mainly due to lack of 3
telecommunication towers and limited telecommunication switches in the country. All the mobile telecommunication providers have a limited number of towers, and they cannot route calls for a small area. As a result, sometimes when a person in Galle (southern tip of Sri Lanka) dials 1-1-0 from their mobile phone, the call is diverted to the Jaffna (northern tip of Sri Lanka) dispatch center. At the time of the review, Medical Teams International and the Trauma Secretariat were the only organizations providing EMS (Emergency Medical Services) education in Sri Lanka.Pre-hospital care providers faced a problem of not having enough opportunities for training and continuing and advanced education. Also, most of local Pre-hospital Care Systems do not have an established system or qualiďŹ ed personnel to internally provide continuing education for their staff. In Sri Lanka, St John Ambulance and the Red Cross provide ďŹ rst-aid training. Based on the results of the review, it is recommended that the following actions be considered: expand the pre-hospital care service island-wide as a combined service of ďŹ re brigades, general hospitals and RDHS services; initiate a national communication center which will receive all 1-1-0 calls and dispatch the appropriate pre-hospital care unit; and create a regulatory body/registry to oversee the EMS education and services. During the review program, all pre-hospital care systems showed a strong potential for expanding and developing their services if they receive the proper guidance and support and if the proper protocols were in place.
4
Main Objective To review the pre-hospital care systemin Sri Lanka Objectives 1. Assess the current situation 2. Verify the achievements in pre hospital care during the past six years 3. Find areas which need further improvement The data indicators assessed areas follows: 1. Physical resources · Ambulances--Quality and Quantity · Call dispatch centers · Financial support and equipmentsupply 2. EMT and EMD (Emergency Medical Technician and Emergency Medical Dispatcher) · Numbers · Skills and knowledge · Continuing education · Number in service · Expired certificates · Skills check list 3. Efficiency of service · Hospital data on mortality after a trauma · Data from call center records · Public-awareness and comments · Comments from direct beneficiaries
5
Background Medical Teams International Medical Teams International (MTI) is an international, nongovernmental organization based in the United States of America that works with more than 30 countries in their humanitarian missions. MTI began workingin Sri Lanka after the devastating 2004 Tsunami and, after its initial response activities, started to work towards the development of pre-hospital care in Sri Lanka with the collaboration of the Trauma Secretariat of the Ministry of Health Care and Nutrition.
Trauma Secretariat The Trauma Secretariat of Sri Lanka was established by the Ministry of Health Care and Nutrition in September 2006 and officially launched on January 1, 2007. Its vision is to provide timely, appropriate, quality and cost-effective medical care to trauma victims by a coordinated, sustainable trauma system with improved preparedness. Current Situation of the Pre-hospital Care System After the devastating Tsunami in December 2004, the Ministry of Health and Nutrition of Sri Lanka established the Trauma Secretariat to develop a trauma response system in Sri Lanka. Medical Teams International worked in collaboration with the Trauma Secretariat to develop the pre-hospital care system in Sri Lanka during past half a decade. Medical Teams International and the Trauma Secretariat were able to develop seven pre-hospital care systems throughout the country using existing government structures. In Sri Lanka there are pre-hospital care systems in eight cities that run under three different government structures. 1. Fire Brigade-Centered There are 18 fire brigades in Sri Lanka and all of them are managed by their respective municipal councils. Colombo, Galle, Badulla, Kandy fire brigades are functioning as prehospital care systems within their municipal council limits. In keeping with the regulations ofmunicipal councils and budget limitations, these pre-hospital care providersdo not respond outside of their municipal council limits. 2. Hospital-Centered With the development of pre-hospital care in Sri Lanka, some hospitals took the initiative of providing these services. Out of the seven pre-hospital care systems, Anuradhapura, Kurunagala systems are managed by the General Hospital of the respective area. These hospital-based pre-hospital care systems respond only within a five-kilometer radius from their hospitals. 3. Regional Director of Health Service-Centered Jaffna and Mannar Pre-hospitalCare Systems are managed by the Regional Director of Health Services (RDHS)in those areas. The above systems use the ambulances belonging to hospitals in their respective areas to respond toemergencies. The RDHS systems charge a voluntary fee for the service they provide. 6
Private companies also provide ambulance services in Sri Lanka. Most of these services are limited to the Colombo district and they are charging a fee for their services. Most of these private ambulance services donot respond to emergencies. Components of the Pre-hospital care System
The development of the Sri Lanka Pre-hospital Care System (EMS system) is in its ďŹ rst stage and has ten main components. Some of these components are presently active and other components are in the initial planning process, to be activated in near future. 1 Regulations, Policies and Protocols. 2 Professional Training in Pre-Hospital Care 3 Public Education and Information 4 Immediate Care 5 Communications 6 Ambulances 7 Medical Directions 8 Receiving Facility 9 Continuous Quality Assurance and Research 10 Disaster Management and Mass Casualty Planning – Response 7
Regulations, Policies and Protocols HistoricallySri Lankan fire fighters were trained only in fire fighting and rescue skills. They were given first aid training but fire brigades were not equipped with ambulances. After the Tsunami on 2004, the Sri Lankan government worked with ICET (International Center of Emergency Techniques –a Netherlands-based INGO) to upgrade fire brigades with new equipment. This equipment included ambulances and rapid intervention vehicles. Currently Emergency Medical Technician training is included in fire fighter recruit training, and Medical Teams International developedEmergency Medical Technician (EMT) text books and EMT skill DVDs in two Sri Lankan national languages to train pre-hospital care providers. These books and EMTskills DVDs are now recognized as the national guidelines for EMT training and printed under the Ministry of Health Sri Lanka logo. In addition, a system of Emergency Medical Service regulations, policies and protocols are in the process of being created atthe National, Provincial, District and Divisional levels. These regulations, policies and protocols will provide a set of standard operational guidelines for ambulance usage and provider scope of practice at all levels of the national pre-hospital system.
Immediate Care Presently many organizations such as St John Ambulance and the Red Cross in Sri Lanka train people in basic first aid. Medical Teams International also conducted basic life support training for the public (three wheel drivers, school children, etc). Plans have been made under the road safety decade plan to expand these efforts and give access to have same level of knowledge to everyone.
Professional Training in Pre-hospitalCare The aim of pre-hospital care training is to reduce mortality and morbidity due to medical or trauma condition by providing professionally trained personnel to the pre-hospital care system. Currently in Sri Lanka, EMTs and pre-hospital care providers are working in fire brigades, hospitals, social organizations and the private sector. EMT training has been conducted by the Trauma Secretariat of Ministry of Health and Medical Teams International using the national guidelines in alignment withinternationally recognized standards. These same standards are similar to those used in countries like the USA and the United Kingdom.
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EMT Level-1 The Sri Lanka EMT Level-1 is the first level of EMS training beyond community responder level trainings (First Aid and Advanced First Aid). Manycountries refer to this level as Medical First Responders. Typically, first responders may be fire fighters, police officers, lifeguards, coaches, or teachers. Level-1 EMTs are trained in basic rescue, oxygen use, CPR, splinting, and safe ambulance operations.
EMT Level-2 Level-2 EMTs are typicallyreferred to as EMT-Basics or EMT-Ambulance Officers in other countries. Training at this level ideally requires 120-180hours of classroom,clinical education and field experience for students to demonstrate the knowledge, attitude and skills required. Some examples of the skills of an EMT include: v v v v v v v v
Assessment of vital signs Airway management with the use of oral and nasal airways Assisting patients with prescribed medications (NTG, Aspirin, inhalers) Automatic External Defibrillators Medical and trauma patient assessments Extrication of trauma patients with spinal injuries Spinal immobilization Assisting with unexpected emergency deliveries during transport
EMT Level-3 Level-3 EMTs or EMT-Intermediate Level is a more advanced professional level of prehospital care providers. Typically, Level-3 EMTs are more senior and experienced EMTs and also have additional training in establishing IV cannulation, and, in some areas (Canada, USA, and Australia), limited access to lifesaving medications and advanced emergency airway management.
EMT Level-4 Internationally, Level-4 is known as EMT-Paramedics. They have yet to be introduced as the experts of pre-hospital care in Sri Lanka. In most countries, a Paramedic is a person who is trained in Advance Life Support skills and specialized in pre-hospital care. In Sri Lanka, however, the word “paramedic” refers to persons who work in allied health services, e.g. lab technician. The skills, education, and protocols of paramedics vary from country to country.
9
Public Education Necessary actions have been taken to educate and inform the public about the pre-hospital care system and how to access it. Public education and support is essential for the success of a national Emergency Medical Services system in Sri Lanka. All citizens and visitors of Sri Lanka should know about the emergency 1-1-0 system and have access to pre-hospital care. Access to emergency care is important;the most important part of an EMS system is, however, the prevention of emergencies through community education and awareness. Emergency Medical Technicians play an essential role in providing community-based education and leadership in preventing medical and trauma emergencies.
Communication The Communication System in an EMS system encompasses a wide area. For example, it includes communication between emergency care providers and the hospital,the general public and dispatch, andintra- and inter-agency communication. Effective communication is an important aspect in emergency management. It requires coordination between many organizations such as fire fighters, police, and medical officials. When there is good communication between organizations, emergency situations will be under control and the care given to the patient will be effective. When there are errors in communication there can be duplication of effort, resources may not be used effectively, and rescuers’ lives may also be in danger. Internationally to overcome these matters, a unified command system is used when many organizations are responding to same emergency. These command systems are called “incident command systems (ICS).” In Sri Lanka, disaster management units have been established at the district level after the Tsunami in 2004. In major disasters or in major emergency situations,these centers work as the emergency operation centers (EOC). Currently in Sri Lanka, pre-hospital care systems run under the three-digit number 1-1-0 which is not centralized and there is no system in place for coordination between fire fighters, police, medical officials, and/or hospitals. Pre-hospital care provider use general access numbers to contact supporting services.An interagency communication system should be put in place to overcome the communication gaps.
Ambulances Ambulances in Sri Lanka are undergoing a transformation from simple transport vehicles to a mobile treatment and stabilization units. This transformation is following the same historical transformation that actually led to the development of modern Emergency Medical Services. Over the past four decades, many countries have undergone this same transformation. In the USA, for example, until the1970s emergency patients were often transported in hearses 10
without medical equipment or trained personnel. An ambulance was simply a transportation tool. Based on international research, doctors proved that perhaps the most critical time for trauma and major medical patients is the first hour of the emergency, also known as the “golden hour.” Although the need for trained EMTs was recognized in Sri Lanka prior to the tsunami, the tsunami disaster of 2004provided an influx of international aid, technical assistance, and the donation of many fully-equipped ambulances. In Colombo, representatives from the National Hospital of Sri Lanka Accident and Emergency Unit, the Colombo Fire Brigade, the Colombo Municipal Council, St. John’s Ambulance, and the Sri Lanka Telecom joined together to capture these resources and implement the first Emergency 1-1-0 pilot project. Likewise, in Hikkaduwa,“Operation Phoenix,” which is now known as the Hikkaduwa Area Ambulance Service’, was formed as a community-based model.
Medical Direction For EMTs to appropriately be an extension of the hospital-based patient care, coordination, supervision, education, and advocacy are required from the system’s Medical Director. The Medical Director should be a doctor registered with the Sri Lanka Medical Council (SLMC) who is interested in pre-hospital care, and if possible, has additional professional training in emergency medical care. EMTs are providing an extension of hospital care because a doctor is generally not present at the scene of the emergency or in the ambulance during transport. Therefore, EMTs function with both on-line and off-line medical direction. On-line medical direction is given with live communication between the EMT and the doctor by telephone, radio, or perhaps even video conference ability. The doctor is able to gather information, and give instructions and advice regarding patient management. However, many of the patients transported by ambulances could often be considered “routine” and standard written protocols can be followed. On-line medical direction is not yet in place in Sri Lankan pre-hospital care systems. Written protocols created and reviewed by an agency’s Medical Director are an example of off-line medical direction. Another essential role of the Medical Director is to provide continuous quality assurance and reviews of the services provided by the EMTs.
Receiving Facilities (Hospitals) EMTs are trained to provide pre-hospital care; patients must, however, be quickly and efficiently delivered to the most appropriate hospital where definitive care is available. Hospital staff should be aware of the pre-hospital care services available in the community and trained on how to receive patients stabilized by EMTs. As an extension of definitive hospital care, the EMT has the unique opportunity to serve as the “eyes and ears” of the hospital medical staff at the scene of the incident. For example, an EMT can describe the 11
mechanism of injury from an automobile crash. A damaged steering wheel or a “starred windscreen” can provide valuable clues to hospital staff when evaluating for specific injuries. At present, theGovernment of Sri Lanka hastaken initiative in building two trauma centers: one in Galle (Southern Province) and one in Colombo, the commercial capital.
Quality Assurance and Improvement The goal of pre-hospital care is to reduce unnecessary death and disability while providing the highest possible quality of services at the lowest cost. Providing quality pre-hospital care requires leadership at all levels: national, local, and individual providers. The guidelines, processes, and/or protocols are not completely in place for quality assurance and improvement of pre-hospital care in Sri Lanka. During the establishment of pre-hospital care systems, Medical Teams International trainedpre-hospital care providers to follow the quality assurance process defined by Mr. Malcolm Baldridge, a former U.S. Senator known by many to be a pioneer in defining the quality assurance (QA) process. This QA process is used by businesses, hospitals, governments, and EMS agencies around the world. He identified seven key action areas (modifiedfor the Sri Lankan pre-hospital care system context): v v v v v v
Leadership Information and Analysis Strategic Planning Human Resource Development EMS System Results Satisfaction of Patients and Stakeholders
Disaster Management and Mass Casualty Planning – Response After the 2004 Tsunami, Sri Lanka modified its mind set on disaster management and immediately took necessary actions. Community-based training and awareness programs took place effectively. Sri Lanka also recognized that a country’s ability to face a disaster or a mass casualty incident also depends of the strength and ability of its EMS system. Medical Teams International conducted several mass casualty field exercises in different areas of the island to train pre-hospital care providers for such situations and also to build up the interagency relationships. Sri Lankan pre-hospital care providers responded to the Post War IDP (Internally Displaced People) situation by providing emergency care for more than 300,000 people in IDP camps.
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Methodology This project focused mainly on auditing thepre-hospital care system in Sri Lanka. The review mainly targeted the assessments of EMTs, their physical and financial resources and the efficiency of the services provided by them. Five out of seven 1-1-0 pre-hospital care systems participated in the review program. Those systems include: · Badulla - Municipal Fire Brigade-based system · Galle - Municipal Fire Brigade-based system · Jaffna - Regional Directorate of Health Services-based system · Kandy - Municipal Fire Brigade-based system · Kurunagala - District Hospital-based system Pre-hospital care providers based at the Colombo Municipal Council System and Anuradhapura District Hospital System did not participate in the review howevertheir respective higher officials had given permission to conduct the program. Tangalle and Kaluthara Urban Council Fire brigades were included in the review as areas that have resources and trained personal without a 1-1-0 pre-hospital care system. For the assessment of the factors above, the following fourteen assessment tools were used. Physical Resources 01. Ambulance accessory assessment sheet. Standards from the World Health Organization (WHO) and the Pre-hospitalCare Subcommittee in Sri Lanka were used to assess the quality of an ambulance with regards to the number and quality of items available. 02. Emergency medical dispatch center standards. The assessment sheet was developed using the standards from the WHO and the Sri Lankan recommendations by the Subcommittee for Pre-hospital Care Systems. This assessment focused on the equipment and facilities available at the center. A grading system was used to describe the each facility. 03. Emergency dispatch center accessory equipment assessment sheet. This sheet was used to assess the equipment and accessories available at a dispatch center in addition to the emergency medical dispatch center standards. EMT and EMD 04. Self-administered questionnaire for the EMTs. The EMTs were assessed on their level of training, work experience, education, and problems faced during work in the pre-hospital care system. Their opinions on future enhancements to the system and public awareness were also garnered. 05. Self-assessment sheet for EMT skills. The EMTs were given lists of essential skills on which they have been trained and assessed in the past and asked to assess their competency at several skill levels. This assessment was to be filled out by each EMT separately and, in addition, they were 13
asked to provide the number of times they have used each skill within the past 3 months and the past 6 months. This self assessmentof skills was compared with the skills grading each EMT received during their initial training and refresher trainings. 06. Multiple Choice Question (MCQ) paper for the EMTs. Each EMT’s knowledge of pre-hospital care theory was assessed. Here they were given 50 MCQs. The time allocated was one hour. Results of this MCQ review was compared with the results each EMT received in their initial training and refresher trainings. Efficiency of the Service 07. Interviewer-administered questionnaire for the OIC. The primary purpose of this questionnaire was to discuss the main resources available to EMTs, physical and financial, and to determine the main problems in running the system in eacharea. In addition, plans and opinions on the future enhancements of the system were derived from this questionnaire. 08. Interviewer-administered questionnaire for the high officials (municipal mayor, municipal engineer, municipal commissioner). This questionnaire was used to assess the level of awareness among the officials and to identify the problems they face in running the system. Their opinions on future enhancement of the system were also requested. 09. Medical dispatch case evaluation record. A medical dispatch case evaluation sheet was used to assess the quality of the service at the dispatch center during an emergency call. The tool had a separate scoring system for assessment purposes. When a dispatch center did not receive a call during the time of review team’s visit, a false call was used for assessment with the permission of the Officer in charge without informing the on-shift dispatchers. 10. EMT field assessment sheet. The standard of careprovided by the EMTs was to be assessed by this evaluation form. The intention of this assessment was to be a “live” assessment. However due to the inability to predict call volume the assessment was simulated by the review team. 11. Quality assessment/Quality improvement sheet for MTI. This assessment tool was used for the overall assessment of the pre-hospital care system. 12. Beneficiary questionnaire. An interviewer-administered questionnaire was used with the benefiting public to grade the service they obtained from a certain agency and their opinion on further enhancement of the service. 13. Public awareness questionnaire. Public awareness, service enhancement opinion and the possibility of charging a fee from the public were assessed using this interviewer-administered questionnaire.
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14. Hospital staff questionnaire. The opinions on further enhancement of the pre-hospital care system, the knowledge and skill level of the EMTs and the quality of the service provided by EMTs were obtained by using this interviewer-administered questionnaire.
15
Result and Discussion Physical resources Ambulance- Quality and Quantity After the devastating Tsunami in 2004, the International Center on Emergency Techniques (ICET) in the Netherlands worked with the government of Sri Lanka to upgrade the 18 fire brigades. During this upgrade, fire brigades were given 23ambulances and 20 rapid intervention vehicles. Out of the 18 fire brigades, only four are providing pre-hospital care services. The following chart shows the vehicles owned and used by each pre-hospital care system for emergency response.
Number of dedicated vehicles for response 20 18 16 14 12 10 8 6 4 2 0
Badulla
Galle
Jaffna
Kandy
Kurunegala
Ambulances
1
2
18
3
2
RIV
1
1
0
2
0 Chart 01
Badulla, Galle and Kandy Pre-hospital care systems are equipped with Rapid Intervention Vehicles (RIVs) except for their ambulances which have additional equipment to extricate patients in a rescue situation. The Jaffna Pre-hospitalCare System is equipped with 18 ambulances owned by RDHS which is the highest number of ambulances owned by an established pre-hospital care system. Jaffna is the only system in Sri Lanka that owns two boat ambulances to transport patients from islands. According to the officers in charge in these pre-hospital care systems, none of these systems have a sufficient number of ambulances to respond to all the emergency calls they receive. In some cases, a dispatcher must decline requests made by the public because all of their vehicles are in use. This situation has caused some resistance from the public to dial 1-1-0 for an emergency. Ambulances, RIVs and essential dispatch center equipment were donated by ICET to all the fire brigade systems. The Kurunagala System received additional ambulances and dispatch equipment from a private donor in Australia. Jaffna received donated ambulances and two 16
boat ambulances from Medical Teams International and it is also using ambulances owned by the RDHS division. Officers in charge of the pre-hospital care systems stated that it is difficult to restock the ambulance equipment after responding to calls due to lack of supplies. Extra supplies available on site are limited amount due to current budget allocations. Additionally each location indicated that was there is insufficient publicity about the local emergency service. Publicity needs to be expanded further. Each location confirmed that they were very pleased with the support they are receiving for their service from the hospital staff and other public workers. Ambulance equipment was compared with the basic life support ambulance standards of the World Health Organization and standards stated in Pre-hospital Subcommittee (PSC) regulations. The following table shows the basic life support ambulance standards drafted by WHO and PSC. Ambulance Standards – (WHO and PSC of trauma secretariat) General (part-A) Specification Item 1. 2. 3. 4.
With changing equipment With six assorted blades 90 centimeter in length Battery-operated
8. Safety Vests 9. Warning Lights 10. Warning Siren
Multi-Purpose Radio / Cellular 10" crescent wrench, multi-screwdriver, one claw hammer, one set of pliers Orange, reflective Red, visible 360 degrees Multiple pitch external audible
Spare Tire Hacksaw Pry Bar Portable Hand Lights (Torch) 5. Fire Extinguisher 6. Communication Equipment 7. Tool Kit
Table 01
In general, equipment in all the ambulances that were checked during the review included neither a hacksaw nor a pry bar, items that can be used in a small rescue operation or in an extrication situation. Ninety percent of the ambulances had not checked the status of their fire extinguishers which review teams found to have expired one year back. Ambulances had technical problems with their warning sirens and lights which are essential when transporting a critical patient and to audibly and visually identify emergency vehicles. Ambulances did not carry their spare tire with the vehicle because they had sent it to be patched and it had not been fixed and returned after weeks. This situation is mainly due to money allocation issues; most of the pre-hospital care systems use their normal channels to 17
get approvals evenfor emergency repairs. This same issue arises when repairing and replacing a vehicle after a breakdown; repairs may take days or even months. Ambulance Standards – (WHO and PSC of trauma secretariat) Patient Care (Part-B) Item 11. Stretcher
Specification Adjustable, wheeled, with mattress and restraining straps Folding variety, with two restraining I.V. hook-mounted May be extrication device such as the K.E.D. With slots to permit handhold and straps Complete set, or individual Cloth or Plastic
two
12. Portable Stretcher 13. Intravenous supports 14. Short spine device 15. Long spine board 16. Spine board straps 17. Sheets 18. Scoop Stretcher 19. Kendrick Extrication Device 20. Towels Cloth 21. Kidney Basins
Table 02
Twenty-five ambulances and twentyRIVs had their patient care equipment donated by ICET, WHO and MTI during the initial process of establishing the pre-hospital care system. All the ambulances have only one set of equipment which creates a problem when the equipment isexpendedwhile treating a patient. The ambulance staff must wait until the equipment is released by the hospital after stabilizing the patient Ambulance Standards – (WHO and PSC of trauma secretariat) Medical Equipment (Part-C) Item 22. Oxygen cylinders 23. Regulators 24. Adult oxygen masks 25. Pediatric oxygen masks 26. Nasal cannula 27. Oxygen tubing 28. Bag-Valve -Mask Adult Size 29. Bag-Valve -Mask Pediatric Size 30. Suction apparatus 31. Flexible suction catheters 32. Rigid suction catheters
Specification Minimum capacity of500 psi Designed for the oxygentank used
Resuscitation mask with oxygen inletand masks Resuscitation mask with oxygen inletand masks Portable battery or manual operation Various sizes 18
33. Oropharyngeal airways 34. Cervical collars 35. Rigid splints 36. Bandages 37. Triangular bandages 38. Adhesive tape 39. Scissors 40. Sphygmomanometer 41. Stethoscope 42. AED 43. Pocket mask 44. Glucometer 45. Portable ventilator 46. Pulse oxy meter 47. Burn Shield gel 48. Bed Pan 49. Obstetrical Kit 50. Portable trauma kit 51. Bio-Hazard Container
Graduated sizes Two small, two medium, two large For use with all extremities Roller conforming gauze, dressings Assorted sizes Bandage or heavy duty, able to cut clothing 1 adult size, 1 small size With adult and pediatric pads, extra batteries With strips and lancets
Male and female Sterilized, prepackaged; containing gloves, scissors, umbilical clamps, towels and dressings With adequate supplies to meet immediate patient treatment needs away from the ambulance
Sharp Table 03
All ambulances except ambulances in Jaffna, where they do not have AEDs in the ambulances, wereshown to follow the above standards. Pre-hospital care providers in the established systems have problems withdelay in restocking patient care supplies in the ambulance because they do not have stock in place at their stations. This situation is somewhat controlled in hospital-based and RDHS-based systems because they can get supplies from the general stores and replace them when they receive their own supplies. In ďŹ re brigade systems, personnelmust go through normal municipal council procedures which sometimes take days even months to replace items.
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Call dispatch center Pre-hospital Care System Dispatch Center
Not Established
Established
Item
Badulla
Galle
Jaffna
Kandy
Kuru nagla
Kaluth ara
Tanga lle
Telephone lines designated for 1-1-0 Telephone lines designated for other requirements Fax machine Computer Recorder Logbook Handheld and equipment
base
radio
Maps EMD card set
Available Not Available Table 04
The Galle Fire Brigade uses the telephone that receives 1-1-0 calls for their other communication needs as well. Only Jaffna, Galle and Kurunegala dispatch centers have maps of their designated areas and none of the seven dispatch centers are using an EMD (Emergency Medical Dispatch) Card set for dispatching. Jaffna and Kurunagala dispatch centers do not use radios to communicate with their ambulances but they use mobile phones for that purpose. Every established pre-hospital care system has its own dispatch center. Galle, Kandy and Badulla dispatch centers are located at the Fire Brigade. The Kurunagala dispatch center is located in Kurunagala Hospital. TheJaffna dispatch center is on the RDHS premises. 20
Locations Category
Badulla
Galle
Jaffna
Kandy
Kurun agala
Dispatch personal EMD center designate at a minimum a 1 dispatcher to ensure the functions of the dispatch center Dispatch procedure The designated dispatch center uses an 2 EMD card system and priority dispatch assignment approved by the OIC Calls Designated dispatch center hasresponsibility to ensure that the EMD is appropriately handling calls · All calls handled by an EMD will be 3 recorded and maintained on tape for a minimum of 180 days · Dispatch times will be recorded on calls and maintained in the EMS data base or dispatch log. Time will be reviewed as needed Supplies, equipment Dispatch center hasappropriate supplies and equipment available to accomplish 4a system duties including, but not limited to, adequate computer hardware and software for data collection and analysis to meet reporting requirements Communication Dispatch center hascommunications equipment necessary to function as an 4b EMD center and ensures the equipment is maintained and updated to reflect current technology Computers and software 5 Dispatch center maintains and upgrades all computer hardware and software Telephone System Telephone system has1-1-0 direct receiving facility, 1-1-0 secondary Public Safety Access Point capability, or 6 dedicated method contact primary Public Safety Access Points, private ambulance dispatch, and Designated Fire Dispatch Centers. Radio equipment Radio communication system has 7 · Necessary medical frequencies to conduct daily business 21
Necessary common frequencies for interagency activities, MCI’s or disasters Recording equipment · Equipment capable of continuously recording all elements of dispatching (phone calls, radio traffic, etc) · Retention of tapes for 180 days unless an unusual occurrence has occurred. In this case, the tape should be held for a period designated by the communication manager Backup power Backup power supply generator and fuel is available on site and adequate to continue operations for 24 hours Education The dispatch center provides on-going education of its staff in new technology and advances in pre-hospital care as they relate to dispatch Data Requirements At a minimum, the following is collected on every call, as appropriate, by the dispatching center responsible for tracking the units dispatched ·Time of call receipt at EMD center ·Time of unit dispatch ·Time of units en route to call ·Time of units on scene of incident ·Time of ambulance en route to hospital ·Time of ambulance arrival at hospital ETU area ·Time of ambulance clearing hospital ·Time of cancellation, if applicable Quality Improvements Review requested by EMS personal Mandatory reviews Call related to complaint received Quality Improvements Audits Written records of all the calls reviewed should be kept for seven years Audit Written records of all the calls reviewed should be kept for seven years ·
8
9
10
11
12 13 14
15
Table 05 Key: Available / Functioning Not Available / Not Functioning
22
Each and every dispatch center has designated personal during the shift to work as dispatchers. None of the dispatch centers use an EMD card system but they receive prior approval from the Officer In-Charge before dispatching an ambulance. Galle, Badulla and Kandy have recorders that can record the calls but they are not using them due to lack of technological knowledge to use them. Dispatch times are recorded in the dispatch center log books. All dispatch centers have necessary supplies of communicationequipment, but some of the equipment is not used because the dispatcher does not have the required knowledge to use them. As an example, computers are available to keep a database but only Jaffna and Kurunagala Dispatch centers are using them. All dispatch centers have a designated telephone line for the pre-hospital care access number 1-1-0. Radio equipment is available in fire brigade-centered dispatch centers with multifrequency facilities; this equipment is, however, also not used due to lack of knowledge. All the dispatchers have received three-hour training from Medical Teams International on dispatching but they have not gone through any professional training to become dispatchers. Written records of calls are kept for review purposes. Financial support and equipments supply Officers in charge of the pre-hospital care systems stated that it is difficult to restock the ambulance equipment after responding to calls because they have only a limited amount of supplies on handdue to limited budget allocations. Additional due to the lack of budgetary support for publicity during the review the officers in charge stated there is insufficient publicity about the service. Local publicity budget line items need to be expanded further. The officers in chargewere very pleased with the support they are receiving for their service from the hospital staff and other public workers. Kandy, Galle and Badulla Pre-hospital care systems mainly respond to emergencies within the municipal limits. The Kurunegala system responds to emergencies within a 5 km radius or to emergencies they can respond within 5 minutes. Jaffna system responds to emergencies within their Regional Directory of Health Services operational area.Scopes of these limited response areas are due limited budgetary allocations to adequately cover each responding agency service area. In some cases the assessment team recorded that agencies were unable to fully respond to their entire designated area. Kandy, Galle and Badulla pre-hospital care systems mainly respond to trauma. Kurunagala only responds for medical emergencies, and in cardiac emergencies, it will only respond if a bystander has started to resuscitate the patient. In the Jaffna system, they respond to both medical and trauma emergencies. There are many different ways to subsidizepre-hospital systems in Sri Lanka. The systems in Kandy, Galle, Badulla, and Kurunegala are completelyfree of charge for emergencies.Additionally the Kandy, Galle and Badulla systems have a paid ambulance23
based transport system for nonemergency and hospital transfers which charges are based perkilometer. The Jaffna system has a fee of Rs300 which is not mandatory.
EMT and EMD (Emergency Medical Technicians and Emergency Medical Dispatchers) Numbers Emergency Medical Technicians (EMT) Medical Teams International trained 2,836 Emergency Medical Technicians to support the pre-hospital care systems under MOUs with the Ministry of Health and Nutrition and the Ministry of Local Governments of Sri Lanka.These EMTs include a variety of professions including doctors, nurses, and ambulance drivers. (See Chart 05) Distribu on of EMTs by Provinces 60.0 50.0 48.1
40.0 30.0 20.0 10.0
19.8
8.7
7.9
1.7
6.4
1.2
4.8
1.2
0.0
Chart 02
Chart 02shows the distribution of EMTs by each province and it shows us that almost ďŹ fty percent of the trained EMTs are from Northern Province. Out of these trained EMTs, 46% percent have received training at EMT Level-1, 20% have received training atLevel-2, and 32% percent have received training atboth Levels 1 and 2. Only 2% of EMTs have, however, received training on Level-3. These details are shown in Chart 03.
24
Distribu on of EMTs By the Level of Training 2%
Level 1
32% 46%
Level 2 Level 1& 2 Level 3
20%
Chart 03
Distribu on of EMTs By Gender
Female 44% Male 56%
Chart 04
Chart 04 shows the distribution of EMTs by gender and Chart 05 shows the distribution of EMTs by their professions.
25
Distribu on of EMTs by Profession 1% 6%
6%
Doctor Ambulance Driver
15% 21% 2%
A endant Nursing Officer Volunteer
27%
22%
PHI / PHNS Fire Fighter Private Ambulance Services Chart 05
Emergency Medical Dispatchers (EMD) Professional training for Emergency Medical Dispatchers in the Sri Lankan pre-hospital care system is not currently available. In the absence of professional dispatch training, current dispatchers have received a three-hour training session from Medical Teams International which covers the basics of call taking and dispatch procedures. Skills and knowledge Of theEMTs who have participated in Review Program, 50% have completed the General Certification of Education Ordinary Level (G.C.E. O/L) and 41% have completed the Advance Level (G.C.E. A/L). Others have completed a higher education level such as University, Masters Degree, or PhD or received another education qualification such as a diploma (Chart 06). Thirty-eight percent of the participants are fire fighters, 9% are ambulance drivers, 6% are nurses and 47%work in other professions such as attendants or common labors and are working in the pre-hospital care systems as Emergency Medical Technicians (Chart 07). Fifty-seven percent of the EMTs who participated in the review program are working full time as Emergency Medical Technicians.
26
Level of Educa on 4% 5% G.C.E. (O/L) 50%
G.C.E. (A/L) Higher Educa on
41%
Other
Chart 06
Profession
9% Ambulance Driver 47%
Fire Fighter 38%
Nurse Other
6%
Chart 07
EMT Training 0% 2% 4% 2005 25%
2006 29%
2007 2008 2009
40%
2010
Chart 08
27
Forty percent of the participants had received their initial EMT training in 2009, 29% percent received their initial EMT training in 2008, and 25% in 2010 (Chart 8). Forty-five percent of the participants of the pre-hospital care review programs participated in an EMT refresher training program conducted by Medical Teams International during 2009 and 2010. Fortyeight percent of the review program participants completed Level-1 EMT training and the remainder completed EMT Level-2 training. Only 19.8% of the Emergency Medical Technicians have participated in other emergency medical services trainings excluding initial EMT training and refresher training. But 48.8% of participants have participated in trainings other than emergency medical services including rope rescue training and water rescue training. Nearly 82% stated that they are practicing their skills with 29% practicing their skills once a month and 21.5% practicing their skills once a week. But only 13.2% are practicing all the basic skills needed to be recognized as an EMT. Table 06 shows the percentage of persons practicing each basic skill required of an EMT.
Basic skills required of an EMT
Percentage of Persons who are Practicing
Bleeding Control Fracture Immobilization Trauma Patient Assessment Medical Patient Assessment Cardio Pulmonary Resuscitation Practicing All above Skills
41.90% 21.00% 38.10% 40.90% 37.60% 13.20% Table 06
Nearly 24% of the EMTs who are practicing their skills are doing so during the time that they are not responding to emergency calls and 46.1% are using an allocated time during their shift. The majority of the EMTs who are not practicing the skills gave as a reason that they do not have an allocated time during their shift. More than sixty percent of the EMTs agreed that EMT refresher courses must be held every six months and others agreed a refresher course should be held at least once a year. Nearly 57% of EMTs are filling out Patient Care Report (PCR) forms during their calls. Others stated lack of knowledge in the English language, short distance to hospital, and inability to fill out the form while riding in the ambulance as reasons for not filling out PCR forms. Eighty percent the Emergency Medical Technicians confirmed that they have enough support from the public during calls, but only 56.6% voted that they think the public is willing to pay a fee for the service they are rendering. Ninety-four percent of EMTs are satisfied with their career as EMTs and 97% are willing to continue their career as EMTs.
28
Able to Perform needed skills during an actual response
No 32%
Yes 68%
Chart 09
Sixty-eight percent of the EMTs remarked that they are able to perform the skills that they have learned through training during an actual call (Chart 09). Others who remarked that they are not able to perform the skills suggested there should be an intern period with experienced EMTs before sending them alone for emergency calls. Ninety-nine percent of the EMTs suggested there should be programs to increase public awareness and to educate the public what to do in an emergency. Fifty multiple choice questions were used to assess the current theoretical knowledge of EMTs. The overall mean of theory knowledge during initial training for all trained EMTs were 70 out of 100. The total scores in the review theory question paper were compared with the mean of EMT scores in the initial trainings and refresher courses.
80
70
70
80 62.5
Theory
Prac cal
Refresher
Refresher
Ini al Marks
Review
Refresher
55
Review
75
Ini al Marks
80 65
Ini al Marks
90 80 70 60 50 40 30 20 10 0
Review
Practical assessment was also done during the review and compared with the scores obtained in the initial trainings and refresher trainings (Chart 10).
Overall
Chart 10
29
The following Chartsshow changes in the theoretical, practical and overall scores during the initial, refresher and review exams. Kurunegala results were not included because it has not completed any EMT courses. Kandy, Kaluthara and Jaffna have not participated in any of the refresher programs.
Theore cal Results 100 80 60 40 20 0
Ini al Refresher Review
Chart 11
Prac cal Results 100 80 60 40 20 0
Ini al Refresher Review
Chart 12
Overall Results 100 80 60 40 20 0
Ini al Refresher Review
Chart 13
30
In most places, refresher courses were conducted without a pretest. In the post-test conducted after a two-day training session, students received higher scores than following initial training in all theory, practical and overall marks. During the review assessment, however, students have shown a decrease in both theory and practical assessments. To assess this loss more closely, the Badulla Fire Brigade was selected to conduct a refresher course with a pretest during the review. The analyzed results of the 24 students who participatedin the program are shown below.
Chart 14
Chart 15
Chart 16
Participants in this evaluation showed a signiďŹ cant dropin the scores achieved in theory and practical assessment. But after going through two-day refresher program, they were able to catch up on their knowledge and skills and show even better results than the initial exam. 31
This refresher course was conducted six months after the initial training. If the time period was longer, it might have shown a greater gap between the score on the initial tests and the pretest before the refresher program. Information collected from the self-assessment questionnaire shows that EMTs are not continuously practicing their skills. The EMT self-assessment scalegrading shows that the more they perform the skill, the more they grow confidence in their ability to perform the skill. Continuing education Each and every officer in charge statedthat their EMTs are not informed about current updates and trends in field of Emergency Medical Services. Of the five pre-hospital care systems that participated in the survey, only Galle, Badulla and Jaffna have conducted refresher training using facilitators from Medical Teams International. All EMTs working in the Badulla Pre-hospitalCare System have participated in a refresher course while in Galle and Jaffna only eighty percent of the EMTs who are working in the system have participated in a refresher program. The Kandy Officer in Charge stated that his EMTs are not willing to participate in a refresher course because they are not working as permanent employees. All officers in charges stated that there should at least be mini lecture sessions of one to three hours every month and a refresher course should be held at least every six months or annually to keep EMTs up-to-date with current knowledge. Badulla and Kandy Pre-hospitalCare Systems have a time allocated in their schedules for EMTs to practice their skills. In the Badulla system, they have allocated a time every two weeks and in Kandy it is every two months. The Kandy Emergency Medical Technicians have received rope rescue training and hospital training. Galle Emergency Medical Technicians have gone through two EMT trainings conducted by Japan and Israel, hospital training from the Karapitiya teaching hospital and mass casualty response training by the Sri Lanka Initiative for Disaster Management and Awareness (SLIDMA). Number in service The pre-hospital care review team met with the officer in charge of each pre-hospital care system that participated in the pre-hospital care review program and gathered information from them using a 40-question interviewer-administered questionnaire. Chart 17 below was created from the data in the EMT database and the information collected from the officers in charge of the pre-hospital care system.
32
Emergency Medical Technicians 1200 965
1000 800 600 400 200
200 190
158 35
24
24
17
97
12
51
34
24
0
0
0 Badulla
Galle
Jaffna
Number of EMTsTrained in the Province
Kandy
Kurunagala
Number of EMTsTrained for 1-1-0
Number of EMTs Currently Working in 1-1-0 Chart 17
As we see in the Chart 18 below, the Northern Province not only has the highest number of trained Emergency Medical Technicians, but the Jaffna pre-hospital care system of the Northern Province uses the highest number of EMTs in their ambulances. Uva Province has 24 trained EMTs. The Kurunegala Pre-hospitalCare System does not, however, have any trained EMTs for their 1-1-0 pre-hospital care system: it functions using nurses and doctors in their ambulances.
Number of Working EMTs in each Level 150
40 12 12
12
0
Badulla
Galle
34 0
Jaffna Level 1
Kandy
0
0
Kurunagala
Level 2 Chart 18
More than three quarters of the EMTs working in Jaffna pre-hospitalcare system are trained at EMTLevel-1 which is internationally known as first responders. Galle and Kandy Prehospital care systems uses only EMT Level-2 which is internationally known as EMT-basic. The Badulla system has an equal number of EMTs atboth Level-1 and Level-2. The Kurunegala system only uses doctors and nurses in their ambulances (Chart 18).
33
Expired with certificate According tomost recognized international regulations, EMTs must renew their certificates at least every two years. Among the 2,836 Sri Lankan EMTs, only 300 have participated in a refresher program and 1,050 have expired certificates. Skills check list A self assessment scale was applied to 29 essential skills. EMTs were asked to assess their level of performance in each skill using the following six grades on the scale sheet. 0 1 2 3 4 5 6
- Fail to perform the skill - Weak - Satisfactory - Average - Good - Very good - Excellent
The following charts show the percentage at which EMTs graded their ability to perform each given skill according to their confidence level of performing the skill.
Prcentage of EMts
Skill No 01 : Primary and secondary patient examinations 30 25 20 15 10 5 0 0 - Fail 1
2.2
235 - Very 61 - Weak Sa sfact 4 - Good Average Good Excellent ory 6.6
10
27.5
19.7
19.2
14.8 Chart 19
34
Precentage of EMTs
Skill No 02 : Take and record breathing 25 20 15 10 5 0 0 - Fail 2
2.6
231 - Weak Sa sfacto Average ry 3.9
12.2
4 - Good
5 - Very Good
6Excellent
21.8
22.3
19.3
17.9
Chart 20
Precentage of EMTs
Skill No 03 : Recognizing different lung sounds 25 20 15 10 5 0 0 - Fail 3
7.9
21 - Weak Sa sfact ory 10.9
15.3
3Average
4 - Good
5 - Very Good
6Excellent
21
19.7
11.4
13.8 Chart 21
Skill No 04 : Take and record pulse
Precentage of EMTs
35 30 25 20 15 10 5 0 0 - Fail 4
2.6
231 - Weak Sa sfact 4 - Good Average ory 3.1
5.2
13.1
23.6
5 - Very 6Good Excellent 22.7
29.7 Chart 22
35
Skill No 05 : Take and record blood pressure
Precentage of EMTs
25 20 15 10 5 0 0 - Fail 5
6.1
231 - Weak Sa sfact 4 - Good Average ory 6.6
8.3
14.4
23.1
5 - Very 6Good Excellent 21
20.5 Chart 23
Precentage of EMTs
Skill No 06 : Take and record pupil reactivity 25 20 15 10 5 0 0 - Fail 6
8.3
231 - Weak Sa sfact 4 - Good Average ory 11.8
10.9
22.3
15.7
5 - Very 6Good Excellent 15.3
15.7 Chart 24
Skill No 07 : Take and record skin condition
Precentage of EMTs
25 20 15 10 5 0 0 - Fail 7
3.1
231 - Weak Sa sfact 4 - Good Average ory 7.4
10.9
22.3
19.2
5 - Very 6Good Excellent 19.2
17.9 Chart 25
36
Skill No 08 : Take and record capillary refill in infants and children
Precentage of EMTs
25 20 15 10 5 0 0 - Fail 8
16.6
235 - Very 61 - Weak Sa sfact 4 - Good Average Good Excellent ory 17
12.7
22.3
10.9
8.7
11.8 Chart 26
Precentage of EMTs
Skill No 09 : Open and maintain an airway by positioning the patient’s head 35 30 25 20 15 10 5 0 0 - Fail 9
6.6
235 - Very 61 - Weak Sa sfact 4 - Good Average Good Excellent ory 2.6
3.9
12.2
20.5
22.7
31.5 Chart 27
Skill No 10 : Provide CPR
Precentage of EMTs
30 25 20 15 10 5 0 0 - Fail 10
5.7
235 - Very 61 - Weak Sa sfact 4 - Good Average Good Excellent ory 1.3
6.6
12.7
24.5
21.8
27.4 Chart 28
37
Precentage of EMTs
Skill No 11 : Obstructed airway treatment for infants, children and adults 25 20 15 10 5 0 0 - Fail 11
7.4
21 - Weak Sa sfact ory 5.7
8.3
3Average
4 - Good
5 - Very Good
6Excellent
16.6
23.6
19.6
18.8 Chart 29
Precentage of EMTs
Skill No 12 : Provide care for soft tissue injuries 30 25 20 15 10 5 0 0 - Fail 12
4.4
21 - Weak Sa sfact ory 6.6
7.4
3Average
4 - Good
5 - Very Good
6Excellent
26.2
23.6
17.9
13.9 Chart 30
Skill No 13 : Provide care for suspected fractures Precentage of EMTs
25 20 15 10 5 0 0 - Fail 13
3.1
235 - Very 61 - Weak Sa sfact 4 - Good Average Good Excellent ory 5.2
13.1
22.7
22.7
15.7
17.5 Chart 31
38
Precentage of EMTs
Skill No 14 : Assists with pre-hospital child birth 20 15 10 5 0 0 - Fail 14
17
231 - Weak Sa sfact 4 - Good Average ory 18.8
17.9
13.1
10.9
5 - Very 6Good Excellent 10.5
11.8 Chart 32
Precentage of EMTs
Skill No 15 : Complete a clear and accurate pre-hospital emergency care report on all patient contacts and provide a copy of that report to the senior EMT accompanying the transporting ambulance or to the hospital authorities 25 20 15 10 5 0 0 - Fail 15
22.7
235 - Very 61 - Weak Sa sfact 4 - Good Average Good Excellent ory 13.1
12.7
17.5
12.7
12.2
9.1 Chart 33
Skill No 16 : Administration of oxygen Precentage of EMTs
30 25 20 15 10 5 0 0 - Fail 16
3.5
235 - Very 61 - Weak Sa sfact 4 - Good Average Good Excellent ory 4.4
6.6
15.7
21.4
21.4
27 Chart 34
39
Precentage of EMts
Skill No 17 : Open and maintain an airway through the use of airway adjuncts 25 20 15 10 5 0 0 - Fail 17
8.7
231 - Weak Sa sfact 4 - Good Average ory 6.6
10.9
20.1
18.8
5 - Very 6Good Excellent 17.9
17 Chart 35
Skill No 18 : Using a manual- or battery- powered suction device
Precentage of EMTs
25 20 15 10 5 0 0 - Fail 18
19.7
235 - Very 61 - Weak Sa sfact 4 - Good Average Good Excellent ory 9.6
12.7
18.8
12.2
13.5
13.5 Chart 36
Skill No 19 : Operate a bag mask ventilation device with reservoir
Precentage of EMTs
30 25 20 15 10 5 0 0 - Fail 19
25.3
235 - Very 61 - Weak Sa sfact 4 - Good Average Good Excellent ory 15.7
10.5
14
13.5
12.2
8.8 Chart 37
40
Precentage of EMTs
Skill No 20 : Provision of care for suspected medical emergencies, administering liquid oral glucose for hypoglycemia 20 18 16 14 12 10 8 6 4 2 0 0 - Fail 20
8.7
including
235 - Very 61 - Weak Sa sfact 4 - Good Average Good Excellent ory 13.5
17.5
16.6
17.9
13.1
12.7 Chart 38
Precentage of EMTs
Skill No 21 : Administer epinephrine by automatic injection device for anaphylaxis 45 40 35 30 25 20 15 10 5 0 0 - Fail 21
40.6
235 - Very 61 - Weak Sa sfact 4 - Good Average Good Excellent ory 18.3
14.4
9.6
7.9
4.8
4.4 Chart 39
Precentage of EMTs
Skill No 22 : Perform cardiac defibrillation with an automatic defibrillator 40 35 30 25 20 15 10 5 0 0 - Fail 22
37.1
235 - Very 61 - Weak Sa sfact 4 - Good Average Good Excellent ory 17.9
12.2
12.2
11.8
4.8
4 Chart 40
41
Precentage of EMTs
Skill No 23 : Provide care for suspected shock 25 20 15 10 5 0
23
0 - Fail
1Weak
8.8
10.1
23Sa sfac Averag tory e 15.4
4Good
18.4
22.4
65 - Very Excelle Good nt 12.3
12.6 Chart 41
Precentage of EMTs
Skill No 24 : Provide care for suspected medical emergencies 25 20 15 10 5 0 0 - Fail 24
10.1
235 - Very 61 - Weak Sa sfact 4 - Good Average Good Excellent ory 5.7
14
17.1
21.5
19.3
12.3 Chart 42
Precentage of EMTs
Skill No 25 : Obtaining a capillary blood specimen for glucose monitoring 30 25 20 15 10 5 0 0 - Fail 25
27.2
231 - Weak Sa sfact 4 - Good Average ory 16.7
10.1
13.2
12.3
5 - Very 6Good Excellent 7.9
12.6 Chart 43
42
Precentage of EMTs
Skill No 26 : Support with aspirin for suspected myocardial infarction if prescribed by doctor 25 20 15 10 5 0 0 - Fail 26
11.4
235 - Very 61 - Weak Sa sfact 4 - Good Average Good Excellent ory 9.2
12.3
13.2
18
15.4
20.5 Chart 44
Precentage of EMTs
Skill No 27 : Transport patients with saline locks, Heparin lock, Foley catheters or in dwelling vascular devices 25 20 15 10 5 0 0 - Fail 27
11.8
235 - Very 61 - Weak Sa sfact 4 - Good Average Good Excellent ory 7.9
13.6
14
19.3
17.1
16.3 Chart 45
Precentage of EMts
Skill No 28 : Perform other emergency tasks if under the supervision of an on-scene physician or under the commands of an off-scene physician (Ex. Start an IV access) 20 15 10 5 0 0 - Fail 28
17.1
235 - Very 61 - Weak Sa sfact 4 - Good Average Good Excellent ory 10.5
15.4
15.4
14.9
13.2
13.5 Chart 46
43
Skill No 29 : Assist patient with administration of sublingual nitroglycerine tablets or spray and with metered dose inhalers that have been previously prescribed by that patient’s personal physician and that are in the possession of the patient at the time the EMT is summoned to assist the patient.
Precentage of EMTs
25 20 15 10 5 0 0 - Fail 29
21.1
235 - Very 61 - Weak Sa sfact 4 - Good Average Good Excellent ory 15.8
15.4
16.7
12.7
9.2
9.1 Chart 47
While EMTs were asked to grade themselves in the 29 skills above, they were also asked to state how many times they have performed these skills in the field during past three months and during the past six months. Analysis of this data showed that whenever anEMT graded himself high in any of the skills, he had performed that skill more than ten times during past six months and more than three times during last three months. EMTs showed a higher level of confidence in performing basic skills (Skills 1-15 with the exception of Skill 14assist with pre-hospital child birth) because they perform these skills with each and every patient to whom they provide care. In addition, EMTs showed a lower level of confidence in performing skills to assist a patient with administration of sublingual nitroglycerine tablets or spray and with metered dose inhalers that have been previously prescribed by that patient’s personal physician.(Skill 29)Additionallyperformingother emergency tasks if under the supervision of an on-scene physician or under the commands of an off-scene physician (for example, start an IV access) (Skill 28) because they need both medical direction and advance training which they have not yet received. Using a manual- or battery- powered suction device(Skill18) andperform cardiac defibrillation with an automatic defibrillator(Skill 22) show lower confidence levels because the majority of the EMTs who participated do not have AEDs and battery-powered suction devices in their ambulances and also because the majority of the Jaffna pre-hospital care providers who participated in the survey are Level-1 providers who do not have these skills with their scope of expertise. For most of the skills that have high fail rate, either the EMTs have only performed the skill once during past six months or have not performed it at all during past six months.
44
Other Other than the officers in charge, the review team met other officers who are decision makers and work closely with the pre-hospital care systems. The review team used a unique interviewer-administered questionnaire to collect information from the above mentioned officials. Each and every official who participated in the survey was satisfied with the service provided by pre-hospital care providers. One issue they brought up was that, in hospital- and RDHSbased systems, staffs are not assigned separately to the pre-hospital care system. Because of this, when the staff members are transferred to another hospital, the previous hospital does not have enough trained personal to staff its ambulances. Another issue was the lack of ambulances to respond to needs. Other than the official in Kandy, officials believe that they have enough publicity for the service and they cannot increase the publicity because then they would then have to expand the service using more ambulances which they do not have at the moment. One of the major issues faced by the pre-hospital care systems according to the officials is not having enough funds to run the service. Currently they are running with the funds allocated in their annual budgets by their respective authorities except in Jaffna. The Jaffna system charges a fee of Rs. 300/= which is not mandatory, but 99 percentof the time is paid by the beneficiaries sometimes even a few days after the service was provided. Non-emergency services in Kandy, Galle and Badulla charge a fee based upon kilometers traveled but they have to limit this service because they are using the same ambulances for emergencies.
Efficiency of service Hospital data on mortality after a trauma To determine the outcomes of the existing pre-hospital care systems, receiving centers were assessed using an interviewer-administered questionnaire. Emergency Treatment Unit (ETU) and Out Patient Department (OPD) staffs in hospitals at pre-hospital care system-established areas were selected for this review because they are the first contacts in the hospital when a patient is brought in by the Emergency Medical Technicians. According to the feedback from the staff at receiving centers, 46% of cases transferred by the pre-hospital care system were trauma patients, medical emergencies and other emergencies such as near drowning and patients with behavioral emergencies were second with 27%of the transfers (Chart 48).
45
Common Cases transferred to Hospital By Prehospital System Other 27%
Medical Emergencie s 27%
Trauma 46%
Chart 48
More than 80% of the staff who participated in the survey was knowledgeable inthe scope of work of Emergency Medical Technicians. According to the feedback received from the receiving center staffs, most of the time Emergency Medical Technicians are not providing the initial vital signs taken by them but, when they do provide them, the vital signs are at a satisfactory level of accuracy. More than 90% out of the 80% who knew the scope of EMTs stated that the scope of an EMT should be expanded. 100.00%
Skills need to be improved
80.00% Airay Management 60.00%
Provding Cardio Pulmonary Resuscita on Management of Medical Pa ents
40.00%
Management of Trauma Pa ents Obtaining Vital Signs
20.00% 0.00% Chart 49
According to the feedback received during the survey, more than 80% of the staff stated that Emergency Medical Technicians need improved skills in obtaining vital signs. More than 50% stated that EMTs need improvement in skills such as airway management, management of trauma and medical patients, and in providing cardio pulmonary resuscitation (Chart 49). Each and every staff which participated in the survey stated that pre-hospital care systems contribute positively to the ďŹ nal outcome of the patients whom they are transporting and that EMTs’ skills/scope should be expanded allowing them to perform procedures such as IV cannulations and intubations so they can contribute more to the outcome of the patients. In addition, these participants stated that public awareness of the services has to be initiated and service should be expanded using more ambulances. 46
Data from call center records In all five areas, the public is using 1-1-0 and their 10-digit numbers to contact pre-hospital care providers. All five pre-hospital care systems have responded to a total of 1,906 emergency situations during 2010. They have received 1,815 calls from the public and 91 calls from either police or other emergency services. The dispatch centers log only the calls that relate to emergencies. They enter calls received through both 1-1-0 and the 10-digit number in the same log book. It is, therefore, difficult to obtain the actual number of calls received excluding false alarms and to take a count of the calls received through 1-1-0, the 3-digit prehospital care access number.
Number of Calls 2500
2000
1500
1000
500
0
Last Week
Last Month
Last 3 Months
Last 6 Months
Last year
Received
34
146
450
766
1815
Actual Emergencies
36
155
483
818
1906
Responded
36
155
483
818
1906 Chart 50
The Jaffna Pre-hospitalCare System responded to more than 1500 emergency calls during2010 (Chart 50).
47
Number of Calls recieved 1800 1600 1400 1200 1000 800 600 400 200 0
Badulla
Galle
Jana
Kandy
Kurunagala
Last Week
1
0
30
3
Last Month
3
2
120
15
6
Last 3 Months
7
7
386
40
10
Last 6 Months
0
21
650
80
15
Last year
0
49
1591
150
25
Chart 51
40% of the calls responded to by the Jaffna Pre-hospitalCare System were the result of the post war IDP (Internally Displaced Population) situation. The Jaffna Pre-hospitalCare System supported the health system by extending their services to IDP camps situated in the North by transporting critical patients to the hospital. The Badulla system was launched only three months before thisreview was conducted. Number of actual emergency Calls 1800 1600 1400 1200 1000 800 600 400 200 0
Badulla
Galle
Jana
Kandy
Kurunagala
Last Week
1
2
30
3
Last Month
3
11
120
15
6
Last 3 Months
7
40
386
40
10
Last 6 Months
0
73
650
80
15
Last year
0
140
1591
150
25
Chart 52
48
Number of Call Responses 1800 1600 1400 1200 1000 800 600 400 200 0
Badulla
Galle
Jaffna
Kandy
Kurunagala
Last Week
1
2
30
3
Last Month
3
11
120
15
6
Last 3 Months
7
40
386
40
10
Last 6 Months
73
650
80
15
Last year
140
1591
150
25
Chart 53
All dispatch centers verify each and every call before dispatching an ambulance. Jaffna, Galle, Kandy, and Badulla staff their ambulances with a minimum of two EMTs including the driver whereas the Kurunagala system has five people responding to a call within the ambulance including a police officer, driver, nurse, doctor and an attendant. None of the pre-hospital care systems except for Jaffna has a Mass Casualty Incident Plan. Number of dedicated vehicles for response 20 18 16 14 12 10 8 6 4 2 0
Badulla
Galle
Jaffna
Kandy
Kurunegala
Ambulances
1
2
18
3
2
RIV
1
1
0
2
0 Chart 54
Badulla, Galle and Kandy pre-hospital care systems are equipped with Rapid Intervention Vehicles (RIVs) except for their ambulances which have equipment to extricate patients in a 49
rescue situation. The Jaffna Pre-hospitalCare System is equipped with 18 ambulances owned by RDHS which is the highest number of ambulances owned by an established pre-hospital care system in Sri Lanka. Additionally, Jaffna is the only system in Sri Lanka that includes two boat ambulances to transport patients from islands. According to the officers in charge in these pre-hospital care systems, none of these systems have a sufficient number of ambulances to respond to all the emergency calls they receive. In some cases, the dispatcher declines requests made by the public because all of their vehicles are in use. This situation has caused some resistance from the public to dial 1-1-0 for an emergency.
Public- awareness and comments The public awareness survey was conducted in five cities that have established pre-hospital care systems. Colombo and Anuradhapura were excluded because other assessments were not conducted in those areas. The public awareness survey was conducted in Kalutara and Tangalle because they were the two cities which participated in the Pre-hospital Care Review Program as cities that do not have functioning systems. Survey samples were selected randomly according to the population of each surveyed area using the raosoft sample calculator (http://www.raosoft.com/samplesize.html) which uses the univariate normal distribution method to calculate sample size. Margin of error accepted was given as ten percent, confidence level need was given as 95% percent and response distribution was given as 50%. Public Awareness Survey Overall Responses 74.50%
18.20% 12.00%
11.30%
Dial 1-1-0
1.40%
2.00%
Dial 1-1-8
Dial 1-1-9
Call the Police
Transport to Hospital
Other
Chart 55
50
From overall results in all five cities that have established pre-hospital care systems, we can see that only 11.3% of the people are dialing “1-1-0”, the dedicated number for the prehospital care system in an emergency. More than 70% of the people are willing to transport patients themselves (Chart 55). But from the more than 70% of the people who are transporting patients to the hospital themselves, only 23.2% percent have knowledge of first aid (Chart 56). The remainder is transporting patients in an emergency without giving any kind of initial emergency basic life support care. 80.00% 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% People transpor ng People who know first pa ents by themselves aid
Chart 56
More than 45% of the people think it is correct to transport to a hospital without giving initial first aid. If this result is stratified by locations that have established pre-hospital care systems, Badulla has the highest response of 85.2%and Galle is second with response rate of 65.5% (Chart 57). Correct to transport a pa ent to hospital without giving ini al first aid
85.20%
Badulla
65.50% Galle
38.20%
39.80%
Jaffna
Kandy
60.40% Kurunagala
Chart 57
Most of the people who participated in the survey are using other methods such as any vehicle available at time, a car, or a motor bike to transport patients. About 30% responded that they use a three wheeler to transport patients. Only 11%of the people responded that they use an ambulance and more than 14% responded that they will call 1-1-0, the pre-hospital care service access number (Chart 58).
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Transporta on Methods 50.10% 32.40% 14.10%
11.10%
Call 1-1-0
Ambulance
13.90%
Three Wheeler
Van
Other
Chart 58
More than 80% of the persons responded that they are not willing to keep the patient at the scene of emergency until the ambulance arrives. More than 68%gave as their reason that the patient can die from the injury if they wait for an ambulance.Less than 43% of the people knew that there are pre-hospital care systems in place in Sri Lanka and only 35% of the people who participated in the survey were aware about the pre-hospital care system in their area. Out of those 35%,less than 17% knew the pre-hospital care three-digit access numbers “1-1-0”; others were using ten-digit numbers according to the respective area. People who aware about the Prehospital Care System in their Area 80.00% 60.00% 40.00% 20.00% 0.00%
56.80%
59.80% 43.10%
22.30%
21.70%
Badulla
Galle
Jaffna
Kandy
Kurunegala
Chart 59
In Galle, Jaffna and Kurunagala, more than 40%from each area knew about the pre-hospital care system in their area (Chart 59).Chart 60 shows how many of them knew about the prehospital care system and the three-digit access number 1-1-0. People who know Prehospital Care System in area and "1-1-0"
44.40% 11.60% Badulla
24.90% Galle
Jaffna
7.60%
14.40%
Kandy
Kurunagala
Chart 60
52
In Jaffna, more than 44%of the survey participants knew about the Jaffna pre-hospital care system and the three-digit access number “1-1-0” (Chart 60). In Galle, the percentage wasless than 25%. From the people who know that their area has a pre-hospital care system, less than 16%know that the service is free of charge. Almost 41% of overall respondents expressed that the service is not easily accessible in the area. Accessibility of the Service 41.30%
28.30% 18.70%
16.90% 5.90% Badulla
Galle
Jaffna
Kandy
Kurunagala
Chart 61
Jaffna showed a peak by more than 41% of the responses expressing that it is easy to access the pre-hospital care system in their area (Chart 61). Only in Jaffna did more than 50%of the responses express that there is enough publicity about the pre-hospital care system in the area while overall responses of more than 86% expressed that there is not enough publicity about the service (Chart 62).
Enough Publicity
55.30% 16.90% Badulla
26.40%
24.70% 8.00%
Galle
Jaffna
Kandy
Kurunagala
Chart 62
Tothe survey question are you willing to pay for the service, more than fifty percent responded that they are not willing to pay for emergency calls. 53
Areas that do not have 1-1-0 Analysis of the data collected through the survey conducted at Kaluthara and Tangalle, two cities that do not have pre-hospital care systems, showed the following results. Ninety-ďŹ ve percent of the surveyed persons in areas where pre-hospital care systems are nonexistent responded that they will transport patients to the hospital by themselves in a case of an emergency or an accident. Eighty percent of these responders conďŹ rmed that what they are doing is correct giving as the reason that it is the best thing they know to do to save the life of the injured patient. Only 20%of these responders have knowledge of first aid and will give basic life support care before they transport the patients (Chart 63).
Knowledge of First Aid Know First Aid 20% Don't Know First Aid 80%
Chart 63
According to the responses gathered during the survey, thirty-four percent of the people are using three wheelers to transport patients to the hospital. Thirty-seven percent are using cars, motor bikes or any other method that is available to transport patients excluding vans, ambulances or three wheelers (Chart 64). Pa ent Transporta on Method Ambulance 11% Other Methods 37%
Van 18%
Three Wheeler 34%
Chart 64
54
Eighty-two percent of those surveyed expressed that it is not acceptable to keep a patient until an ambulance arrives because the patient can die from the injury due to delaying treatment. 38% of the people who participated in the survey knew that pre-hospital care systems exist in other areas of Sri Lanka and 99% of the survey population responded that they need a prehospital care system in their area. Thirty-four percent of the respondents stated that pre-hospital care systems should be initiated by hospitals and 21% of respondents stated that systems should be initiated by a combination of the Ministry of Health, Ministry of Local Government and Ministry of Defense because police, fire and ambulances should all three respond to an emergency. Seventy-seven percent of the people responded that they are not willing to pay for the service because it is a service used in an emergency situation (Chart 65). Service should be ini ate by
21%
17%
Fire Brigade Hospital RDHS
12% 34% 16%
Police Combined
Chart 65
Beneficiaries None of the pre-hospital care systems had information about any of the patients or people who have benefited from their service because they are not filling out the patient care report forms. The review team used an interviewer-administered questionnaire with six questions to get feedback from other agencies such as police and public workers who work closely with the pre-hospital care system. Pre-hospital care providers are working closely with the police and other public workers in each area. In Galle, police mobile services contact 1-1-0 when they see an emergency situation. Most of the participants in the review stated that public awareness of the service should be increased and field exercises should be conducted to build the intra-agency relationships.
55
Recommendation and Conclusions · Establish a National EMS registry or Regulatory An EMS registry or Regulatory body should be established to be responsible for all aspects of pre-hospital care including training and services. It must be the authorizing body for pre-hospital care activities and pre-hospital care training. The Registry or Regulatory bodyshould oversee the standards of EMS trainings provided from private and public partners and also shouldfosterdeveloping national standards with international recognition. This support will help the public receive upto-date, standardized training from their training providers.Also it can create guidelines for ambulance operations and quality assurance which will help to standardize the care and to provide a quality service for the public. Additionally the Registry or Regulatorybody should work with the Sri Lankan government to createemergency medical service systems regulations, policies and protocols at thenational level and also support local authorities in creatingregulations, policies and protocols at the provincial, district anddivisional levels. The Registry should be chaired by Trauma Secretariat with the Ministry of Health and the Ministry of Local Government Officials. The Registry should be the sole board working towards the development of pre-hospital care in Sri Lanka and its powers and limitations should defined in a ParliamentaryAct. The Registry or Regulatory body should be allowed to raise funds for providing EMS education to the private sector through government grants and through fund raising projects. It should use the funds to help develop potential pre-hospital care providers, to upgrade ambulances, to spread the pre-hospital care service island-wide and to provide continuing education. · Establish a national communication center for 1-1-0 1-1-0 communication should be centralized by establishing a national communication center. Dispatchers in the national communication center should be trained to triage calls and dispatch the most appropriate and closest pre-hospital care providers to the incident. Call verification and tracking will be done atthe national level removing the burden from the local communication centers. The national communication center should also help to link emergency response efforts with other public workers such as police. Having a national communication center will help in incidents of mass casualty and disaster response activities by callingin necessary additional resources from nearby cities and also by maintaining the day-to- day responses while responding to such an event. 56
It will remove the communication lapses resulting from technical issues because all 11-0 calls will be routed to a single location and will help to use EMS resources more effectively and efficiently.
· Public awareness campaigns through mass media Although individual efforts have been taken on the local level to increase public awareness about the pre-hospital care services, a national effort has not being undertaken. National public awareness campaigns should be launched through government and national mass media. Local pre-hospital care providers should continue their public awareness campaigns in special events or at least once every three months. Budgets should be allocated at the national and local level for these campaigns. Field exercises and exhibitions should be organized to educate the public about prehospital care services and coordinated efforts should be taken with the support of other public services to increase the public awareness efforts. Basic Life Support and Disaster Preparedness trainings should be included in school curriculums. · Continue education programs. Local authorities should take efforts to include daily practice sessions during the working shifts of pre-hospital care providers. A refresher course and exam in EMT education should be made mandatory at least every two years. Monthly training sessions and practice sessions should be organized on local level and necessary resources, equipment and funds should be allocated. · Separate procedure to reimburse and purchase supplies. Currently all pre-hospital care systems are using normal local authority procedures to purchase supplies which take weeks or even months. New protocols and procedures should be established at the local level to purchase immediate medical supplies and stocks of supplies should be available for daily needs. A separate, sufficient budget fund should be allocated at the national and local level for pre-hospital care services. · Initiate a NON-Mandatory fee for non-emergencies.
57
A non-mandatory, affordable fee should be charged for nonemergencies and hospital transfers. The collected funds can bereturned back into the development of the local pre-hospital care resources. · Private public partnership towards a national Pre-hospital care system A private/public partnership to provide services in the areas where government is deficientin resources should be initiated. The Government can subcontractto the private sector to provide pre-hospital care services in rural areas. After reviewing the different systems and efforts taken to develop the pre-hospital care system in Sri Lanka, it is evident that a national system should be created as a combination of fire brigades, RDHS services and Central Government hospitals. The private sector can be included in the system as necessary to ensure the effective long term development of a sustainable emergency response system.
58