A New Sphere for EMS

     Since its inception in the late 1960s, fire-based EMS has continually improved upon the original concept of providing rapid response to medical emergencies with trained firefighter/paramedics. Among the first in the United States to implement the concept, the Seattle/King County Medic One system often garners honors for the long-term survival rates of its sudden cardiac arrest patients. Many other excellent models exist, and annual incremental improvements have come to be expected as technology and medical studies further refine the state of the art. Everything from closest-unit dispatching to automated external defibrillators placed in public venues has been employed to help reduce the time needed to answer calls and give lifesaving care to those in need. But what if the very best response time to a medical emergency was actually 0:00?

     Through the SPHERE program in Seattle/King County, there is a new goal in place: to actually prevent future 9-1-1 calls by identifying potentially life-threatening conditions whenever a patient is seen by responders.

     Consider these two scenarios:

• EMTs evaluate a 57-year-old with a mild allergic reaction. Prior to EMS arrival the patient self-administered diphenhydramine (Benadryl) and has improved upon arrival of fire department EMTs. He is stable on exam, with a mild rash on his arms and trunk. His blood pressure is 170/105 and blood glucose (checked because the patient says he has bouts of low blood sugar) is 182 mg. He says he will follow up with his doctor. The EMTs casually mention to the patient that his blood pressure and blood sugar are both high. But because of his stable condition, the EMTs decide that evaluation in a hospital is not needed. The medical incident report is completed and duly filed.
• Same situation, but this time the EMTs not only mention that the blood pressure and sugar are high, but also give the patient a personalized written "High Blood Pressure Alert" and "High Blood Sugar Alert" that strongly advise him to have follow-up for possible hypertension and diabetes. They indicate on the incident report that the alerts were given, and one month later the patient receives a call from the EMS office asking if he has followed up with a physician.

     Which scenario do you think best serves the patient?

THE SPHERE PROGRAM
     Every day, EMTs respond to countless medical emergencies. While providers' top priority is to deal with the immediate problem, stabilize the patient and arrange further appropriate care, they also have opportunities to identify and help control major public health problems. In the second scenario above, the patient's abnormal blood pressure and blood sugar are discussed, and he is given written, personalized and specific sets of instructions for follow-up. Such practice is now routine in the Seattle/King County metropolitan area.

     The program is called SPHERE, which stands for Supporting Public Health with Emergency Responders. The sphere represents the concept of obtaining clinical information and feeding it back to the patient in a useful and consistent fashion—a circle of information from the patient to the EMT and back. SPHERE is designed to help identify and control two major public health problems: hypertension and diabetes. Though the program is an expansion of the traditional role EMS personnel play in their communities, it affords the opportunity to have a large impact with little extra effort. EMS personnel can respond to medical emergencies and simultaneously help fight chronic disease (and possibly prevent future emergency responses).

     High blood pressure (HBP) and diabetes are two major public health problems. High blood pressure affects 65 million Americans. It is estimated that one third of patients with HBP are unaware they have the condition, and another third inadequately control it. Around 20 million Americans have diabetes (85% have type II diabetes), and another 6–7 million have undiagnosed type II diabetes. Both conditions are major contributors to heart disease, stroke and kidney failure.

     Since EMTs almost always determine blood pressure as part of routine vital signs, and frequently check blood glucose, they have a unique opportunity to identify new and uncontrolled cases of HBP and diabetes. In this sense the EMS system and its hundreds of thousands of personnel can serve as a virtual cadre of public health advocates. They enter the homes and businesses of a considerable portion of the population every year. In King County, the EMS system responds to approximately 7% of the population annually, many of whom are underserved or without a source of regular medical care.

HOW SPHERE WORKS
     The inclusion criteria for SPHERE are simple (see Table 1). For blood pressure the criteria are a systolic of 160 or higher or a diastolic of 100 or higher. For diabetes the criteria are a blood glucose measurement of 175 or greater in a nondiabetic patient or 300 or greater in a diabetic. If these inclusion values are found, the patient is given the appropriate alert card and urged to follow up. The patient is also offered the opportunity to have follow-up checks at the fire station. EMTs are encouraged to use judgment when giving alerts; if the scene or situation is too unstable or simply inappropriate, alerts should not be provided. Examples of such situations are critical patients, major trauma, crime scenes not yet controlled by police, and mass-casualty incidents.

PILOT PROJECT
     In order to decide whether EMTs should take on this new role, we conducted a pilot project between January and August 2006. EMTs in two King County fire departments participated. Eligible patients received high blood pressure and/or high blood sugar alerts during their medical incidents (see Figure 1). The cards also listed a contact phone number for the fire department and numbers for the American Heart Association and American Diabetes Association. On the medical incident report form, EMS personnel recorded whether they gave an alert to each patient.

     During the pilot project more than 250 alerts were distributed, the majority (86%) given for high blood pressure. These patients had an average systolic blood pressure of 175 and an average diastolic of 94. Thirty-five patients (15%) received high blood sugar alerts; they had an average glucose level of 330.

     Patients who received alerts were called about four weeks after their medical incidents. While the number of high blood sugar patients reached was not large enough to draw any meaningful conclusions, the analysis of high blood pressure patients, drawn from 69 telephone surveys, was extremely encouraging.

     A majority of the patients interviewed remembered receiving alerts from EMS personnel (74%), and most reported positive reactions to receiving them (85%). Over half of the patients (59%) reported being motivated by their alerts to seek follow-up medical care after their medical incidents. In addition, almost two thirds (62%) of alert patients noted that their alerts influenced them to get their blood pressure checked again.

     To complement the patient perspective on SPHERE, EMS personnel who participated in the alert interventions were also surveyed. Of the surveys returned within two weeks, an overwhelming majority were supportive of the SPHERE project, noting that it was not difficult to distribute alerts at scenes (77%) and that distributing alerts did not take up an inordinate amount of their time on scene (88%).

     Open-ended questions on the EMS survey yielded in-depth information from the provider perspective. A few respondents noted it was sometimes difficult to remember to give patients alerts, depending on the nature of the call.

NEXT STEPS
     It is clear from the pilot study that EMS responders have the ability to help in the battle against chronic diseases in their communities, although further study is necessary to determine what works best in different locations. It may be that an alert followed by a personal letter from the EMS agency is more effective than an alert alone. Such a letter could include information about community resources for follow-up and treatment of high blood pressure and high blood sugar, especially for those who are underinsured.

     The importance of properly training EMTs in this new role of public health advocates cannot be overemphasized. EMTs need to be equipped with background information about these public health problems and given the tools to properly respond to questions patients may ask when they are given alerts. EMTs need to buy into the importance of this program and view it as part of their mission for the program to be successful.

     Although the pilot study was small, the results show the immense promise of SPHERE. Consequently, the SPHERE concept became part of the 2007 EMT protocols in King County, and all fire departments within the county are participating in the program.

THE POTENTIAL
     EMTs visit a significant portion of the population in any given year. Though patients call for specific medical problems, there is an opportunity to, with little extra effort, help identify and control major public health problems. Blood pressure determination is a routine vital sign and part of virtually every patient's workup; thus high blood pressure values are readily and easily identified. Glucometry and blood sugar determination is not authorized throughout the EMT world, and in those agencies that are trained in glucometry, the indications for blood sugar determination may be limited (such as for patients with altered mental status or decreased level of consciousness). Despite these restraints, it seems reasonable to contemplate blood glucose as a routine procedure. If glucose were to become a fifth vital sign, it would provide opportunities to help identify Americans who have undiagnosed type II diabetes. The public health benefit to the communities served by participating EMS agencies would be invaluable, and clearly lives could be saved if strokes or other maladies could be averted through notification, proper medical care and appropriate medication. By the same token, the fire/EMS community would also benefit due to a potential reduction in emergency call volume, reduced exposure to emergency traffic hazards, and the consumption of fewer resources.

     For more on the SPHERE program, e-mail gingy@u.washington.edu.

     We thank the 3,500 EMTs in King County for their excellent patient care and constant commitment to improvement. We are also grateful to the fire departments and fire chiefs in King County for their support and encouragement of SPHERE. These are: Arlington Fire Department, Chief Jim Rankin; Bellevue Fire Department, Chief Mario Treviño; Black Diamond Fire Department (#17), Chief Greg Smith; Bothell Fire & EMS, Chief Warren Burns; Duvall Fire Department (#45), Chief John Lambert; Eastside Fire & Rescue, Chief Lee Soptich; Enumclaw Fire Department, Chief Jim Zoll; Kent Fire & Life Safety, Chief Jim Schneider; King County Fire District #2, Chief Mike Marrs; King County Fire District #20, Chief Mark Fitzgerald; King County Fire District #27, Chief Chris Connor; King County Fire District #40, Chief Paul Witt; King County Fire District #44, Chief Greg Smith; King County Fire District #47, Chief Mark Tessen; King County Fire District #50, Chief James Knisley; King County Fire District #51, Chief Matt Cowan; Kirkland Fire Department, Chief Jeff Blake; Maple Valley Fire & Life Safety, Chief Tim Lemon; Mercer Island Fire Department, Chief Walt Mauldin; North Highline Fire District, Chief Russ Pritchard; Northshore Fire Department, Chief Bob Peterson; Port of Seattle Fire Department, Chief Mike Mandella; Redmond Fire Department, Chief Tim Fuller; Renton Fire Department, Chief David Daniels; SeaTac Fire Department, Chief Bob Meyer; Seattle Fire Department, Chief Gregory Dean; Shoreline Fire Department, Chief Marcus Kragness; Snoqualmie Fire & Rescue, Deputy Chief Bob Rowe; South King Fire & Rescue, Chief Al Church; Tukwila Fire Department, Chief Nick Olivas; Valley Regional Fire Authority, Chief Mike Gerber; Vashon-Maury Fire & Rescue, Chief Keith Yamane; Woodinville Fire & Life Safety, Chief Dennis Johnson. List current in 2007.

Mario H. Treviño, MPA, CFOD, is chief of the Bellevue (WA) Fire Department. He has 35 years of experience in the fire service, and has served as chief in San Francisco and Las Vegas.

Lindsay White, MPH, is a research assistant in the Medical QI section of King County Emergency Medical Services. She has been working in EMS since 2006. She is particularly interested in out-of-hospital cardiac arrest and the contribution of EMTs to the identification and management of chronic conditions.

Hendrika Meischke, PhD, is a professor of health services at the University of Washington and very interested in the role of EMS in addressing public health needs.

Mickey S. Eisenberg, MD, PhD, is medical director of King County EMS and professor of medicine at the University of Washington. He has been actively involved in studying and creating innovative programs to improve EMS for over 33 years.