R-E-S-P-E-C-T: Quality Measures Beyond Response...

R-E-S-P-E-C-T: Quality Measures Beyond Response Time

Brent Myers, MD MPH Director | Medical Director Wake County Dept of EMS

Raleigh, NC

We succeed only as we identify in life, or in war, or

in anything else a single overriding objective

and make all other considerations bend to that

one objective. - Eisenhower

“Everybody gets so much information all day long

that they lose their common sense.”

-Gertrude Stein

Broadening Your Data Horizon: The Significance of EMS Integration & Data Exchange within the Healthcare Community October 21, 2014 Session ID: 101

Key performance indicators

Sir Winston Churchill

“Sometimes it not enough that we do our best –

sometimes we must do what is required.”

Lost in Translation

Adolescence

Confirmation Bias

Artificial assessment of one’s performance based on intermittent endpoints rather than on the ultimate, desired outcomes Classic example in EMS is ROSC on hospital arrival

Confirmation Bias

As a profession, it is a bias we have historically had to accept It permeates every measure we utilize

Response time intervals RSI/airway management Pain control You name it

Source of Response Time Measure

De Maio: Ann Emerg Med, Volume 42(2). August 2003.242-250

Proportion of Patient’s Surviving Vs. Response Time of Defibrillator

Ultra-Time Critical = BLS Clinical Condition Ultra-time critical

treatment BLS or ALS

Cardiac arrest Compressions and defibrillation

BLS

Severe trauma Hemorrhage control, reduction of fracture, rapid transport, chest decompression

BLS (save for chest decompression today)

Anaphylaxis IM Epinephrine BLS Asthma Inhaled beta agonist, IM

Epinephrine BLS

Data to Demonstrate Response Time Matters *IF* Rapid First

Response Available

Lost in Translation

IAFF Fi

IAFF Fire-Based EMS Video

ALS Response Times that Matter?

Severe respiratory distress CPAP (can’t this be BLS?) IV medications for treatment Advanced airway management

Chest pain/STEMI Dysrhythmia treatment EKG interpretation

Cardiac arrest management

The Paramedic Paradox

If you have too many paramedics due to over emphasis on response times, then each individual paramedic will encounter relatively few critical patients per year If you have too few paramedics, they may not reach critical patients in a sufficient time frame

Sayre MR et al. Cardiac Arrest Survival Rates Depend on Paramedic Experience. Academic Emergency Medicine May 2006;13(5) Suppl 1: S55-56

Percent Survival Cardiac Arrest

0

5

10

15

20

25

30

35

0.68 1.63 1.16 2.62 4.68

Annual Cases Per Medic

Per

cent

Sur

vive

d to

D

isch

arge

Paramedics per 100,000 vs. Cardiac Arrest Survival

05

101520253035404550

Boston(9.5)

Seattle(13.5)

Milw aukee(18)

Wake (25) SanAntonio

(33)

Nashville(33)

Omaha(44)

City (Medics/100,000)

Perc

ent S

urvi

val

http://www.usatoday.com/news/nation/ems-day1-cover.htm

Houston Experience

Time vs Experience Ultra-time critical Certification

That Can Perform

Experience Critical

Certification That Can Perform

Compression and Defibrillation

EMR, EMT, EMT-A, Paramedic

Treatment of Refractory Arrest

Paramedic with adequate annual experience

IM Epinephrine and Inhaled Beta-Agonist for Anaphylaxis/Severe Asthma

EMT, EMT-A, Paramedic

Consideration of IV steroids, advanced airway management

Paramedic with adequate annual experience

BVM and naloxone for narcotic OD

EMT, EMT-A, Paramedic

Correction for other overdoses (e.g, TCA)

Paramedic with adequate annual experience

BVM and hemorrhage control for trauma

EMR, EMT, EMT-A, Paramedic

?? Chest decompression

Paramedic with adequate annual experience

Spaceballs’ EMS Measures

PEC 2001;5:261-9

Lost in Translation The data supporting paramedic response time are weak at best Most individuals killed in EMS crashes are not in the ambulance – we are not heroes risking only our own lives but also the lives of the entire public There are time critical emergencies and we should send the appropriate response to these

Broadening Your Data Horizon: The Significance of EMS Integration & Data Exchange within the Healthcare Community October 21, 2014 Session ID: 101

Key performance indicators

These are usually not outcome measures but rather process measures Examples for hospitals are: 1) Door-to-EKG time 2) ASA for Chest Pain 3) Door-to-Balloon time This is the language of CMS – we must speak their language

Broadening Your Data Horizon: The Significance of EMS Integration & Data Exchange within the Healthcare Community October 21, 2014 Session ID: 101

Key performance indicators

What About Our Non-Emergency Providers?

• Stretcher Tips per 10,000 transports

• MVCs per 10,000 miles driven

Broadening Your Data Horizon: The Significance of EMS Integration & Data Exchange within the Healthcare Community October 21, 2014 Session ID: 101

Broadening Your Data Horizon: The Significance of EMS Integration & Data Exchange within the Healthcare Community October 21, 2014 Session ID: 101

Patient experience

Broadening Your Data Horizon: The Significance of EMS Integration & Data Exchange within the Healthcare Community October 21, 2014 Session ID: 101

Patient experience

Medication Errors and Adverse Events

Use of drug dosing cards and clinical checklists can help reduce errors One example from the literature: Bernius M, Thibodeau B, Jones A, Clothier B, Witting M. Prevention of pediatric drug calculation errors by prehospital care providers. Prehosp Emerg Care 2008;12:486-94.

Results

With and without drug dosing cards: ◦ Accuracy 65% vs 94% ◦ Severe errors 20% vs 5% ◦ Ten fold error rate 6.8% vs 0.8% ◦ Correct size ETT 23% vs 98%

Major Recommendations Establish a home agency for EMS at the federal level Restructure payment mechanisms to include preparedness and payment not tied to transport Improve regionalization and coordination Develop EMS physician subspecialty Develop evidence based measures for EMS performance

Areas of Focus

Clinical Decision Making Medication errors and adverse events Vehicle incidents Endotracheal intubation/airway

CHF Example

Process measures one Response time < 10 minutes Scene time < 15 minutes Emergency Transport to hospital

Process measures two CPAP appropriately applied Experienced provider at the patient’s side Appropriately control blood pressure

STEMI Treatment Bundle

ASA Administration or justified 12 Lead transmitted Scene time <15 Transport to PCI center PCI < 90 min NNT=15

Avoid re-infarction, stroke, death

0

10

20

30

40

50

60

70

80

Mean 90th Percentile

Time in Minutes

Door to Intervention Times

Hosp AHosp B

0

20

40

60

80

100

120

140

Mean 90th Percentile

Time in Minutes

Dispatch to Intervention Time

Hosp AHosp B

Broadening Your Data Horizon: The Significance of EMS Integration & Data Exchange within the Healthcare Community October 21, 2014 Session ID: 101

I would rather try to persuade a man to go along, because

once I have persuaded him, he will stick. If I scare him, he will stay just as long as he is scared,

and then he will be gone. - Eisenhower

Our Future

We do things FOR rather than TO patients We are rapid when needed, experienced when required We measure ourselves by outcome first and preparedness/prevention second Our incentives will follow these principles