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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