From backboards to VOMIT, first responders work to improve patient care
One day in late March, three cars collided on an icy road in rural southern Minnesota. Each car had several passengers — all with serious injuries — so first responders immediately notified the receiving hospital to expect multiple patients.
"It was terrible weather, and you can bet those weren't the only accident victims hospitals were seeing that day," says Meghan B. Lamp, R.N., director for Grand Meadow Area Ambulance and a flight nurse at Mayo Clinic's campus in Rochester, Minnesota. "Early notification is extremely important because it doesn't take long to overwhelm hospital resources, especially in winter. Emergency Medical Services (EMS) providers have an enormous responsibility when it comes to giving hospitals advance notice."
EMS providers are, in fact, responsible for carrying out the fundamental tenet of a trauma system: getting injured patients to the right place at the right time. Doing that requires well-defined regional trauma team activation (TTA) criteria. In southern Minnesota, criteria developed by the Southern Minnesota Regional Trauma Advisory Committee (SMRTAC) in 2014 helped standardize care across a trauma region spanning 22 counties with 20 hospitals and close to 80 EMS agencies.
The criteria use a Red and Yellow system, in which vital signs-driven signs and clinically based assessments of injuries are used to provide the most accurate triage, while still allowing use of local criteria and EMS provider judgment.
"Say I'm responding to a farm accident where someone's leg is caught in an auger," Lamp says. "The EMTs know right away if the patient meets Red criteria and needs air transport; air medical knows that that means and so does the receiving hospital. In the past, EMS providers would use their own guidelines and hospitals would use theirs. Now, we have criteria in common, and we're all talking the same language."
The main goal of the guidelines is to simplify and improve the trauma triage process across the care continuum. That's easier to do now that prehospital providers are more fully involved in the quality improvement process on both the hospital and regional level.
For instance, EMS providers are on the front lines of new and sweeping changes regarding the use of field spinal immobilization. Long the standard of care for patients with suspected spine injuries, backboards are now known to have significant risks, including pain, pressure sores and compromised breathing, and to offer little if any benefit for many patients. Immobilization in the field also takes time, thereby delaying transfer to definitive care. The National Association of EMS Physicians and the American College of Surgeons now recommend limiting use of long backboards and cervical collars, even for some severely injured patients.
Lamp says re-educating providers about backboards is a big job because in the past, every trauma patient was automatically put on one. "It's a big learning curve because for years and years it was drilled into EMS providers' heads, and so much emphasis was placed on the skills involved in placing patients on long backboards for testing and recertification. It's really hard to change that behavior," she says.
It's not surprising the issue comes up repeatedly in run reviews. "We look at all the patients who were backboarded and go down the list of criteria to see if they meet those criteria," Lamp explains. "One place where we still see backboards used too much is in elderly patients who fall. They don't need to be on a backboard and are at risk of complications because they're frail and have comorbidities.
"Backboards may also not be a good idea for people who experience significant injuries in a major motor vehicle crash and are intoxicated and clearly not going to cooperate. You put them at added risk by trying to forcibly place them on a backboard instead of letting them lie quietly on a stretcher. When we talk about these issues, we are very respectful of providers, who are giving so much of themselves to do this job. It just takes time."
Another issue considered during run reviews is whether air transport was autolaunched or requested and whether local ambulances were called for advanced life support intercept when necessary.
VOMIT: Not what you think
Just as on that icy March morning, EMS providers should notify receiving centers 20 minutes before arrival and provide them with enough information to ensure patients receive appropriate care. The VOMIT report — a standardized list of vital but stripped-down information — can lead to better treatment decisions before and after patients arrive.
The VOMIT report includes only:
V = Vital signs (Highest HR and lowest BP)
O = Origin (Are patients being transferred from the scene or another hospital?)
M = Mechanism of injury
I = Injuries
T = Treatments given
"The report includes everything that's needed for resuscitation and nothing that isn't, such as past medical history. We've used it for nearly six years in all the health systems across southern Minnesota, and area ambulances have gotten used to referring to it when calling in a report, Lamp says.
One of SMRTAC's missions is to improve trauma care through education and outreach, and a volunteer consortium of hospital and prehospital providers, including flight nurses and paramedics, provides a variety of educational programs for southern Minnesota ambulance services.
"First responders are a great group; they are excited to learn new things and are extremely concerned about providing high-quality care," says Lamp, who chairs SMRTAC's Education and Outreach subcommittee. "Everything we do is about the best care for trauma patients. EMS providers give their all to help accomplish that goal."
For more information
Mayo Clinic. Report Format for Trauma Patients to Trauma Report Nurse (VOMIT).