‘Never Stop Improving’: New Hanover Wins 2016 Career Service of the Year

Ed's Note: For additional National EMS Awards of Excellence recipients, click here.

If you want something done, the saying goes, give it to a busy person. Their time may be limited, but what they get done with it so far exceeds everyone else, they’re still your best bet to do it fast and well.

That’s kind of how it is for our 2016 Dick Ferneau Career Service of the Year, New Hanover Regional Medical Center’s Emergency Transport Services, based in Wilmington, NC. They take on a lot of stuff beyond just 9-1-1 response—and they’re really good at it. 

“One of the philosophies we’ve tried to impart here is kind of a foxhole mentality,” says service administrator Terry McDowell, who did 26 years in the Army before joining the service. “When you initially go into a position, you dig a really hasty fighting position—just a hole to get down in. But as time goes by, you add cover, you dig it deeper, you put sides on it. You never stop improving where you’re at. And that’s how I think it is with the leadership team we have here now: We are always constantly looking for the next best thing.”

New Hanover representatives will be recognized at EMS World Expo and the NAEMT General Membership Meeting and Awards Presentation Oct. 4 in New Orleans. For winning they’ll get $1,000 cash, three Expo core program registrations and $1,200 toward travel and lodging. 

There have been a lot of next best things for the service in recent years. NHRMC ETS delivers 9-1-1 response, critical care transport and nonemergent transport by way of 45 ground vehicles and two helicopters that cover more than 1.1 million miles a year. It serves a broad array of patients with wildly diverse needs. 

“The way we lay it out for our folks is, we’re here to take care of our patients,” says McDowell. “If there’s ever a conflict between that and anything else, we’re going to default to taking care of the patient. And our job as leaders is to set the environment through education, training, equipment and everything else so that when our providers are with a patient, all they have to focus on is taking care of that patient.” 

Just some of what that supporting groundwork covers is: 

• Active shooters and the mentally disturbed—As shooting events accumulate, New Hanover enhanced its SWAT medic team with training for all field operations staff. Front-line medics drilled with partners like the FBI, and EMS leaders helped drive creation of the county’s first high-threat response plan for emergency services. 

“Everybody wants to be on the same sheet of music, but I don’t know that we were moving fast enough for things that could happen,” says McDowell. “One of our battalion chiefs and also the EMS chief jumped on it and decided, ‘We have to go ahead and get this done.’ They helped us bring a realistic level to our training, and now everybody knows what the expectations are for fire and police and EMS when we get on scene.”

On a related mental health note, the service partnered with local providers to create EMS-focused crisis intervention training. This equips supervisors and community paramedics to deescalate potentially volatile situations and in some cases has let patients be redirected to mental health services. 

• Sepsis—All transport team members—BLS, paramedics and critical care—have been trained on recognition and early notification for severe sepsis. The critical care side has a comprehensive protocol driven by point-of-care serum lactate testing and three different antibiotics. A sepsis alert protocol speeds ED treatment. In four years, these efforts have driven local sepsis mortality from 47% to 15%. 

New Hanover’s critical care division recently became the first EMS system to earn mobile clinical lab accreditation from the College of American Pathologists. It uses epoc lab technology that identifies a baseline serum lactate and permits measurement of arterial blood gas, serum electrolytes, hematorcit and hemoglobin, and whole blood glucose. More than 36% of lab tests directly impact transport patient care. 

“Some of our outlying hospitals don’t have their own full lab capabilities,” notes McDowell. “We can get on scene, draw the labs, get immediate results and start on a sepsis protocol that will be carried through, all while that outlying facility may not even have gotten lab results back yet.”

• Mobile integrated healthcare/community paramedicine—New Hanover’s grant-funded program, focused on readmission reduction and aversion of unnecessary ED visits, had statewide repercussions when leaders briefed lawmakers in Raleigh and got funding, along with two other CP programs, to show the concept works. 

The effort has yielded collaborations throughout the community and enhanced relationships with primary care providers, civic organizations and mental health professionals. A particular group to benefit has been veterans: New Hanover County has a large population, and leaders worked with the CMO of the local VA clinic to improve their services. 

“I’d put our community paramedic program up against anybody’s,” says McDowell. “With the data we’re reporting to the state—for our frequent utilizers, being able to reduce their percentage of ED visits and admissions—there is a huge savings there if we can do that well.” 

The project includes a nurse help line and even a pharmacist who can accompany CPs and deal with medication issues (New Hanover also has an emergency medicine pharmacist  on its clinical outcomes and education committees). All told, the initiatives are thought to be saving around $2.7 million systemwide. 

Other Best Practices

There’s lots more both common to top systems and unique to New Hanover: 

• Pit-crew cardiac arrest care, integrated with local fire departments, that’s helped boost survival to discharge from 14% to 32%; 

• A performance improvement team developed an anonymous safety reporting system that allows staff to raise any operational, clinical or safety issue. Everyone can then view the issue and its resolution; 

• Electronic orientation and testing: New employees get a tablet linked to a personalized cloud-based e-library that contains protocols, checklists, competencies and evaluations. This lets educators monitor new members’ progress remotely and in real time. Deficits can be quickly identified and remedied. It saves nearly $400 per new team member; 

• A research focus that includes a prospective clinical trial on therapeutic hypothermia and eight other publications over the last two years. A forthcoming trial will look at prehospital identification of internal hemorrhage through ultrasound FAST exams; 

• Telemetry-only interfacility transports of certain patients by EMT-Is (and a study showing they can do it as safely as paramedics); 

• Evidence-based prospective critical care utilization criteria to screen every referral, a practice shared with critical care programs in other states; 

• A naloxone partnership with law enforcement; 

• An ED patient arrival liaison medic to speed hospital turnarounds; 

• A focus on safety in patient lifting/movement, with bariatric ambulances and powered lifts, as well as recent evaluations by physical therapists; 

• A bulked-up program of mental health support for employees, plus numerous efforts to enhance their safety and physical health; 

• A project to deliver hands-only CPR training to 200,000 people (plus all nonclinical hospital staff);  • Both the 9-1-1 system and regional air/ground critical care transport teams received 2014 and 2015 Mission: Lifeline Gold EMS recognition. Regional medics can active a STEMI alert without ECG transmission or physician interpretation; 

• Collaboration with hospice on a Sentimental Journey program for dying patients.

Future plans involve seeking CAAS and CAMTS accreditations and exploring the addition of blood and ultrasound to helicopters.