PPRP Webinar Recording

Good afternoon and good morning to those that are on the west coast. My name is Patrick Bavaro. I am the vice president of business development here at Handevi. We do have Dr. Peter Entebbe, along with some additional esteemed colleagues, which I'm sure we'll introduce here in just a minute. But just for the purposes of today's session, since we do have so many individuals registered for today's presentation, I do ask that you keep your microphones muted. If you do have questions towards the end, we will, of course, have the opportunity to answer some of those questions. And you can unmute yourself at that point, but you can enter questions through the chat. Those will be monitored, and today's session will be recorded as well. So if there's anyone that does want to share this presentation afterwards, we will have that opportunity. But I would like to introduce Dr. Peter Anteby, the CMO and founder of Handebbe, as well as a pediatric medical emergency medicine physician out here in South Florida. Dr. Antebe is also the EMS medical director for several departments out here in the Broward county and Palm beach county areas, working with over 2,000 paramedics. And so, doc, I'll go ahead and turn over to you.

All right, Patrick, thank you. Welcome, everybody. Very excited about today. And I know we have a lot of things to go over, so we're gonna. We're gonna go, go, go. It's all going to be recorded. And not to worry. I do have a great lineup. And as I was getting ready for today, I kept saying, okay, I gotta. I gotta ask that person to come in and ask that person to come in. And.

My luck, everyone said yes. But we are going to have a lot to go over. I do have just a couple of initial thoughts, but first, let me at least say hello to our guest. And I don't know if Kathleen is on yet. Kathleen Adelgate. Kathleen, are you here yet?

Yep, I just.

Hi.

All right, so we have Kathleen Adelgates, and everyone will be speaking, and they can make intros in a moment. Maya Dorsett is another EMS medical director from northern New York. Chief Pat Staub is someone I work very closely with. Him and Chief John Berry at Coral Springs Parkland Fire Department. And I wanted him to come in to bring in the kind of like the boots on the ground, like the people are doing the hard work. I wanted him to come in and talk. Caitlin Pearl and Phyllis Henry, the two on the. On the outers here, are from the state of Florida. They do incredible work. And I wanted to highlight their work. And of course, Pat Frost, who has become a dear friend. We've known each other for a long time, and we're Twitter buddies, we're LinkedIn buddies, and she does a lot of great work in pediatric disasters. So just a few initial thoughts. Oh, and I can't forget Patrick. So Patrick, at the end, I've asked him to go over some items with Henpevi and kind of highlight some of the things that we do that go exactly along with what the EMSD and the national folks are trying to do. So together, we can create this partnership where people are actually getting resources, getting information from more than one source, so that we can actually make a difference in outcomes in this country. So some opening thoughts, and then I'm going to pass it over to my esteemed colleague, Kathleen. So I wanted to make a few comments before we got started. You know, the main reason for this webinar is really to help EMS systems, you know, on their journey to greatness in pediatric care. For some of you, this will be an inspiration to, like, rethink pediatrics altogether in your system. For others, it'll be a way to refine your policies, refine your procedures and policies, refine your education. You may be doing a lot of great things, but this may be a way to say, you know what? I went through this assessment, and boy, that was great. And I really learned a lot. I can tell you that. I've gone through it twice already, and each time I took a lot of notes saying, hey, this is a great idea. So even in my agencies, who I have incredible people, we're an incredible team. We focus on pediatrics quite heavily. Even even we looked at that survey and said, that was wonderful, and we learned a lot from it.

So hopefully, with all the experts we have on the call today, everyone will gain something. But a lot of the work, remember that I have, I'm not involved with the eprp. I didn't create it. I don't want to take any credit for it. But there were a lot of people who did a lot of work. We're talking years and years of work. And I wanted to make sure that we highlighted those folks, because if you remember back in 2006, when people were first starting to talk about how we have to improve the care for children, well, it turns out that this document is now an adult. It's 18 years ago.

We've been talking about this for a long time, and even the documents are now grown up. It's incredible.

Before I passed the Techathleen I found this beautiful document here, this, this graphic that's the stages of commitment to change. So you look at this and you say, where am I on this graphic with respect to pediatrics? Am I in the initial preparation phases? And I'm going through the survey and I'm saying, oh my goodness, I have so much work to do now. I have the awareness and then I have the understanding and then I'm going to decide to implement and then I'm going to install it and then next thing you know, it's been institutionalized, if you will. So this is a journey. And I know that Kathleen is going to probably echo the same thing, but I really wanted Kathleen to come in. So Kathleen has just done amazing things. She comes out of University of Colorado Children's Hospital of Colorado. She is a pre hospital domain lead for EMS for Children Innovation and Improvement center, the eiig. And she co led the pprp. That's what we're going to call it, the Pre Hospital Pediatric Readiness Project, pprp. So Kathleen, if you wouldn't mind coming in, thank you so much for all the great work. We are just so grateful to have you and the others on your team, if you wouldn't mind making a further introduction and giving us more information on your overall thoughts on the PPRP and where do you think this will take pediatric ems?

Thank you so much. And also thanks. You know, it's an auspicious group to be a part of here today. Pat Frost has been on our PPRP steering committee for the last couple of years, as well as liaison to the National Pediatric Disaster Coalition. So, you know, equally engaged, equally involved and supportive of all of this work. And as Peter had mentioned, Dr. Entebbe mentioned at the start of this that the PPRP, the pre hospital Pediatric Readiness Project, is a project. The thing that's currently available right now is to do an agency level self assessment of pediatric readiness. And for those who may not be aware, there's been an ongoing process to improve pediatric readiness in hospitals now for two decades aligned with that Institute of Medicine report. It's also 18, 20 years old, also an adult. And over the last two decades, as that project has grown, there's been an improvement not only in pediatric readiness scores among hospitals, but also now research that shows its impact on outcomes for children, specifically mortality of critically ill children, injured children.

And also what you wouldn't be surprised by a reduction in disparities in care.

The fact that there was an equalizing of risk of mortality across all racial and ethnic groups, I think really just speaks to the power of what pediatric readiness is. It's about really lifting all boats. And the goal to extend this pediatric readiness work back into the out of hospital environment is because of the things we know related to pre hospital care that really do impact the downstream events of children when they arrive in emergency departments. If you put a child in a seat collar, for example, they're more likely to get imaging. If you fail to treat a child in pain from an injury, it's going to add almost an hour or longer before they actually get any pain medication. And also if an, you know, incorrect dose is given, then that also can be problematic. The flip side of that is also just the goal to really improve the resilience and the confidence and the power of an EMS agency that when they do get a call for a child, they feel ready to be there. And I can't say how important that is when, you know, as myself, as a, as a pediatrician and pediatric emergency medicine physician, when adults come into our emergency department, you know, you'll never see people get more stressed out because we're not used to taking care of them. We know the absolute reverse is true for the large majority of EMS agencies and community hospitals who see kids. And especially since kids are vulnerable, maybe they're not verbal and able to communicate. It's just, it can be a very stressful thing. So, so the pediatric readiness assessment, which is open till the end of July, the goal is that we get 15,000 DMS agencies across the country to complete this assessment. It takes about 30 minutes. I believe Dr. Entebbe is going to go over some of the work that he's done to do the assessment in his own agencies and kind of give you a detailed step by step. The at the end of doing the assessment as an agency, you will get a score. Your score will also have the average score benchmarked to other agencies of your type in terms of size and volume of children, whether it's a volunteer agency, whether it's a BLS only agency. And the additional thing you'll get is what's known as a gap report. So if there are things that you indicated or not, resources or tools you have or practices you're doing, you'll get information about how to, you know, the importance of that and, or how to get resources to be able to put change into place.

I do want to also point out that our goal was to create a national assessment that could be done by any EMS agency of any kind, whether it's volunteer, fire based, hospital based, county based, ALS only, BLS only. And so you know the goal is to answer the questions relevant to your agency. There are no wrong answers and there is no bad score. We've never done an assessment of pre hospital readiness ever before pediatric readiness ever before in ems. And the original pediatric readiness assessments done in hospitals showed the average score was 55. And at the same time, there's now been a significant improvement because we know where hospitals have been and we know what resources they need and we know where they can go. So with that, I can turn it back over to you, but I wanted to just kind of lay out the, the goal of that. And one other thing I'll I'll mention before is that the questions on the assessment were derived from what we know is best practice in pre hospital care through research and other studies. And it's based on a joint policy statement that was co authored by five organizations, including the American Academy of Pediatrics and the National association of EMS Physicians, the Emergency Nurses association, the National association of EMTs, and the American College of Emergency Physicians. So we had five key stakeholder organizations, all involved in EMS education, all involved in pre hospital care, helping write that joint policy statement. And we derived the metrics of pediatric readiness from that. We will see in the next couple of years once we gather this data. Where are the gaps and what can we do to help EMS agencies? So thank you so much, Peter, for having me on and I'll stay on for the webinar so that I can answer any questions that might come up in the chat or otherwise.

Thank you so much, Kathleen. That was a great overview. And I do think that's an important point that you just made, that everything in that assessment was done based off of research. That document that you just discussed, I'm going to have it here in a couple of slides. Thank you for coming on today. Thanks for sticking around. And please put your questions in the chat for Dr. Adelgate. So why are we here today? So some of you, I see we have almost 150 people here. And so here's a couple of reasons you may be here. I was voluntold to be here. Okay, so how many people are here? Because you got to fill out that survey, I got to fill out that checklist. That's kind of the mentality that we want to move away from. And I'm going to talk a little bit about some inspirational stuff of how to get there.

Some people may be here because, you know, we don't. They think that their agency doesn't focus enough on peace. And you're going to be that person. You're going to be. You're the one sitting in here saying, you know what? It's about time. I'm going to make this thing happen. And good for you, because you're going to have all the tools you'll see here in a minute to make that happen. And then I want to really talk about, like, what's the magic here? How do you really make pediatrics matter? You have to have, you know, Dr. Abigail is your medical director. To make peds matter, it turns out you don't. You have to have me as your medical director. I mean, I'm probably going to push you a little bit harder because I'm a pediatric person, too. But it turns out you don't have to. And we're going to get to Dr. Dorset in a little bit because she's not pediatric trained, but she's done incredible things, so she's made the magic happen. So let's talk a little bit about how to make the magic happen. How do you take your. Yourself, your single person, and then your agency into an organization that actually makes pediatrics matter? So I have some thoughts on this that I want to share. First, let me ask a question. Who can guess what this graphic is showing? Any guesses? And I'm going to give you a hint in a minute. On the left, it says viewers in the thousands. And suddenly in 2024, something magical happened.

See if anybody has any chat. Just for the sake of time. I'll continue. Here's an image that'll give you an idea. All right. This is viewership of the wnba. Okay? Think about that. What happened all of a sudden, suddenly that. Suddenly we became, like, enamored with the wnba. Well, it's. It could be an individual person who, who just takes that level of thinking and says, oh, my goodness, I want to buy tickets. I want to watch the games. Little girls growing up. I want to be just like her. Right. We have the ability to do this in medicine. Understand that fact, and you can make it happen. And to kind of. This thought I have up here of developing parody, and I've. I've tried to do this ever since I've come into ems, which is. I want people to think of adult and pediatric the same. When I say treat kids like adult, I kind of mean that a little jokingly, but what I do mean is that when you're in the room, you shouldn't have the pediatric thought process over there somewhere. And over here, we talk about the adult. That's the mistake. So just about A thought process of how this is. Here's a picture from a long time ago. How many of you sat at the kids table? Right. Yeah. Yeah, right. So what these kids are missing out on is what's going on at the adult table. So if you only relegate pediatrics to that, only like an hour, you know, a month or once every two years, you've made a mistake. If your protocol have a separate pediatric section, you're signaling they're different. What we have done, and I'm happy to share my protocols at the end, we've combined everything together. When we talk about adults, we talk about kids. When we show our metrics for cardiac arrest, we talk about adults, we talk about kids. So go from this table to this table. You have to do that at your organization if you want people to understand that pediatrics matter. Patrick will show you later that in our application, it's adult and pediatric. I spoke to a guy yesterday from Rancho Cucamonga. I'm out here in California. He says we, we use that on every single call, adult and pediatrics. And he says over time they've all become one. So, yes, there's different policies, and yes, their physiology is different, and yes, the dose, we get all that. But when you're, when you're training an organization and getting an organization up to speed, get them, get them at parody by talking about them all the time together instead of making them look different. So real quickly, some background stat. You'll hear this all the time, that 90% of your volume is adults and 10% of your volume is peed. And that's kind of nationally known. Some people say 5 to 13%. I actually ran the numbers last night at two of my departments, and you can see the numbers here. It's 90 and 10 exactly in one and it's 92 and 8 in another. So this is very easy to do. Depending on what EPCR you have, I use several. But for just for the sake of this demonstration, I ran the Numbers yesterday for ESO for 20, 23, 96, 99, and the kids are 722. So this will be part of the information you'll need on the assessment. You'll have to know how to get this information. Okay. There's lots of data out there, and this is just one study that was done by Garth Meckler. This was back in 2018. But they looked at code three responses, 378 of them, and they showed that trauma was the highest. Seizure, altered level of consciousness, respiratory distress. When you go through, you could Also look at all these at your agency. By just looking at the data, by looking at the EPCR that you have, you can easily get this information. And then you should say, hey, you know what, maybe we should train on those things. The data is there for you in the same paper. This is the interesting part where I wanted to bring it up is that of the 378 CO3 transports, there were 456 unintended injury or consequences, near misses, suboptimal actions, errors, and management complications. So you see that, right? There were more than one per patient. And you can see here how it breaks down on the left. But we've known this to be true for quite a long time. And when you look at these errors, if you will, by domain, you can see that it splits off into assessment, impression diagnosis, resuscitation, airway management, medications, all the things that the assessment will look at. So as we're going through the assessment in a second, understand that like Kathleen said, this all comes from the evidence based. This is how they came up with these items for us in EMS to then focus on Dr. Hoyle and Dr. Fail, two great people out of Michigan, they published this. This was a landmark paper back in 2012, and this still is true today. Unless you make a change that, you know, there's. And I think I have the total number here, 5547 children were looked at. 4.1% received drug and had a documented weight in the chart. 360 medication administrations, but 34.7% had errors. Other studies have shown up to 50%. And there's a document now that the NMESP has put out regarding medication safety. Those are all things that are in the toolkit that the assessment has for you. And I'll show you that here in a little bit. Okay, so Kathleen mentioned this paper. It's literally like five pages and only like one of them has actually the information on it. So there's 16 recommendations. You need to look at this as a starting point. Right? This is where everything started here with respect to the pediatric readiness.

Hit. So here, here they all are. But I'm gonna. I'm gonna make it. I'm gonna go a little different for you. I'm gonna make it like a bingo card. The first one says, think of the kid. Engage the experts, Integrate kids just like adults. I added that part. Have pediatric equipment and evaluate its competency. Disaster planning. That's going to be pat. We'll talk about that in a minute. Education and competencies, cognitive and psychomotor, promote and Teach why kids are unique, Reduce medication errors, PDF performance improvement, transport policies, Submit your data to a registry, NEMSIS, safe transport policies, destination protocol, collaboration with receiving ERs, and use the EMSC resources that are available to you. So when you look at that document, I just distilled it into a bingo card. Print out this bingo card and start to make your plan for how are we going to address these items as we go along? It's not that hard. You got to make it happen. So I want to bring in Dr. Phyllis Hendry. And I don't know if Caitlin's on. I hope she is, but Dr. Hendry is an incredible human being. We're very fortunate to have her at the state of Florida as a medical director. Caitlin is the program manager for emsd. So she has done. I mean, Phyllis, you've just done incredible work. Are you here? If you can unmute yourself and just talk for a minute or two about all the work that you're doing at the state level and how you can impact the local department, great.

Thanks so much for the introduction. And Caitlin is on. I have to give her a lot of the credit. I'm the program director, she's the program manager. This program was housed for many years under our state department of health. We recently moved it to University of Florida, similar to what Dr. Adelgase does in Colorado. But it is a state program. We are unique in that we are a super large state. So we have over 300 agencies to deal with and over 300 emergency departments. This is our website. We're showing here. We have all of our advisory committee documents, all of our information, information about how to be a PEC in your EMS agency. We've done a similar process with our eds. We're also rolling out, hopefully soon. We're working on a draft pediatric readiness recognition program for EMS that will be voluntary and have two levels, a silver level and a gold level. And I was actually kind of dreading, no offense, Kathleen, because we know we love this, but I was kind of dreading doing rolling out this survey. But it has really been. It's amazing how serious people are taking it. We have some agencies we've got to remove. They're not 911 responders. I think we're probably around 25% now. But, you know, people are reaching out to us, asking questions. They're completing the survey, they're excited about it, and we're giving them a little treat, a little PED ready resource bag if they complete the survey. So it's been a great experience. So far and super excited about what we're going to find out in this survey. And big shout out to Caitlin, who, I don't know if she wants to say anything, who really keeps everything moving in the background. Thanks for recognizing us today.

Thank you. Thank you so much, Phyllis and Caitlin. And if you're, if you're in a state and you don't know who your state EMSE folks are, that's step number one. They have all the resources you need. They can plug you in with national. And we're very fortunate. Thank you so much, Phyllis and Caitlin. All right, we're going to keep on moving on. So what is a national prp, the pprp? Well, there's a website. You're going to get to the website. The first thing I want you to do is don't click on start the assessment. That's not the first thing to do. I highlighted where it says printed copy of the assessment. That's step number one. Print out the version that you need. And now you're going to have all the information you need. And then once you go through that with your team, then you can go back and start the assessment. And then you can kind of go through it once you've filled it out separately.

Again, this is what that PDF looks like. It'll give you all the information. Just understand that the PDF version will flow differently than the online assessment because basically it's logic involved on the online assessment. So again, that should be step number one. Then go to the toolkit. They've put a lot of work into this. The PPRP toolkit is on the website. You have all the seven categories. And if you say, and you're going to do this, you're going to say, you know what, I have no idea. We do not even do that. Okay, go to the toolkit and the toolkit will show you exactly. It'll have webinars on there, PowerPoint Flyers PDF. There's, there's nothing that they have left kind of unturned here. Everything is there for the taking. You just are going to add that to your plan. And that plan may not be the next six months. You may want to add that for later once you get some other things done. That's okay. But just so you know, you really need to have this on your favorite if you're going to be the person at your agency doing this. Now I'm going to highlight Dr. Dorset, Dr. O. From Pittsburgh, and.

The chief, the assistant chief from Pittsburgh, ems. They did an amazing thing. So I actually watched all these videos in preparation for this. And they were amazing. They were amazing. So you go to YouTube and this was all done by Prodigy. We love Prodigy. So thank you, Prodigy, for doing this. But basically they're like 12 minutes here, 7 minutes here, 14 minutes here. Before you go through the, the assessment, they go through every single question and they give you some color commentary. It's almost like you're watching the game they're giving you. And Sylvia and Mark from Pittsburgh did an incredible job explaining all those things. Okay, now I kind of going to go through these real quick, only because they've already done the work. I don't want to kind of do that all over again for you, but just to take you through to get a little taste of what exactly they're going to be asking on this assessment. So they're going to ask you about education and competencies. What process do you use to evaluate your provider's skills? Right. Also the cognitive education, they're going to be looking at that. How do you do it at the skill station? Do you do it at a simulated event or an actual encounter? So how are you actually evaluating skills? How often are you doing it? Which skills are being tested? And again, there's no right or wrong answer. Just kind of click in what you actually do so that you actually get an exact answer and you have an exact assessment. You're not, you're not cheating anyone by saying that you do this when you really don't. That's the goal here, is to show yourselves where you are and then the gap assessment will tell you where you need to go.

There is a document which we're going to have in our Dropbox folder for the next step, which is equipment and supplies. Many states require this. Here's a national document that requires this. I'm just going to keep on moving on because this is pretty standard and make sure not only you have the equipment, but Dr. Dorset in her in the YouTube webinar makes a good comment like, evaluate the competency of people knowing how to use that equipment. Having. Having a piece of equipment without knowing how to use it and only looking at it once every two years. Probably not good enough. Medication safety, obviously this is something that we focus on at hent heavy. Quite significantly, I think that the document, the toolkit does a great job here. Patrick will talk more about this a little later. But you have a length based tape. Everyone's focusing on volumetric dosing. We're huge believers in that. We believe that you should never ever do math. And the flip side of that is that you have to be customized. Patrick will talk later that the hardest thing that we do at Hand Heavy is customization. The people who have customized with us know it's a little painful because we take it seriously and it's important for outcomes. And Dr. Dorcett will talk about that here shortly. How do you identify potential dosing errors? Where are you looking? How are you looking? Which medications are you looking at? You should know which ones are the most common. Do you have a proper child restraint policy and a device? So this is not just patient safety, it's also medication safety. So here's where I want to bring in a very good friend of mine. He's an amazing EMS medical director up in the Rochester area of New York. She's a medical director for Prodigy, which is an incredible company. But I only learned about what she did after she did it. So I want to as Dr. Dorset come on and talk about and I'll stop to share Maya so you can, you can share your screen. But she implemented Hand Heavy across her region and then she actually did a huge data report on it and that's the kind of thing we're talking about. So Dr. Dorset, take it away.

And I am far from did this alone. We did this. It was a huge group. And I'm joined very luckily with Shane o' Donnell, who was the person I'm sure the Hand Heavy folks recognize because he put in all our customization requests, who manage the app and a bunch of the education initiatives and can speak to what it's like to do the work. So I'm going to talk about efforts that we did in our region to improve pediatric medication safety. And I think I want to start out in the context of thinking about the pediatric preparedness checklist. And we started this before this came out, but I think we're talking about where we are here. But I'm hoping that what people understand as we go through this project that every single component of this is interconnected. There really isn't like one section without something else. And we're going to talk about the educational efforts we did the quality improvement and data work because I don't think it's just about one part of the checklist. These are all sort of ingredients into the final thing that you're going to put forward forth. So a little bit about our region so people understand we are New York State is divided into 17 or 18 EMS regions that have overlying councils. We have the state collaborative protocol. So above New York City, there's protocols are consistent between all the different Agencies, but we are in Monroe Livingston, which is sort of right at the tip of the nose, but also sort of like southern Canada. And in our region we have Monroe county that has Rochester, which is an urban area served by a large private agency. But we also have areas like Livingston county to the south, which is rural and has county based ems. And then we have volunteer agencies and sort of everything in between. And so we knew that we wanted to work on medication safety in a number of ways and in particular based on the data, like the work that John Hoyle did in Michigan, that this was likely an issue. But how to address this in an area where we had 12 different ALS agencies, a bunch of different BLS agencies who used four different EP PCRs to say like, how are we making this better? And so I think I have to highlight this document which you talked about, Peter, which was a position statement. And really the nuts and bolts of this is the resource document to give us guidance on. We knew, like, how do we actually start addressing this problem and improving things. And this paper did a systematic review of evidence based ways to reduce pediatric medication error. And these were the key recommendations that you need to wait, that we should be using kilograms, the no math and volume based dosing and then the opportunity to practice and perform this task. And this really rung true because prior to us doing this project, we had implemented a medication cross check initiative. And the case I used in my agency was like a five year old with a seizure where, you know, I had a mannequin and I saw the struggle that people had coming up with the right volume dose. And so that was the moment that I knew like something had to change. And we ended up using the hand heavy application. So I'm gonna say like, I don't, I love Peter to death, but I don't work for him. Right. But we chose this because it had all those elements. There was a quick way to get age things in kilograms. And the key component was volume based dosing, no math, and the integration and then the integration of protocol so that people wouldn't just be pulling it out and adult dosing. And then I was also lucky enough that Shane, who's here with me, worked for, had experience in implementing hand heavy on a smaller scale at Mercy Flight, which is our critical care helicopter EMS service who had already implemented. And so we had like knowledge and know how on how to go through this. So I'm going to turn it over to Shane to talk a bit about like what did our implementation timeline look like?

Yes, we had our initial Implementation process started in October 2022. So the regional policy and identifying that we needed to create or identify some sort of system to improve the pediatric safety.

And then we sent out a survey to, as Maya said, there's a bunch of different ALS agencies, BLS agencies and BLS first response agencies. We wanted to ensure that there was a consistency amongst the medications that we had out there. So we're giving everybody the proper consultation concentrations to utilize.

Yeah, and I'm gonna. Shane always says I interrupt him, which is true, but I was gonna say like this is a really important part because if you're doing cross agency implementation of something like this, if you don't have the right concentration of the drug in the app and you're using volume based dosing right, you're gonna cause errors. And so this was a key step. And we were surprised to find that there was only one drug that had variable concentration in our region, which was ketamine. All the other drugs, every agency, carry the right concentration. And so in our rollout we really spent a compiling different ways to represent different concentrations of the same drug in the application.

And we developed an education plan that primarily revolved around like a train the trainer style where you'd go out to individual agencies and bring in the key leadership for them to demonstrate and go through kind of like a pseudo credentialing policy with their individuals at the agency.

So we went through February, March, did a lot of the refinement for the application, going through, verifying concentrations, working with the hand heavy team as far as inputting the information and ensuring that the protocols and everything were up to date. And then we initially started with a very small group to basically we told them to go in and try and break the application, which obviously isn't possible to go through and find stuff that we had missed or concentrations that we didn't expect.

And this is very, I have to say, like, you know, in quality improvement world we talk about your PDSAs, you need to fail fast and on small scale before the big rollout. And so this was. And it worked out because we had like an issue with our login right away and if we tried to roll it out to everybody and there was issues, we would have lost a lot of engagement right away. And so we were able to like, it's a complicated system like to set up, which is why you have set so much back and forth. But you can do it right when you invest the time. But we had this small group of people we really trusted to give us very direct and honest feedback. Which let us iron out all those little inconsistencies before we went live with a larger group.

They really became champions of the system too because they would show people the system and they'd be like, I want that, that's incredible. So we went out to individual agencies. We tried to hit different aspects of the region to try and bring in folks into the more centralized locations to train the trainers. But we went basically throughout the region to do so and then we began the individual training with agencies. So this is an example of one of the cases. So we created five different cases and as Peter mentioned before, kind of integrating the adults and pediatrics. Two of our cases were adults, this one's an infant who is seizing. So we had folks go through, verify with length based tape, determine the appropriate route which would be intramuscular for midazolam in this region, the volume in which they would give it, and then going.

Through a cross check.

And the two scenarios we did for adults were ketamine for analgesia and then norepinephrine for a septic patient.

And the peds were, the other ones were a school age child for pain management. Partly because we knew that pain was being undertreated and we wanted to improve people's confidence in doing that. And then a pediatric cardiac arrest where they ran a mini scenario. And the reality was is that there was variable implementation across different agencies. So we had, we needed to create a system that whether or not you were a large private urban agency, that you could pull crews quickly off a road and run them through a bunch of scenarios versus a suburban service that might bring people in for like regular trainings, that there was flexibility in the way that could be implemented. We surveyed people subsequently about what type of experience they received and we got greater than 80% had at least some form of hands on training. I wanted it to be 100, but this is real life and we didn't get there. But we'll talk about the measurement of outcomes. So this is, it's a rolling rollout. So you can plot as an administrator, you can pull the number of users and when they joined the application. You can also look to see when they last opened it. And we have, we rolled it out because of the number of licenses we had. This was, this was actually a state funded pilot. So I didn't say that earlier, but I'm a regional council. Like we didn't have sort of initial seed money from that perspective. But luckily I was very fortunate to have Amy Eisenhower as the EMSC coordinator for New York State who When I approached her with this idea as a project that we wanted to do and implement, she was able to find funding for us to do this with the idea that we would share what we learned back to the rest of New York State, including, like, how to implement this across a number of agencies. So we rolled out initially at the ALS and we have 350 paramedics, give or take, within our region. This is looking at the timeline to sort of this is important for our data. I said, really around July, like, the majority of paramedics in our region were trained and had access to the app. And really, it wasn't until probably September that we sort of hidden that 350 threshold. But this is important when we look at the data. And one of the things that we did to verify that we were looking at the right metrics, right, which was percent medication error, is I was using the documented weight in the chart. Speaking of, like, how did we get that data with four different EPCRs? One of the things within that checklist is, are you sharing data with your data bridge for your state? So we were able to take actually our regional state bridge data through which is managed by image trend and create which the state helped us with a regional report that had every patient age 13 and under who received a medication within our region so that we could look at it across all regions. It didn't matter what EPCR was somebody was using. But since we were using the denominator of the weight that was documented in the chart, we actually wanted to verify whether or not we were using the right denominator or if people were making sure the denominator match what they administered a patient. And so we pulled a bunch of charts that were transported to the U of R Pediatric Hospital. I had pediatric Emergency medicine fellows named Ward, Strickland and wilchang who were wonderful. And they actually looked to see what was the patient's weight on that day in the emergency department and verified that the denominators were correct. So when we're looking at the med error rate, we're getting an accurate picture. So this is something called a P chart, which is our medication error over time. So what's plotted here is the percent correct dosing across all medications. And what you can see is that we started out, there are some bad months. Okay. But we started out, this is. You look at the median over time that we were about 70%. So remember that paper that Peter talked about where they said 37 incorrect dosing? Right. So this is. We saw this more like, oh, my God. But this is like think this is at or better where most of the country is whenever it's been looked at. But I think we can all agree that 70% is not good enough. And we'll talk about what it was for critical medications like midazolam. So around right, this is the time course, July, the majority of paramedics were trained and we've seen a shift. And then we're continuing to track this every month. But like as of March, we had right, like 90% correct dosing. Our median is 84%. And my goal through continued efforts is that I want things consistently greater than 90% correct because I think that's what we owe our children. This is not every medication is dosed incorrectly the same proportion of the time. So if you think about dexamethasone turned out to be the most commonly administered medication to children in our region. And kids top out at 10 milligrams very early. So that was like 90% greater than 90% correct dosing because it's actually harder to get wrong. But when we looked at a medication like midazolam. Right, So I think we all can agree that midazolam for seizure needs to be dosed correctly. It was only dosed correctly 60% of the time. And Peter showed that graph of what are the common critical complaints for children. Seizure is a top reason that EMS responds to children. So what's plotted here is individual. This is since 2020, individual administrations of midazolam. And what it is is the dose administered divided by the correct dose. So this, anything above here, this is like, this is overdose, this is underdose. And what you want the line to be at is one. So you can see how much variability there was in our system. And then in July.

Now the lines are much more central on this line and we still have errors. But what's amazing is when I look at these three errors, I can drill down now. And I know that the app was not used because that person who made the error was not a registered user on my list. And so now I contact those agencies, I tell them about the errors that occur. And I work on thinking, like, how can you get that person onboarded? Like, they should know about the error and we need to get them onboarded. But that means there is one technical error where, where it's 75% of the correct dose because it was a one year old who weighed 13 kilograms, who got 1 milligram, and technically that's like less than 0.8% because they'd use 10, 10 kilos as the estimated weight. But I don't think that's a clinically significant error. And I can go to sleep at night with that. So I love control charts. They feed my soul. I also get messages like this.

And I get messages like this, right? Like, I get like lyrics hooked up thinking about it. And we surveyed. I don't have all the data here, but we surveyed our providers and people are feeling more comfortable taking care of children. So I think as far as lessons, I think the first one is that it's never just about a single tool. It's about all the elements of the system, right? Without education, people would not be. I can't just like buy one thing and do it. I need to think about an implementation plan of how am I going to get people to use something, how they do they have the ability to do hands on education. But you can hit a lot of different components within the assessment and pediatric readiness through a single project because it gives the opportunity to do that. Like when we did that peds arrest mini scenario, right? Like, I realized how many people didn't know how to use a stopcock for administration of epinephrine and allowed me to identify that gap and remedy it in a way that never would have happened if we hadn't done this project. But the last thing also is that data speaks. We pulled our meta error rate and I showed clinicians their own data, right? Like this is our system data. Like not one person owns it. We own this as a system and people were motivated to make a change because, right, we still have people who want to teach more math. But the data speaks in that like, math does not lead to safe medication dosing or timely medication dosing. And when it came to finding. So this was initially grant funded. When it came to finding sustainable funding through our Chiefs association, right, it came to me showing like the impact on patients and making it clear what the return of investment and continuing was. And so I think it's never just one part of this, but when you start tackling one, you sort of pull in and start meeting the other components. And it's really changed the way we've approached it. We've recently created a pediatric advisory council, which is one of the things as a subcomponent of our medical advisory council so that we can regionally tackle these problems, which is something that we learned through this project. And so there's lots of people to thank. But I think mostly I want to thank the people who do the work for EMS Week, but also because if they didn't engage in this, we would never would have made a difference.

Wow. So now everyone understands when I say that you can make pediatrics magical.

But it is all about the data. Maya, I completely agree with you. Whether you use Entebbe or let's say you're integrating a new mechanical TPR device, you owe it to yourself to determine whether what you've implemented works. You can't just assume that what you're doing is working. And so we all thank you so much for what you've done. We're going to keep on moving along here and we're going to go with interactions with system of care. Again, this is engaging with the hospital and ED to promote care in your region. And again, this is something that you can find in the toolkits, et cetera. But I do want to move now to pediatric disaster preparedness. And I'll bring in Patrock here in a minute. This is the question where you may look at yourself and say, well, how do we really do this? You may have to call some people. We're fortunate in Florida that we're now moving to Pulsera. I'll give them a little shout out here because they are going to help us do a lot of these things. And so many agencies in Florida, because Florida purchased it for the state like other states have done. So we're excited about this because it helped us there a lot. But I wanted to highlight Pat Frost. So Pat spent many years in Contra Costa and now she is the head of the National Pediatric Disaster Coalition. She will give you as many resources as you need. Pediatric disaster preparedness is very important. So, Pat, you're on. Tell us what you think.

Well, thank you so much, Peter. It was such a pleasure to talk to this group. And I know we have a limited amount of time. Basically, the National Pediatric Disaster Coalition is a grassroots organization who's dedicated to information sharing. And we're really focused on the last mile, connecting novice to expert. And we have been at this for a really, really long time. And our, you know, executive advisory committee's members are extremely well connected and engaged every single day. It's hard to stay up on what is going on in EMS.

And EMS for children. But we have found that there is no lack of resources that are open access, that are free, that are evidence based, that are really focused on solutions. And part of our support for the pediatric.

You know, pre hospital preparedness program or readiness assessment is that you can't. That is the foundation. That's the foundation of being able to have disaster preparedness so we feel that these things are all connected. You know, children's needs are still systematically left out of disaster readiness. And I truly believe, based on my experience, not only as a pediatric clinician, but also as a former EMS director for Contra Acosta county and doing this work in disaster preparedness, that EMS is uniquely qualified to lead a system of care for children. And that's exactly what we're trying to do with these efforts at this point in time. And disaster is just a continuum. We have blue sky days on one side, we have incidents involving smaller groups of children, and then we have disaster. But we really need our EMS community to come to the table. You guys are experts in logistics. You have real world solutions. You give a reality check to the academic work that is being done in this area. And we love connecting you with these experts so that we can have a real dialogue, have real world solutions to come about. And I'll be one of those solutions and those exciting things to happen is just to be able to tell you about the Pediatric Disaster Centers of Excellence and also the Pediatric Pandemic Network, who we are very actively involved in sharing the tremendous work that's coming out. And I'll put their website links in the chat.

Wonderful. And thank you so much, Pat, for all that you do. Also, in the, in the toolkit from the eiic, you'll find other items as well for pediatric disasters. But what I wanted to highlight, Pat, is because she's doing this in collaboration, right? It doesn't all have to come from one person. Just like we're trying to help out the community. Pat is part of our community and we want to see more and more people join that community so that everyone's hearing about it from all, all sources.

Coordination of Pediatric Emergency Care. You're going to hear the term pec. What is a pec? Who does that? Do they have to be a doctor? Well, I wanted to invite here someone that I work very closely with, the battalion Chief of ems. We all work under Chief John Barry, who is our assistant Chief of ems. And together.

We always work hard to make this happen. So. So, Chief Staab, thank you so much for coming on. You are the boots on the ground guy. You're the one who kind of makes all the magic happen. You're making the sausage. Can you describe, just in a short period of time, what you see as how you as a chief can actually make pediatric matter at an agency?

Absolutely. Thank you, Doctor. And Tebe, I appreciate you having me on.

What?

Well, we're fortunate when it comes to pediatric patient care and management in our system to have you as our medical director. I was here before you came on and obviously the emphasis placed on pediatric care and management has really moved to the forefront of our organization. But as a fire based EMS system we obviously have a lot of things going on. We have a lot of priorities.

To work on. But when it comes to our approach here at Coral Springs Parkland Fire to for training we work very closely. Our EMS division and training division are in the same division actually. So I work very closely with our trainers. The hands heavy.

System is the cornerstone of what it is that we do. We certify on that every two years. That's the cornerstone training for pediatric care in our department. It checks a lot of boxes in and of itself as a system. The app that the speakers earlier mentioned, we've been using that for a number of years. It's very ingrained in what we do. We're very competent with it. We recertify that every two years. But in between that we're fortunate enough to have full time, two full time training instructors on a day schedule that we package training scenarios, both tabletop and skills based and we'll go out to the stations, randomly put a unit out of service with a clear directive of what it is we're doing. They had a couple of nice scenarios. The earlier speakers. We do things like that. We'll bring a manic and we'll pull up and we'll go real time and putting you out of service or run them through a drill. We'll have the takeaways and we'll address any deficiencies thereafter. And we'll do that over a period of time with a capture rate. We try to hit 80, 85% of our members because obviously this is a real world situation and there's a lot of logistical considerations to take into effect. But we make it a real point in between our biannual certification with Hant heavy to always emphasize pediatric care. We also utilize our QA system in our department. Our EMS trainer is always involved in the QA process as well. And we have real world takeaway actionable items there that we try to incorporate into our training as well. It was mentioned earlier, pediatric pain management, always an area that we can do better on. So we look at our data, we bring that to our members whether we share it via our LMS or in person or in conjunction with Dr. And Tebian. Speaking of our LMS system, it's always a nice avenue to approach in between when we can't get out and we can't have that face to face because we have other priorities. We have to address that. We still are pushing information out, whether it's hands heavy minutes that you put out and obviously the case reviews between. We'll grab a case, an interesting low frequency, high risk type of situation in a pediatric arena. I'll send it to you doc. You'll, you'll give a nice takeaway for our crews and we'll send that out. That's been very well received in our department to get your insight as to how we can improve and to get that information out there. Because like anything, it's the frequency and the encounters are what they are. And how do we best prepare in between those low frequency events to prepare our members the best. And that's basically in a nutshell how it is we approach.

Pediatric patient care and education in our department.

Amazing. And everyone can see and I work with incredible people who are, who really are amazing clinicians but they're also great leaders. The magic that I'm talking about, if your leadership is not talking about pediatrics like you're talking about adults, it's never going to work. It's never going to work. And I'm very fortunate. Chief Barry and Chief Staub are two just incredible individuals and my other agencies too. I have to say that there's a lot of magic happening and there's people in these communities and these agencies who are very special people. So thank you Chief Staub for that. I'm going to go back to the EIC toolkit again because if you want to know what the PEC does, there's a whole bunch of documents there. Just go on the website, there's flyers. Don't have to recreate the wheel. Another part of the thing is designation of hospitals. I think this is a big area that we need to work on in the state of Florida. Los Angeles has done an amazing job. Dr. Mary Gashey Hill where they've actually gone out and said we're going to designate you, you're not going to tell us what, what you do. We're going to actually go in and evaluate whether you do it and we're going to give you a list of things that we expect from you hospital before we bring you patients. I went ahead and did that in Palm Beach County. I basically r indeed it from LA county and it's made a huge difference and hopefully now we'll try to get it to the other counties.

It's flip flopping up and down because this is the order it goes in the survey itself, but, but patient and family centered care.

There's some interesting things here that they're going to ask you. If you have policies. I think I have it here. They're going to ask you in this section, do you have a policy? I confirmed with Dr. Adelgate that you don't have to physically have a policy, but if you're doing these things, like we put out education on inflicted bias, cultural competencies, et cetera, family presence, we talk about all the time. And Dr. Alex advised me that if you don't have a policy, just type it in the box in the survey that you may not have a policy, but you're actually doing these types of things.

I just wanted to mention that Policies, procedures, protocols, this is kind of standard stuff. It's pretty obvious, however, some things they're going to ask you. Do you have access 247 to a pediatric physician? You know, my agencies do because they have, they have my phone number. But other agencies will maybe do that on a regional basis. You can call the pediatric ed and get online medical control that way. And also you should be looking at your, at your dispatch guide card. You know, one in some of my agencies who use APCO and the other one, we use mpds. You need to be going through those and making sure that, that everything is to your liking. And with apco, they allow you to modify them. And I do that every year. I look at those cards. Okay, keep on moving on because I know we're, we're probably going to be a few minutes over today. Quality and performance improvement. Dr. Dorsett and Shane spoke about that a little earlier and they really showed you how they do that. There's plenty of ways to get the data from your epcr. There's biospatial that we use out the state, thanks to people like Tom DiBernardo. There's again, ESL is putting out a lot of data, the health data exchange. So if you don't have a health data exchange, I would highly recommend that you do that. And Dr. Dorset actually talked about that on the YouTube videos. If you watch those, there are data mechanisms that exist today for trauma, for stroke, for cardiac arrest. And how the hospitals are doing, you know, EMS into hospital, there's some data in a registry. We need that same thing for pediatrics and we really have to get there. So the trauma registries in Florida, we started a stroke registry. So as a medical director now I know Exactly, I have 11 different metrics. I know exactly how the hospital that I'm transporting patients to are doing it'd be great if we can get to that point for pediatric care. And I know that Dr. Kate Remick is working on that nationally and I have slide for that later Hairs. We know how we do for cardiac arrest. Again, let's get pediatrics into this registry mix. And earlier we spoke about the hospital pediatric readiness project. A lot of great work that started from that 06 IOM report. And Dr. Adelgate and others on this call have done incredible work and really all led by I think a superhuman being, which is Marianne Garchet Hill, who's still working to do not just this project, but some airway projects that she's working on now. So it's been a very collaborative effort with some great, great leaders at the helm. And Kathleen mentioned this earlier, but from the years and years of that survey, they recognize that if you're a high performing hospital, your mortality goes down. And here, they published it here in 2023 that you can see that these what I call four star hospitals, they decrease mortality. So like Kathleen said earlier, if you're ready, you're automatically going to have improved outcomes in children. We see that on the hospital side and this is all hospital side data. But let's see the same thing now on the pediatric side. And here's the data. If you're a four star hospital, I just made that name up, then your mortality is 3.4%. But if you're a low performing one star hospital, Amazon, right, you're 11.1%. None of you would ever buy a product on Amazon if it had one star. I guarantee you, I guarantee you we go to the next one, Right? So think about that as we think about quality and care in pediatrics for both EMS and for hospital. Now, without any further ado, Patrick, I'm going to let you take the reins. Patrick is an incredible human being. Oh, I'm getting a little bit of feedback there. But Patrick, if you want to share your screen and talk to us about what, what we do at hand, Teddy and I'd appreciate that. Thank you so much.

Absolutely. Is that feedback okay right now?

Yeah, we got it. It's good.

Awesome. And I'm honored to be the third Pat in this well, well established Pat lineup. So thank you, Doc. And you know, as everyone on today's call mentioned, it's much more than just a single.

Thing that we do here that improves upon pediatrics.

Right.

You can't just incorporate a single product, a single application. You need an entire system of back end support to kind of make that change. Take place. And so we are proud to say that over the last 12 years of being incorporated and being around, we now have worked with over 2000 EMS and hospital healthcare systems throughout the country to do just that. And over those years, we're proud to say that we've had a very strong relationship with our EMS for Children's programs and have had the chance to partner with various programs throughout the country to improve upon this pediatric readiness. And so I mentioned that to say that we have a very strong foundation in how do we make those improvements happen. And through those successes, we've actually been able to deploy and work with several state departments of health over the years to actually deploy hint heavy as a statewide resource for various organizations throughout these states that we have mentioned here on our, on our call today. Now obviously we know that it takes much more than again, just a single application to really make any sort of change take place. And I think the biggest impact that we can all make here as clinicians is really focusing on incorporating some of those resources but really building them into the education that we improve, that we enhance upon with our clinicians that we work with. And so, you know, having gone through EMS for a long time, I know that, you know, PALS is one of those courses that stands out as a standardized course that we all go through as paramedics. And I think PALS does a great job teaching us science and medicine behind why we're giving ABC drug to treat XYZ intervention. But just like math, I think it's important for us to realize that studying for the test isn't always the same thing as when we're working in that real world scenario. And so we are proud to say that over the years we have learned how to improve upon, you know, learning with, how to work with mom and dad better on scene, how to divvy our roles amongst crew members. We cover Pete's, sepsis, PEDs, respiratory, high performance, pediatric CPR, even pediatric bereavement. A very, very important topic that I think we miss a lot of the times when talking about pediatrics. And so over the last six years now of hosting this formal education, we have really had the chance to see what kind of success this has brought to the table. And I think Dr. Dorsett and Shane did a great job of really highlighting and emphasizing just how important that training really is for organizations deploying whether it's hands heavy or really any other pediatric resource out there. And so here at hand savvy. Anyways, our course is structured like the train, the trainer model and you'll notice that here in these screenshots we have a very heavy emphasis on utilizing the actual Hands Heavy mobile application through that scenario based training. So we practice like we play. And once you go through that instructor training, you then become a certified hands heavy instructor within your organization which will then serve as that subject matter expert in pediatrics. And through that you gain access to, you know, PowerPoints, tests, pre test, post test, etc, to then be able to go back to your department to then teach that four or eight hour provider course completely free of charge in house. Or we can leverage technology, which we're a big fan of doing, to actually deploy that education through an LMS platform called Prodigy, which we mentioned earlier here today, where basically part one is done through the LMS which is about two and a half hours of lecture didactic, it's all self paced. You do it in between calls, during downtime, back at the station and then once you finish part one, you then meet with that in house instructor to complete the remaining two hours of hands on scenarios. And once you get that sign off, you get five hours of CAPSEE award on your behalf for a very low cost. And this tends to be a very efficient way of providing pre hospital specific pediatric education. And so we have talked about Hands Heavy mobile here several times throughout our presentation today. And I think, I think one of the important elements that we need to hit on here is that while Hands Heavy will always be known as a pediatric resource, we do also cover all patient demographics, not just peds. And I think it's important elements to talk about here because I think just like Doc had mentioned earlier with the Thanksgiving dinner, right, having the kids table and the adult table, I think we need to start looking at pediatrics the same exact way as we do with our adult counterparts. And so when we start focusing on, you know, understanding what are those local nuances that affect pediatrics, but then really standardizing the care in which we approach those patients with, we have an enormous change take place in the culture of how we deal with these patients. And so through our mobile application we do customize this to reflect your local protocol, your local pharmacology at your organization. We do cover both pediatrics as well as the adults. We time protocol management, we give you resources for actual, for running cardiac arrest events during those acute care and encounters. And the data Dr. Dorsett mentioned, the data speaks that is absolutely true that when we're now collecting good quality data and incorporating that into our patient care records through the integrations that we offer through various EPCR Partners, we can then actually QA that data effectively to find out where is it that we need to improve upon. And so, you know, here throughout the mobile application, I'll just give us some quick screenshots here for time purposes. You will notice that we do have a very extensive list of all the pharmacology being available inside your mobile application. You can actually tie that into the actual protocol documents and sets that you have at your organization as well. So when we click that protocol button up there at the top right, you can now filter medications by indication. So if we selected the allergic reaction protocol as an example, that would then filter those drugs accordingly based off your protocol. And here in this screenshot you'll notice that they are, you know, alphabetically organized, but you can actually structure these in a way that follow the flow of the protocol. So if Epi101 for instance, is your first line drug during allergic reaction, you can actually have that organized to reflect the EPI one to one. And through this, of course, you will be able to access those PDF documents as that reference point en route to a call by the patient's bedside during long transport if you needed to access those documents quickly.

And obviously that does tie into the actual medications like we showed here earlier. But this goes far beyond just the actual medications. We have drips involved where it's rated milliliters per hour or drops per minute. It you can do titrations within the actual medications themselves. So you know, if we click into the epidrip here as an example, you'll see that we do have the ability to actually calculate and get rid of that math during the actual event itself, which again is a very important differentiator. I think we all agree that it's important as paramedics that we know how to do the math. However, during that, you know, live event, when mom and dad is on scene, kid is dying in front of us, math is not the optimal thing that we want to be doing while treating these patients. And of course our equipment referencing is in there as well. And then the last part here that's important for us to notate is that just like you know, any other industry throughout the country, I think checklists serve a very important part in EMS that unfortunately we have not had a very good way of doing in the past. And so through Hands Heavy Mobile we are able to actually create patient care checklist for your clinicians to have access to while treating these patients. And the simplest way that I like to think of these checklists as is almost like a watered down protocol and that they're designed to give your clinicians those key benchmarks that we make sure we're hitting while treating these patients. And as we're going through and documenting these events in the background, it's actually building out a chart summary, capturing all these data points as well. That again we can then go back and QA and QI properly after that event took place. And that data will then also flow into that patient care record as well.

And the last thing here on the mobile application that I think is important to note is that we did mention cardiac arrest obviously is one of our campuses here at Hint Heavy. And up there in the top right you will notice that there is that Stop CPR button up there that is for something that's called CPR cyst. Think of this as being like a customized metronome. You build it upon your organization's protocol and algorithms. But as you're going through the event in the background, you have those audio cues going off for our ventilations, our compression rates, looking at our epi, when we gave our epi, we gave it 1 time 2 minutes and 4 seconds ago. When we get to 3 minutes, the epi will turn orange. When we get to 5 minutes, that epi will turn red. When we readminister the epi, it'll mark it to reset it to green, restart that clock at zero. And so while this is designed to help keep us on pace with running the actual event, it's again also capturing all these important metrics that afterwards we can now identify what is our average time to EPI time between EPI time, the defib time between defib. How many rounds of EPI are we typically giving? How many rounds of defib are we typically giving? These are all important metrics for us to improve upon those QA processes.

And the last thing that I'll leave you with is that again, while a single resource is a phenomenal asset to any organization out there, when you partner with Hands Heavy, you are partnering with the pros. And this is led of course by Dr. Peter Hins heavy, who leads our clinician team who's involved with physicians, pharmacists, paramedics, critical care team members. On the air side, we have an in house technical team that supports the application here in house and that comes with 24, 7 clinical and technical support as well. And so when your team does have changes to protocol, pharmacology, things like that, you're now able to look.