Clinical Quality in EMS Noah J. Reiter, MPA, EMT-P EMS Director Lenox Hill Hospital (Rice University 00)
Presentation Overview Rationale Definitions Philosophy Prerequisites for a Successful Program The Process / Implementation Examples The Future is epcr right for your agency? Conclusions
Data in EMS What kinds of data are most commonly studied / reported? Response times Call statistics (# responses, call types, # transports) Cardiac arrest survival rate (what about the 99% of the other patients who we take care of?!)
Rationale for Clinical Quality Improvement Programs The primary (response) function of EMS is the provision of timely, compassionate, safe, and exceptional clinical care. Clinical quality cannot be managed (improved) without it being measured.
Definitions What is quality? OED defines quality as the degree of excellence of something as measured against other similar things. More generally, it s how well we provide our services.
Definitions: Quality Assurance QA = Quality Assurance QA is a process that focuses on individual weaknesses Retrospective Generally carries with it a negative connotation
Quality Assurance Clinical offenders are sought out Punitive actions taken against worst offenders Remainder of workforce motivated to perform well enough Status quo, rather than improvement is reinforced Becomes cycle; clinical quality stagnates
Quality Assurance
Definitions: Quality Improvement QI = Quality Improvement CQI CQI focuses on system weaknesses; treats these as golden opportunities Assumes that the system, NOT the individual is the root cause of the vast majority of quality problems
Quality Improvement Weaknesses and defects considered treasures Once identified, analyzed for root causes Improvement initiative tailored to address root causes and elevate the performance of the entire system
QA vs. QI
Is this what we want?
Philosophy Why bother with QI? July 2003
Philosophy What is the central focus of clinical QI? THE PATIENT
Clinical Quality & Medical Errors Recent Medical Alert Issued 700k physicians in U.S. Deaths caused by medical errors: ~ 120k Rate of 0.171 deaths per physician (might be higher for some docs) Think about this: 80M gun owners in U.S. Accidental gun deaths ~ 1,500 / year (0.000188) Doctors ~ 9,000 times more dangerous than gun owners GUNS DON T KILL PEOPLE, DOCTORS DO
Philosophy What occurs between here. and here?
Philosophy Hopefully, a lot of this and only as much of this as necessary.
What other benefits does effective QI have?
Other Benefits of QI Employee Morale Ambulance drivers vs. clinicians Recruitment / Retention Salary Increases / Budget Enhancements
QI Prerequisites The Sell 1. Believing that EMS impacts patient outcomes 2. Believing that we can always perform better than we do currently 3. Being receptive to new concepts 4. Realizing that we must never stop learning 5. Accurate & thorough documentation
QI Process How does QI work?
QI Process 2 Major Types of QI Activities: Random PCR Review Focused PCR Review
QI Process Act - What changes are to be made? - Next cycle? Study - Complete the analysis of the data - Compare data to predictions - Summarize what was learned Plan - Objective - Questions and predictions (Why?) - Plan to carry out the cycle (who, what, where, when) Do - Carry out the plan - Document problems and unexpected observations - Begin analysis of the data
QI Process
QI Process: Focused Chart Review 1. Do not disclose to staff what call type you are reviewing 2. Develop an evaluation tool to review PCRs with (should correspond to agency protocols) 3. Pull all PCRs that meet criteria for a given time period 4. Evaluate performance
QI Process: Focused Chart Review 5. Identify opportunities for improvement 6. Ask questions / identify potential root causes 7. Schedule staff meeting / CE related to the current QI initiative a. Present findings b. Provide education c. Set performance goals that staff buys into 8. Reevaluate performance, share findings, identify further opportunities, celebrate successes.
QI Example: BLS Non-Transports Studied adherence to the non-transport protocol for our BLS providers The following data elements were reviewed: 1. Patient age 2. Vital Signs 3. Patient offered transport 4. Discussion of benefits of transport 5. Lung sounds assessed 6. Medical history documented 7. Blood glucose check, if indicated 8. Medications listed 9. Allergies listed
QI Example: BLS Non-Transports Developed an evaluation tool, adapted from the protocol / documentation requirements. Reviewed one month s worth of PCRs Results were as follows:
QI Example: BLS Non-Transports 90 80 70 60 50 40 30 20 10 0 82 8 71 18 70 19 29 61 25 23 62 27 8 24 13 34 11 33 Pt. Age V/S Recorded Pt. Asked if trans. Needed Discussed Benefits of Trans. Lung Sounds Assessed Complete Med Hx Glucose Check Meds Listed Allergies Listed % Yes % No
QI Example: BLS Non-Transports How do we analyze these data? 1. There is clearly a lot of opportunity for improvement 2. Are the discrepancies related to actual performance or documentation? Probably a little of both 3. Are we pleased with the results? Would you be? 4. What are the potential root causes?
QI Example: BLS Non-Transports Now What? Intervention is developed All EMTs are scheduled for a CE over a fourday period Results are provided to the EMTs Consensus that we can improve the results Education consists of a protocol review, a review of proper documentation, and a review of blood glucose determination
QI Example: ALS Chest Pain Start off similarly to previous example: develop an evaluation tool, review one month s worth of PCRs, plot the data. The following data elements were reviewed: 1. O2 via non-rebreather 2. 3 Lead ECG 3. 12 Lead ECG 4. IV Attempted 5. IV Success 6. VS every 2-3 mins 7. NTG #1 3 8. NTG Paste 9. ASA 162mg 10. Hospital Notified Here s what we find:
QI Example: ALS Chest Pain 100% 100% 100% 100% 100% 100% 100% 100% 100% 92% 90% 83% 80% 70% 69% 60% 52% 50% 40% 30% 20% 10% 0% O2 by NRB 3 Lead 12 Lead IV attempted IV success VS every 2-3 mins NTG #1 NTG #2 NTG #3 NTG Paste ASA 162 mg Hospital Notified
QI Example: ALS Chest Pain 100% 100% 100% 100% 100% 100% 100% 100% 100% 92% 90% 83% 80% 70% 69% 60% 52% 50% 40% 30% 20% 10% 0% O2 by NRB 3 Lead 12 Lead IV attempted IV success VS every 2-3 mins NTG #1 NTG #2 NTG #3 NTG Paste ASA 162 mg Hospital Notified
QI Example: ALS Chest Pain Let s look specifically at the number of patients who received a 12 lead ECG: 1. Again, there is opportunity for improvement 2. Again, some of the gap in performance might be attributed to poor documentation 3. Are we pleased with the results? Would you be? 4. What are some potential root causes? Underestimation of the importance of obtaining an early 12-lead ECG Underestimation of the number of patients who might benefit from obtaining a 12-lead ECG
QI Example: ALS Chest Pain Lack of proficiency applying a 12-lead Not comfortable with interpreting 12-leads Equipment problems Negative reinforcement from receiving facilities How do we identify the biggest issues? WE ASK OUR FIELD PROVIDERS Intervention
QI Example: ALS Chest Pain 100% 90% 80% 70% 67% 60% 50% 52% 12 Lead 40% 30% 20% 10% 0% Initial Follow-Up
epcr: The Present (for some) & Future (for others)
Evaluating an epcr System Does it make sense for your agency? Call volume Operational implications Training issues Billing? BUDGET!!
Justifying epcr to Administration Revenue Clinical Quality
Justifying epcr to Staff / Volunteers Clinical Quality Job Satisfaction Ease of Documentation Program Justification / Budget Enhancements Revenue
Implementing epcr Research Software Hardware Maintenance Compatibility Ease of Use Build specifications / execute a contract Equipment Acquisition Training Implementation
Maximizing Your QI Capabilities through epcr More accurate / thorough documentation Easier access to data Data queries / reports Integration to other pieces of diagnostic equipment
Other Data Management Benefits Public Health / Counter-Terrorism: syndromic surveillance Injury Prevention Educational Programming / New Equipment or Interventions
Conclusions Rationale Definitions Philosophy Prerequisites for a Successful Program The Process / Implementation Examples The Future is epcr right for your agency?
Questions, Comments Noah J. Reiter, MPA, EMT-P EMS Director Lenox Hill Hospital nreiter@lenoxhill.net (212) 434-3043