Specialty Team Activation: 10 Things You Need to Know to Save Lives

A regional, multidisciplinary team approach to time-critical injuries and illnesses is proven to save lives. EMS plays an important role in transporting patients to the most appropriate facility and alerting in-hospital teams before arrival. Here are 10 things you need to know about systems of care and team activation:

1. Not all hospitals are created equal

Designated hospitals - specialty centers- must consistently demonstrate that they identify seriously ill or injured patients and deliver important treatments within specific time periods, and higher survival rates have been found at centers that see high volumes of critically ill patients. [1] Many of these treatments are trained by highly-trained specialists.

Hospital designation began with regional trauma systems, which were developed to concentrate resources at specialty centers. The most seriously injured trauma patients are transported to Level I and II trauma centers, which have streamlined processes from ED arrival to definitive care.

Designated STEMI and stroke centers have followed with similar regional specialty center models. Now there is a movement to direct other critically ill medical patients to specialty centers, including those with severe sepsis and return of spontaneous circulation after cardiac arrest.

2. Pre-arrival alerts give hospitals time to mobilize resources.

Multidisciplinary team members work in areas of the hospital, and are summoned to the ED, surgical suite, or cath lab through hospital-wide alerts for patients who need their services. Advanced notification from EMS, along with a thorough report assessment findings, gives team members time to gather, prepare equipment, and discuss treatment options before the patient arrives. Pre-arrival alerts have been shown to reduce time to definitive care and improve patient outcomes.

3. Trauma alerts for rapid evaluation, imaging, and surgery

Trauma team activations are indicated for patients with injury patterns, assessment findings, or vital signs that suggest emergency surgical intervention may be required. Trauma teams may include a surgeon, a respiratory therapist, specialty trained nurses, and radiology techs. In some cases a CT scanner or operating room may be prepared before patient arrival to the hospital. The goal is to rapidly evaluate the patient and address immediate life threats in the ED. Based on an assessment or findings on a CT scan, the patient may be taken to surgery.

For critically injured trauma patients, the likelihood of death increases with any delay to surgery. Early notification and alerting the hospital can help the hospital accomplish treatment goals faster.

4. STEMI alerts clear a path to cath

Definitive care for STEMI patients is a catheter-fed balloon to open a blocked coronary artery in a catheterization lab. The goal, minimizing the “door to balloon” time, saves heart muscle and improves the chance of survival. This procedure is only available at designated cardiac centers, and requires coordination between ED physicians and cardiologists, and staff members in ED and catheterization labs.

Calling a “STEMI alert” in advance of hospital arrival has been shown to reduce the time to reperfusion.  In ideal systems, EMS may transport STEMI patients directly to the cath lab and bypass the ED.[2]

5. ECMO-CPR at cardiac arrest centers

For select cardiac arrest patients who do not respond to standard ACLS interventions, who were previously healthy and likely have a correctable cause of their arrest, extracorporeal membrane oxygenation (ECMO) in the hospital is a treatment option. Here blood is circulated through a machine for oxygenation and  bypasses the heart and lungs. Once ECMO-CPR has been initiated, a critical care team must also work to correct the cause of the arrest (such as cardiac catheterization for an MI).[3]

ECMO is currently only available at highly specialized centers, involves ED staff, surgeons, specially trained nurses, and perfusionists, and requires a considerable amount of equipment to be prepared quickly. Early contact with EMS is important to determine which patients are candidates for this procedure and to assemble team members before arrival.

6. Hypothermia and comprehensive critical care post-arrest patients

Patients resuscitated from cardiac arrest are at high risk of brain damage and multi-organ dysfunction. Higher survival rates have been found at centers that care for a large volume of post-arrest patients.[4] Early induction of mild hypothermia, blood pressure support, and glucose control have been shown to improve survival and neurologic function after arrest. Post-arrest care may involve specialists in several areas responding to the ED, and for cooling devices to be prepared before receiving the patient.

7. Stoke alerts for imaging, decisions, and drugs

Brain tissue dies each minute until blood flow is restored to the brain. Stroke alert notification alerts neurology physicians and nurses, pharmacists, and radiology physicians and techs to prepare the CT scanner before arrival.

Treatment options for stroke patients depends on a CT scan to determine whether it is ischemic or hemorrhagic. A decision must then be made quickly about whether thrombolytic medications are indicated, which must be given within 4.5 hours of symptoms onset. If bleeding is found, the patient may require an endovascular procedure or neurosurgery. Recent positive studies show endovascular care is useful for large vessel occlusion. Patients transported to designated stroke centers have been shown to receive these interventions faster and have better outcomes.[4]

8. Lactate, fluids, and antibiotics for sepsis

Sepsis often present with vague signs and symptoms of an infection, which has a high-mortality rate if the systemic inflammatory process progresses to cause organ dysfunction and shock. Goal-directed care for sepsis involves a blood lactate reading for detection, antibiotics within one hour of ED arrival, and IV fluids before the patient becomes hypotensive from septic shock. Some hospitals have “sepsis alert” protocols that involve ICU staff and pharmacists to meet these goals faster.

EMS plays a role in alerting the hospital to patients who may have sepsis. Signs include a fever, elevated pulse and respiratory rate, and a suspected infection source. Some EMS services have lactate meters to confirm a differential diagnosis of sepsis, and alert sepsis teams before hospital arrival.

9. Be judicious with team activations

Specialty team activation diverts resources away from other sick patients in the hospital. Surgeries, cardiac catheterizations, or CT scans may be delayed based on a prehospital alert. Consultation with medical control may help make the decision to activate a specialty team. Use a formal quality assurance process to track activations. Use protocol changes and education to fine tune the frequency and appropriateness of specialty team activation.

10. Not all patients require a specialty center

While lives are saved from EMS transport to designated specialty centers, each facility has finite resources. Care for the sickest patients at specialty centers can be affected when they get overwhelmed with patients who can be adequately treated elsewhere. There are different levels of trauma centers and times services are offered at other facilities. Regionalized systems should be designed to distribute less acute patients to other hospitals.

Bonus. Keep an open mind about specialty care

Part of the mission of any specialty care center is to research existing treatments and trial innovative procedures and medications. As evidence is gathered and interpreted some of the treatments we strive to deliver today, like induced hypothermia or thrombolytics, may not be part of care guidelines in the future. Take advantage of opportunities to learn from the specialty care centers in your region and stay-up-to-date on assessment and treatments for trauma, sepsis, and cardiac arrest.

References:

1. Institute of Medicine Committee on the Future of Emergency Care in the United States Health System. Hospital Based Emergency Care: At the Breaking Point. Washington, DC: National Academies Press, 2007

2. Myers JB, Slovis CM, Eckstein M, et al. Evidence based performance measures for emergency medical services systems: a model for expanded EMS benchmarking. Prehosp Emerg Care, 2008; 12: 141–51

3. Cave, DM., Gazmuri, R.J., Otto, C.W, et al. Part 7: CPR Techniques and Devices 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation, 2010; 122: S720-28

4. Peberdy MA, Callaway CW, Neumar RW, et al. Part 9: Post-Cardiac Arrest Care. 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation, 2010; 122: S768–86

5. Jauch EC, Cucchiara B, Adeoye O, et al. Part 11: Adult Stroke. 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation, 2010; 122: S818–28