EMS Excellence in the Rural Reaches

Two presenters discussed forward-thinking initiatives serving patients in remote and rural areas during “EMS Rural Challenges” Friday afternoon Sept. 18, 2020 at EMS World Expo.

First up, James Rhom, BS, NRP, EMS supervisor for St. Luke’s Health System in Magic Valley, Idaho, discussed a novel change to stroke protocols in his area in southern Idaho.

There are two comprehensive stroke centers in Boise, Rhom explained. Six primary stroke centers and five acute stroke-ready centers round out the stroke system of care in Idaho.

Air St. Luke’s transported 1,630 calls in 2018 out of Twin Falls—roughly 8% of which were for stroke, said Rhom. Magic Valley has a large catchment area, and it’s 139 miles from the Twin Falls primary stroke center to the thrombectomy-capable center in Boise.

With this large distance to comprehensive stroke care, Rhom’s team set out on a mission to reduce door-to-needle times in order to get patients with LVO strokes to thrombectomy services as swiftly as possible. “We knew we could do better than this,” said Rhom.

They began by identifying barriers, which included long transport distances, limited ALS services, inclement weather that hampers air transport, on-scene times, and the process of calling in to medical control. The next step was to decide on a standard prehospital screening tool. Magic Valley Paramedics settled on the stroke VAN (vision, aphasia, neglect) scale.

In 2017 a pilot program included education on stroke VAN assessments, building a “relocation standby” process for air dispatch and air medical crews so crews could mobilize to the local ED immediately upon a stroke VAN alert, and the integration of blood draws into field treatments to eliminate the delay of blood testing at the hospital. A VAN tool was loaded on the Twin Valley Paramedics crew phone app. A regional roll-out brought in surrounding agencies on education and training.

When Magic Valley field crews identify a VAN, they call = medical control for a CVA code and provide the ED physician a report. The unit clerk alerts the air transport crew, which immediately travels to the destination ED to rendezvous. The registration clerk preregisters the patient prior to arrival to reduce administrative time.

“This is a significant improvement in our stroke process,” said Rhom. Over a six-month trial period, average door-in-door-out times were reduced from 110 minutes to 73; and ED-to-groin-puncture times from 188 to 157. In 2020, all door-in-door-out times have been less than an hour.

“All of this is built on a strong ground-air crew integration,” stressed Rhom, adding that ongoing areas of improvement include assessing for inclement weather, working with receiving facilities, and further community education initiatives.

Rhom’s group is currently working with their IRB to validate the results and publish the research. Another program on the horizon is to apply the same principles to the diagnosis and transport of posterior strokes.

“This has been the No. 1 focus throughout this whole process, to save those brains,” Rhom said. “To bring the best patient-centered care to the patient, even if they live in the middle of nowhere. It’s been huge for the stroke care in our community.”

Part 2 of the “EMS Rural Challenges” session covered community paramedicine in rural and remote communities. Michelle Brittain, project manager for strategic and process initiatives for BC Emergency Health Services in British Columbia, Canada, discussed the BCEHS Community Paramedicine program.

BCEHS is a single paramedic service that covers 5.1 million British Columbians over 580,000 square miles, Brittain explained. In 2014, the service launched a CP program to help stabilize 9-1-1 utilization in remote areas where access was challenging.

A total of 129 community paramedic positions were created, she said. The majority of these positions are on the primary care paramedic level, equivalent to the U.S. AEMT. BCEHS partnered with area health systems and organizations to roll out the program.

Community paramedicine at BCEHS is founded on three pillars of service: community engagement and health promotion (CPs manage health and provide education such as CPR and drug awareness); community clinics (blood pressure clinics and patient groups); and patient home visits (directed by a primary care provider).

Almost 3,500 patients have been seen so far. Of these, roughly 65% are in communities of less than 3,500 members, and 60% are over 75. Major conditions under management by the team include heart failure, diabetes, COPD and hypertension, and risk of falls. Because of COVID, all visits are now conducted over teleconference, said Brittain, along with remote patient monitoring. Clinical practice guidelines were developed for patient populations such as those with heart failure, COPD, diabetes and flulike illnesses.

A health outcome report due soon will quantify the patient outcomes of the program. The EQ-5D 5L tool was used to quantify effects. Early results are favorable: 52% of patients report that they “maintained or improved their health status,” in addition to an almost 40% reduction in 9-1-1 calls, 46% reduction in 9-1-1 calls for selected chief complaints, and a 47% reduction in the number of low-acuity 9-1-1 calls.

“These can be considered good early results,” Brittain said.

Jonathan Bassett, MA, NREMT, is editorial director at EMS World. Reach him at jon@emsworld.com.