Audrey Fraizer

Audrey Fraizer

Best Practices

by Audrey Fraizer

Was it inspiration, practicality, or compassion—or a combination of all three—that brought Accredited Center of Excellence (ACE) distinction to Service Mobile Emergency Care of São Paulo (SAMU-SP)?

If you ask Col. Luiz Carlos Wilke, he might say not one of the three elements trumps another. They all came into play and when they merged during the accreditation process is a moot point at best.

After all—and this is the practical angle speaking—Wilke, SAMU-SP director, is an ambitious person, determined to offer the best and to be known for offering the best first mobile service for emergency care in Latin America. SAMU-SP was the first center in Latin America to adopt the Medical Priority Dispatch System (MPDS), going live Feb. 24, 2011, and—only 10 months later—ready to submit an accreditation packet that would also make SAMU-SP the first in Latin America to become an ACE.

“The ACE title has special value for our SAMU,” he said. “It’s been our mission to meet the requests classified as medical emergencies or urgencies in the shortest time possible.”

At the Navigator conference held in Baltimore, Md., during the third week in April, Wilke spoke of the compassionate piece of the picture and the inspiration his caring has in turn provided to others.

In 2009, the SAMU went through a phase of restructuring that included the gradual hiring of people with disabilities. The service has a staff of 163 employees (calltakers are known as assistants of medical regulations or, in Portuguese, Tecnicos Auxiliares de Regulacao Medica (TARMs) of which 152 have emergency experience on a very personal level. The employees are divided into four shifts, sending emergency vehicles from their central location in the capitol city.

SAMU-SP draws its staff from a third-party agency representing applicants with various physical or sensory disabilities; the agency sends candidates to SAMU-SP based upon availability and openings. The majority of people with disabilities have not only worked in public service as either firefighters or police officers but they too sustained injuries requiring emergency response and ultimately the loss of jobs due to the severity of the accidents.

Now comes the part about inspiration.

Wilke adamantly refuses and actually becomes rather annoyed regarding any hint of “pity” in the hiring process. The option did not arise by chance or even a desire to fulfill the country’s Quota Law. The end to long stretches of unemployment combined with a newfound profession he believed would translate into dedicated employees, empathetic to a caller in crisis, were behind the decision.

“The focus is not inclusion,” Wilke said. “We are not a philanthropic agency. Our goal has always been to seek excellence in service. The people we have are indeed the best professionals for the job with the skills required for anyone working in a place that has saving lives as a main goal.”

Vinicius Oliveira is an exemplary fit. Seven years ago, Oliveira took three shots in one arm and two in the back while trying to break up a fight at a relative’s graduation ceremony. He left the party in an ambulance and spent months in rehab. With what has been called an impressive calm, today Oliveira responds to calls from people in similar situations.

“I’ve been in the role of the victim, now I can help others,” he said.

The supervisor of ambulance dispatch, Thiago do Santos, was forced to leave his job after fracturing two vertebrae in a car accident. He spent nine months in a hospital bed and has never regained full movement.

“SAMU emerged as the reason that I should not have died,” he said. “It is gratifying to see that I can make a difference in someone’s life.”

The TARMs also “clicked” with the structure of call processing and dispatching response using the Medical ProQA software. TARMs were trained and certified within weeks prior to implementation using a Portuguese language version of ProQA. English-speaking EMD instructors had the benefit of professional translators in a sound booth at the back of the classroom to provide real-time translation.

“The difference in language wasn’t a problem,” said Brett Patterson, International Academies of Emergency Dispatch® Academics & Standards associate and Research Council chair. “I could look directly at the calls and what I said was heard immediately. They could ask questions and I could give answers without waiting for someone in front of the class translating each sentence.”

As in most implementations, the toughest obstacle proved to be the medical staff assigned to patient triage. Under the former system, phone support transferred calls to a medical regulation team of physicians and assistants; they analyzed calls to decide patient need, dispatched the most appropriate mobile care resource, and directed patients to alternative fixed resources or offered advice over the phone.

Prior to MPDS, 15 medical doctors were routinely on duty for every shift. Although the communications center was not the medical team’s preferred venue, desiring field response to phone response, relinquishing call analysis and dispatch was a tough sell. Once again, MPDS rose to the occasion. In just three months after going live, ambulances dispatched on ECHO- and DELTA-level calls were reaching destinations within 10 minutes compared to the former average of 35 minutes. “The 15 doctors had to triage each call,” said IAED International Liaison Amelia Clawson, who directed the Academy side of the implementation.

“That takes time.” Medical staff turned the corner by listening. They heard the questions asked of each caller and the instructions provided while response was on its way. In one day alone, there were seven calls reporting cardiac arrests; three of the seven were revived using Pre-Arrival Instructions (PAIs) and were subsequently released from the hospital. A call in the first few days of operations that required PAIs to successfully resuscitate a patient stands among the calls Walquíria Regia Vilaça Mordjikian will long remember in helping to cement the transition.

“We monitored the call until the patient left the hospital,” said Mordjikian, executive coordinator of central operations for SAMU-192 do Município de São Paulo (SAMU 192). “We have similar cases every day, but this was the first using Pre-Arrival Instructions. MPDS has tremendous benefits for our people.” Wilke said the doctors deemed the system safe.

They are now back in the ambulances, where they want to be, rather than answering calls. The five supervising doctors routinely on the floor at the center are available for medical decisions involving ALPHA, BRAVO, and CHARLIE calls and to give advice for calls coded as OMEGA. With doctors, TARMs, and management on board, the ACE became an attainable goal. Adding fire to the fervor was the 91% compliance level reached within six months of operations and a positive public response. They were at accreditation levels by October 2011 and ready to submit their accreditation packet in January 2012. Nearly 250 invited guests attended an ACE celebration party held on May 30 at SAMU-SP. Wilke said ACE was a goal from the start.

“It is with pride we say that the Service Center SAMU de São Paulo is the largest and most modern in Latin America,” he said. “But nothing is more important than our ability to save lives.” About SAMU-SP SAMU follows international standards of emergency care and is regulated by national standards of the Ministry of Health and the Federal Council of Medicine (CFM). The organization of emergency care systems began with the GM/MS n. 2048 of Nov. 5, 2002, which created the 1st Technical Regulation State System of Urgent and Emergency Care that is currently in force.

The mobile service SAMU opened in a new center in October 2009 in Bom Retiro, the central region of São Paulo. This date was a historical milestone for SAMU because it was when they started to use Intergraph’s Incident Management solution, fully customized by Sisgraph—the same Brazilian company that one year later supported PDC and IAED on the MPDS implementation and the ACE achievement at SAMU. In addition, the three-year-old center is equipped with projectors and LCD televisions, providing the location of vehicles available for response.

São Paulo, with a population of about 10.5 million people, has the largest central pre-hospital care system in Latin America. Since 2004, the original fleet of 63 rescue vehicles has grown to 120 ambulances, a number expected to increase to 140 in 2012. The service also manages 55 technical reserve units to replace ambulances sidelined for repairs or in case of exceptionally high demand. Calltakers answer 8,000 calls daily, sending response to about 1,500 patients.