MCW's department of emergency medicine has invested significantly in improving the care and triaging of patients in the field, which has had a direct impact on medical outcomes, patient costs and systemic efficiencies.
The department's section of emergency medical services and disaster medicine is central to this work in large event settings and field triage. As part of its mission, the section is dedicated to helping the community and nation prepare for providing medical care during large-scale incidents.
Jason Liu, MD, MPH '09, associate professor of emergency medicine, leads mass casualty training efforts for MCW – including regular Advanced Disaster Life Support™ (ADLS®) training, held in conjunction with the Wisconsin Healthcare Emergency Preparedness Program and the National Disaster Life Support Foundation.
The two-day courses designed for healthcare professionals in all capacities allow participants to learn the competencies required to manage a mass-casualty situation.
"As recent events have shown, there is an increasing number of natural and intentional catastrophic incidents occurring in our country that require a community-wide response," Dr. Liu shares. "These events have demonstrated the obvious need for a well-trained team to stabilize a situation and provide life-saving treatment."
"In a large-scale incident, responders must not only know how to care for patients, but be able to efficiently coordinate among and communicate with local, state and federal emergency response agencies, protect themselves and others from further harm, and address the psychological impact and related social chaos that may arise."
While Dr. Liu focuses on coordinating various medical practitioners to prepare for such situations, Dr. Ben Weston manages some of these same people at regularly scheduled occasions as director of mass gathering and event medicine for the department.
Dr. Weston is in charge of the medical care provided at sporting events such as the USA Triathlon (when it comes to Milwaukee) as well as a number of annual marathons and other competitive races. In addition, MCW EMS physicians oversee the paramedic group responsible for care at all events at Milwaukee's Bradley Center.
"One of the most rewarding aspects of these events is their multidisciplinary nature and the opportunity to reach out to the medical community," notes Dr. Weston. "We have a large base of medical professionals and medical learners who work with us at these events, and we bring in a lot of people from the emergency department, including physicians, nurses, physician assistants, nurse practitioners, pharmacists and residents. Additionally, we bring in a lot of students – our medical students as well as nursing students, athletic trainer students and physician assistant students from many area colleges. It's a great opportunity to meet and work with others."
As director, Dr. Weston recruits and organizes all personnel and determines the logistics of medical aid, including necessary supplies based on the number of attendees and what types of injuries are anticipated for each event. "The advantage of having our ED team there is that we can evaluate patients on the scene as appropriate and often avoid ambulance transfers and an emergency department visit," Dr. Weston says.
Meanwhile, E. Brooke Lerner, PhD, professor of emergency medicine and director of the department's research efforts, is leading several research projects aimed at improving outcomes for people who experience cardiac arrest outside a hospital setting.
One project aims to improve the cardiac arrest survival rate in Milwaukee County by making dispatcher-assisted CPR instructions available to all 911 callers in the county. Cardiac arrest causes more than 6,500 deaths annually in Wisconsin, and the likelihood of surviving is only 10 percent if the patient is not administered bystander CPR. The survival rate increases if bystander CPR is involved, but in Milwaukee County, bystander CPR historically has been attempted on only 19 percent of those in cardiac arrest.
To increase the number of patients who are administered bystander CPR and, consequently, the survival rate, Dr. Lerner collaborated with the Milwaukee County Office of Emergency Management (OEM) and 12 Milwaukee County municipalities to implement a system that made dispatcher-assisted CPR instructions available to everyone.
Prior to the start of this program, only three municipalities were providing these instructions, but now each municipality has the ability to route cardiac arrest calls to the Milwaukee County Emergency Medical Services (EMS) Communication Center to provide detailed CPR instructions to the callers.
The project, which was launched with grant funds from MCW's Advancing a Healthier Wisconsin (AHW) Endowment, has shown immediate benefit. Between April 2016 and December 2016, 169 callers were transferred to the central communication center for CPR instructions, and of those, 55 callers performed compressions before EMS arrived. This represents a doubling of the bystander CPR rate from before the program was launched. And of the 55 victims who received compressions, 11 survived past discharge, which almost doubles the county-wide cardiac arrest survival rate of 10 percent.
"I like conducting research that has the ability to immediately impact patient care and then move the results through the system to implementation," Dr. Lerner says.
Another project Dr. Lerner launched to improve cardiac arrest survival is focused around creating the infrastructure for school systems to provide high-quality CPR training to every student.
A bill was passed in Wisconsin that went into effect this September requires all students graduating from a Wisconsin high school to be trained in CPR, but the bill does not include any funding, teaching tools or guidance on how best to implement a CPR program. Using grant funds from AHW, Dr. Lerner, in partnership with Cooperative Educational Service Agency 7 and the American Heart Association, is conducting a two-year project to equip and train teachers from at least 350 Wisconsin schools to teach students to preform high-quality, hands-only CPR. The infrastructure developed by this program will ensure best practices are distributed statewide.
To date, as a result of this project, 167 schools have been equipped with tools and best practices, 200 teachers have been trained, and they, in turn, have trained more than 3,000 students.
Dr. Lerner also just completed collecting data on a project aimed at improving prehospital trauma triage decision-making for pediatric patients, which can affect patient outcomes.
Pediatric patients in this region who have a severe injury are typically directed to Children's, which is staffed by MCW physicians and is the only Level 1 pediatric trauma center in Southeastern Wisconsin.
EMS providers are tasked with having to determine the severity of a patient's injuries and whether those injuries require the additional treatment resources only available at a pediatric trauma center. The guidelines used to make these decisions, however, are based on limited best evidence and focused on adults. Incorrect decisions can lead to a severely injured child not having rapid access to the resources that they need (which has the potential to increase morbidity and mortality) or children with minor injuries traveling long distances and bypassing their local community hospitals (higher healthcare costs and patient and family inconvenience).
In this study, Dr. Lerner and her team collected triage and outcome data from 5,500 injured children to develop and validate criteria that can better assist EMS providers in identifying severely injured children in the prehospital setting. Results of this study, when finalized, will allow care providers to better identify who needs to be transported to the trauma center, as well as when a trauma team should meet the patient when they arrive at the ED. The information will help ensure that severely injured children receive the most appropriate care (decreasing morbidity and mortality) while at the same time conserving resources and minimizing costs.
"This project is innovative and will help us identify simple evidence-based criteria that EMS providers can use every day for the treatment of injured children," Dr. Lerner remarks. "Identifying criteria that improve the accuracy of field triage will improve the quality of care for injured children as well as improve the overall efficiency, cost-effectiveness and safety of community-wide EMS and trauma systems."
Dr. Lerner's efforts are just a few examples of how patient care is strengthened through a 40-year partnership among MCW, Milwaukee County and local fire departments.
"There have been phenomenal accomplishments as a result of this decades-long collaboration, remarkable improvements in emergency care that directly translate into increased survival and quality of life – not only for citizens of Milwaukee but for the nation and the world," says Tom Aufderheide, MD, FEL '86, MS '13, MCW professor of emergency medicine and the department's associate chair of research affairs.
– Anthony Braza • Karri Stock
Impacting Worldwide Patient Care
Tom P. Aufderheide, MD, GME '86, MS '13, professor of emergency medicine, associate chair of research affairs and director of the National Institutes of Health-funded Resuscitation Research Center (RRC), has had a significant impact on the department's field triage and resuscitation efforts as well as patient care around the world. Dr. Aufderheide is an internationally recognized researcher in the field of emergency cardiac care and resuscitation, and his research efforts have led to, among other things, a 38 percent worldwide reduction in mortality from acute heart attacks and a discovery in the CPR process that resulted in a 52 percent improvement in functionally favorable survival from heart attack.
Dr. Aufderheide's research has influenced guidelines for international CPR education, training and clinical practice, and he has played a key role in creating coursework for the American Heart Association, CPR and AED training. But, as with all lifelong learners, he is far from done.
"I am currently participating in the discovery of several simple techniques that profoundly reduce ischemia reperfusion injury in an animal model of prolonged cardiac arrest, thereby significantly improving neurologically intact survival," Dr. Aufderheide shares. "I hope to translate the application of these potentially life-saving techniques to humans." Reperfusion injury is the tissue damage caused when blood supply returns to tissue after a period of time.
The RRC is supported by federal funding to collaborate with researchers, clinicians and EMS at the local and national level on observational and interventional clinical trials in the areas of emergency resuscitation and neurological emergency research. The RRC has dedicated infrastructure to coordinate clinical trial activities 24/7.
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