Evidence-Based Performance Measures for Emergency Medical Services Systems: A Model for Expanded EMS Benchmarking

A consensus-based tool for capability benchmarking of emergency medical services in South Africa

Introduction

Standards for Emergency Medical Services [EMS] have recently been introduced in South Africa in a movement towards the promotion of quality improvement. While these standards identify a minimum set of criteria for EMS quality they do not differentiate between services just meeting them and those exceeding them. Benchmarking may be a helpful exercise in beginning to address the question of comparative levels of capability in EMS beyond a set of minimum standards. The aim of this study was to develop a consensus-based capability benchmarking tool for EMS organizations within the South African context.

Methods

A total of 12 experts in the field of EMS in South Africa consented to participate in two Delphi Surveys in order to achieve consensus on the core components of an EMS organization as well as relevant level descriptors for those components. The resulting data was used to develop a consensus-based capability benchmarking tool for EMS organizations in South Africa.

Results

A consensus-based capability benchmarking tool was developed that allows organizations to distinguish whether the organization's capability, as a whole, is underdeveloped, developing, or well-developed. This is in addition to identifying how capable they are in all individual components or sub-components.

Conclusion

It is recommended that further research be conducted to assess this tool's implementation within different EMS organizations in South Africa, and that this study is used as a stepping-stone for additional research into meaningful quality improvement in emergency medical services in South Africa.

Achieving Equity in EMS Care and Patient Outcomes Through Quality Management Systems: A Position Statement

Improving health and safety in our communities requires deliberate focus and commitment to equity. Inequities are differences in access, treatment, and outcomes between individuals and across populations that are systemic, avoidable, and unjust. Within health care in general, and Emergency Medical Services (EMS) in particular, there are demonstrated inequities in the quality of care provided to patients based on a number of characteristics linked to discrimination, exclusion, or bias. Given the critical role that EMS plays within the health care system, it is imperative that EMS systems reduce inequities by delivering evidence-based, high-quality care for the communities and patients we serve. To achieve equity in EMS care delivery and patient outcomes, the National Association of EMS Physicians recommends that EMS systems and agencies:make health equity a strategic priority and commit to improving equity at all levels.assess and monitor clinical and safety quality measures through the lens of inequities as an integrated part of the quality management process.ensure that data elements are structured to enable equity analysis at every level and routinely evaluate data for limitations hindering equity analysis and improvement.involve patients and community stakeholders in determining data ownership and stewardship to ensure its ongoing evolution and fitness for use for measuring care inequities.address biases as they translate into the quality of care and standards of respect for patients.pursue equity through a framework rooted in the principles of improvement science.

Evaluation of the offset static rope evacuation procedure: insights from a safe job analysis

BACKGROUND

Recently, the Norwegian Helicopter Emergency Medical Service (HEMS) has developed a procedure for a special type of static rope rescue operation, referred to as the offset technique. In this technique, the helicopter is offset from the accident site, and the HEMS technical crew member uses an offset throw line to gain access to the scene. Today, there is little practical experience of such operations, and a need has been identified for more knowledge on the potential hazards encountered during this type of operation. Such knowledge is of importance for further development of the procedure for the offset technique.

OBJECTIVE

To identify potential hazards for helicopter rescue operations using the static rope offset technique and, thereby, to improve the procedure for such operations. This may lead to improved safety for patients and crew members during offset rescue operations.

METHOD

A Safe Job Analysis was used to identify the hazards of offset rescue operations. Such operations are divided into tasks and sub-tasks. For each sub-task, we identified potential hazards and suggested ways of preventing these.

RESULTS

Through the Safe Job Analysis, we suggest some changes in the existing procedure for the offset technique, to make it more robust against potential hazards.

CONCLUSION

We have demonstrated the value of Safe Job Analysis for improving the static rope offset evacuation procedure. Our analysis has led to some changes in the procedure for offset rescue operations. This is the importance of having two throw lines and focusing on "why" in the procedure.

A National Assessment of EMS Performance at the Response and Agency Level

BACKGROUND

In 2019, the National EMS Quality Alliance (NEMSQA) established a suite of 11 evidence-based EMS quality measures, yet little is known regarding EMS performance on a national level. Our objective was to describe EMS performance at a response and agency level using the National EMS Information System (NEMSIS) dataset.

METHODS

The 2019 NEMSIS research dataset of all EMS 9-1-1 responses in the United States was utilized to calculate 10 of 11 NEMSQA quality measures. Measure criteria and pseudocode was implemented to calculate the proportion meeting measure criteria and 95% confidence intervals across all encounters and for each anonymized agency. We omitted Pediatrics-03b because the NEMSIS national dataset does not report patient weight. Agency level analysis was subsequently stratified by call volume and urbanicity.

RESULTS

Records from 9,679 agencies responding to 26,502,968 9-1-1 events were analyzed. Run-level average performance ranged from 12% for Safety-01 (encounter documented as initial response without the use of lights and siren to 82% for Pediatrics-02 (documented respiratory assessment in pediatric patients with respiratory distress) At the agency level, significant variation in measure performance existed by agency size and by urbanicity. At the individual agency performance analysis, Trauma-04 (trauma patients transported to trauma center) had the lowest agency-level performance with 47% of agencies reporting 0% of eligible runs with documented transport to a trauma center.

CONCLUSION

There is a wide range of performance in key EMS quality measures across the United States that demonstrate a need to identify strategies to improve quality and equity of care in the prehospital environment, system performance and data collection.

Access to Trauma Care in a Rural State: A Descriptive Geographic and Demographic Analysis

BACKGROUND

Montana is a rural state with limited access to higher-level trauma care; it also has higher injury fatality rates compared with the rest of the country.

OBJECTIVES

The purpose of this study was to utilize Geographic Information System methodology to assess proximity to trauma care and identify the demographic characteristics of regions without trauma access.

METHODS

Maptitude® Geographic Information System software (Caliper Corporation, Newton, MA) was used to identify regions in Montana within 60 min of trauma care; this included access to a Level II or Level III trauma center with general surgery capabilities and access to any level of trauma care. Demographic characteristics are reported to identify population groups lacking access to trauma care.

RESULTS

Of the 1.1 million residents of Montana, 63% of residents live within 60 driving min of a higher-level trauma center, and 83% of residents live within 60 driving min of any level of trauma center. Elderly residents over age 65 years of age and American Indians had reduced access to both higher-level trauma care and any level trauma care.

CONCLUSIONS

Prompt access to trauma care is significantly lower in Montana than in other parts of the country, with dramatic disparities for American Indians. In a rural state, it is important to ensure that all hospitals are equipped to provide some level of trauma care to reduce these disparities.

Barriers and facilitators for developing a prehospital emergency care system evaluation tool (PEC-SET) for low-resource settings: a qualitative analysis

OBJECTIVES

Strengthening of emergency care systems, including prehospital systems, can reduce death and disability. We aimed to identify perspectives on barriers and facilitators relating to the development and implementation of a prehospital emergency care system assessment tool (PEC-SET) from prehospital providers representing several South and Southeast (SE) Asian countries.

DESIGN

We conducted a qualitative study using focus group discussions (FGD) informed by the Consolidated Framework for Implementation Research (CFIR). FGDs were conducted in English, audioconferencing/videoconferencing was recorded, transcribed verbatim and coded using an inductive and deductive approach. Participants suggested specific elements to be measured within three main 'pillars' of disease conditions proposed by the research team of the tool being developed (cardiovascular, trauma and perinatal emergencies).

SETTING

We explored the perspectives of medical directors in six low-income and middle-income countries (LMICs) in South and SE Asia.

PARTICIPANTS

A total of 16 participants were interviewed (1 Vietnam, 4 Philippines, 4 Thailand, 5 Malaysia, 1 Indonesia and 1 Pakistan) as a part of 4 focus groups.

RESULTS

Themes identified within the four CFIR constructs included: (1) Intervention characteristics: importance of developing an contextually specific tool, need for generalisability, trialling in one geographical area or with one pillar before expanding; (2) Inner setting: data transfer barriers, workforce shortages; (3) Outer setting: underdevelopment of EMS nationally; need for further EMS system development prior to implementing a tool and (4) Individual characteristics: lack of buy-in by prehospital personnel. Elements proposed by participants included both process and outcome measures.

CONCLUSIONS

Through the CFIR framework, we identified several themes which can provide a basis for codeveloping a PEC-SET for LMICs with local stakeholders. This work may inform development of quality improvement tools in LMIC PEC systems.

How do current police practices impact trauma care in the prehospital setting? A scoping review

Objective

In the United States, police are often important co-responders to 911 calls with emergency medical services for medical emergencies. To date, there remains a lack of a comprehensive understanding of the mechanisms by which police response modifies time to in-hospital medical care for traumatically injured patients. Further, it remains unclear if differentials exist within or between communities. A scoping review was performed to identify studies evaluating prehospital transport of traumatically injured patients and the role or impact of police involvement.

Methods

PubMed, SCOPUS, and Criminal Justice Abstracts databases were utilized to identify articles. English-language, US-based, peer-reviewed articles published on or prior to March 30, 2022 were eligible for inclusion.

Results

Of 19,437 articles initially identified, 70 articles were selected for full review and 17 for final inclusion. Key findings included (1) current law enforcement practices involving scene clearance introduce the potential for delayed patient transport but to date there is little research quantifying delays; (2) police transport protocols may decrease transport times; and (3) there are no studies examining the potential impact of scene clearance practices at the patient or community level.

Conclusions

Our results highlight that police are often the first on scene when responding to traumatic injuries and have an active role via scene clearance or, in some systems, patient transport. Despite the significant potential for impact on patient well-being, there remains a paucity of data examining and driving current practices.

Comparison of pre-hospital emergency services time intervals in patients with heart attack in Arak, Iran

Background:

After cardiac arrest, the possibility of death or irreversible complications will highly increase in the absence of cardiac resuscitation within 4 to 6 minutes. Accordingly, measuring the pre-hospital services time intervals is important for better management of emergency medical services delivery. The purpose of this study then was to investigate pre-hospital time intervals for patients with heart attack in Arak city, based on locations and time variables.

Methods:

This is a retrospective descriptive cross-sectional study, which was conducted at the Arak Emergency Medical Services (EMS) during 2017-2018. Data were analyzed by SPSS version 13.

Results:

The total number of heart attack patients registered in Arak emergency medical services was 2,659 of which 51% of patients were males. Six percent of patients were under 25 and about 49 percent were between 46 and 65 years old. The average of activation, response, on-scene, transportation, recovery and total time intervals were 3:30, 7:56, 15:15, 13:34, 11:07, 12:11, and 41:25, respectively. In the city area, the shortest and longest average response time intervals were in spring and winter, respectively. In out of the city area, the shortest average response time interval was in summer and the longest one in autumn. The shortest and the longest average response time intervals in the city area were in June and March, respectively, and in out of the city area, the shortest average response time interval was in June and the longest one in April.

Conclusions:

The shorter response and delivery time interval compared to the other studies may indicate improvement in the provision of EMS. Special attention should be paid to the facilities and equipment of vehicles during cold seasons to be in the shortest possible time. Also, training and informing the staff more about the code of cardiac patients along with general public education can help improve these intervals.

Applying a Model of Teamwork Processes to Emergency Medical Services

Introduction

Effective teamwork has been shown to optimize patient safety. However, research centered on the critical inputs, processes, and outcomes of team effectiveness in emergency medical services (EMS) has only recently begun to emerge. We conducted a theory-driven qualitative study of teamwork processes—the interdependent actions that convert inputs to outputs—by frontline EMS personnel in order to provide a model for use in EMS education and research.

Methods

We purposively sampled participants from an EMS agency in Houston, TX. Full-time employees with a valid emergency medical technician license were eligible. Using semi-structured format, we queried respondents on task/team functions and enablers/obstacles of teamwork in EMS. Phone interviews were recorded and transcribed. Using a thematic analytic approach, we combined codes into candidate themes through an iterative process. Analytic memos during coding and analysis identified potential themes, which were reviewed/refined and then compared against a model of teamwork processes in emergency medicine.

Results

We reached saturation once 32 respondents completed interviews. Among participants, 30 (94%) were male; the median experience was 15 years. The data demonstrated general support for the framework. Teamwork processes were clustered into four domains: planning; action; reflection; and interpersonal processes. Additionally, we identified six emergent concepts during open coding: leadership; crew familiarity; team cohesion; interpersonal trust; shared mental models; and procedural knowledge.

Conclusion

In this thematic analysis, we outlined a new framework of EMS teamwork processes to describe the procedures that EMS operators employ to convert individual inputs into team performance outputs. The revised framework may be useful in both EMS education and research to empirically evaluate the key planning, action, reflection, and interpersonal processes that are critical to teamwork effectiveness in EMS.

Systematic Review of Evidence-Based Guidelines for Prehospital Care

Introduction: Multiple national organizations have identified a need to incorporate more evidence-based medicine in emergency medical services (EMS) through the creation of evidence-based guidelines (EBGs). Tools like the Appraisal of Guidelines for Research and Evaluation (AGREE) II and criteria outlined by the National Academy of Medicine (NAM) have established concrete recommendations for the development of high-quality guidelines. While many guidelines have been created that address topics within EMS medicine, neither the quantity nor quality of prehospital EBGs have been previously reported. Objectives: To perform a systematic review to identify existing EBGs related to prehospital care and evaluate the quality of these guidelines using the AGREE II tool and criteria for clinical guidelines described by the NAM. Methods: We performed a systematic search of the literature in MEDLINE, EMBASE, PubMED, Trip, and guidelines.gov, through September 2018. Guideline topics were categorized based on the 2019 Core Content of EMS Medicine. Two independent reviewers screened titles for relevance and then abstracts for essential guideline features. Included guidelines were appraised with the AGREE II tool across 6 domains by 3 independent reviewers and scores averaged. Two additional reviewers determined if each guideline reported the key elements of clinical practice guidelines recommended by the NAM via consensus. Results: We identified 71 guidelines, of which 89% addressed clinical aspects of EMS medicine. Only 9 guidelines scored >75% across AGREE II domains and most (63%) scored between 50 and 75%. Domain 4 (Clarity of Presentation) had the highest (79.7%) and domain 5 (Applicability) had the lowest average score across EMS guidelines. Only 38% of EMS guidelines included a reporting of all criteria identified by the NAM for clinical practice guidelines, with elements of a systematic review of the literature most commonly missing. Conclusions: EBGs exist addressing a variety of topics in EMS medicine. This systematic review and appraisal of EMS guidelines identified a wide range in the quality of these guidelines and variable reporting of key elements of clinical guidelines. Future guideline developers should consider established methodological and reporting recommendations to improve the quality of EMS guidelines.

Paramedic equipment bags: How their position during out-of-hospital cardiopulmonary resuscitation (CPR) affect paramedic ergonomics and performance

This study investigates how the positions of paramedic equipment bags affect paramedic performance and biomechanical loads during out-of-hospital Cardiopulmonary Resuscitation (CPR). An experiment was conducted in which 12 paramedic teams (each including two paramedics) performed in-situ simulations of a cardiac-arrest scenario. CPR quality was evaluated using five standard resuscitation measures (i.e., pre- and post-shock pauses, and compression rate, depth and fraction). The spinal loads while lifting, pulling and pushing the equipment bags were assessed using digital human modeling software (Jack) and prediction equation from previous studies. The results highlight where paramedics are currently choosing to position their equipment. They also demonstrate that the positions of the equipment bags affect CPR quality as well as the paramedics' work efficiency, physiological effort and biomechanical loads. The spinal loads ranged from 1901 to 4030N; furthermore, every occasion on which an equipment bag was lifted resulted in spinal forces higher than 3400N, thus exceeding the maximum threshold stipulated by the National Institute for Occupational Safety and Health. 72% of paramedics' postures were categorized as high or very high risk for musculoskeletal disorders by the Rapid Entire Body Assessment. Guidelines related to bag positioning and equipment handling might improve CPR quality and patient outcomes, and reduce paramedics' risk of injury.

Indicators to measure prehospital care quality: a scoping review

OBJECTIVE

The purpose of this scoping review was to locate, examine and describe the literature on indicators used to measure prehospital care quality.

INTRODUCTION

The performance of ambulance services and quality of prehospital care has traditionally been measured using simple indicators, such as response time intervals, based on low-level evidence. The discipline of paramedicine has evolved significantly over the last few decades. Consequently, the validity of utilizing such measures as holistic prehospital care quality indicators (QIs) has been challenged. There is growing interest in finding new and more significant ways to measure prehospital care quality.

INCLUSION CRITERIA

This scoping review examined the concepts of prehospital care quality and QIs developed for ambulance services. This review considered primary and secondary research in any paradigm and utilizing any methods, as well as text and opinion research.

METHODS

Joanna Briggs Institute methodology for conducting scoping reviews was employed. Separate searches were conducted for two review questions; review question 1 addressed the definition of prehospital care quality and review question 2 addressed characteristics of QIs in the context of prehospital care. The following databases were searched: PubMed, CINAHL, Embase, Scopus, Cochrane Library and Web of Science. The searches were limited to publications from January 1, 2000 to the day of the search (April 16, 2017). Non-English articles were excluded. To supplement the above, searches for gray literature were performed, experts in the field of study were consulted and applicable websites were perused.

RESULTS

Review question 1: Nine articles were included. These originated mostly from England (n = 3, 33.3%) and the USA (n = 3, 33.3%). Only one study specifically aimed at defining prehospital care quality. Five articles (55.5%) described attributes specific to prehospital care quality and four (44.4%) articles considered generic healthcare quality attributes to be applicable to the prehospital context. A total of 17 attributes were identified. The most common attributes were Clinical effectiveness (n = 17, 100%), Efficiency (n = 7, 77.8%), Equitability (n = 7, 77.8%) and Safety (n = 6, 66.7%). Timeliness and Accessibility were referred to by four and three (44.4% and 33.3%) articles, respectively.Review question 2: Thirty articles were included. The predominant source of articles was research literature (n = 23; 76.7%) originating mostly from the USA (n = 13; 43.3%). The most frequently applied QI development method was a form of consensus process (n = 15; 50%). A total of 526 QIs were identified. Of these, 283 (53.8%) were categorized as Clinical and 243 (46.2%) as System/Organizational QIs. Within these categories respectively, QIs related to Out-of-hospital cardiac arrest (n = 57; 10.8%) and Time intervals (n = 75; 14.3%) contributed the most. The most commonly addressed prehospital care quality attributes were Appropriateness (n = 250, 47.5%), Clinical effectiveness (n = 174, 33.1%) and Accessibility (n = 124, 23.6%). Most QIs were process indicators (n = 386, 73.4%).

CONCLUSION

Whilst there is paucity in research aiming to specifically define prehospital care quality, the attributes of generic healthcare quality definitions appear to be accepted and applicable to the prehospital context. There is growing interest in developing prehospital care QIs. However, there is a need for validation of existing QIs and de novo development addressing broader aspects of prehospital care.

Assessing the pre-hospital care preparedness to face mass casualty incident in Saudi Arabia in 2017-2018

Objectives:

To assess the mass casualty incident (MCI) preparedness of pre-hospital care providers in Saudi Arabia and to identify and highlight their strengths and weaknesses when responding to MCIs.

Methods:

This cross-sectional descriptive quantitative analysis was conducted between January 2017 and 2018 and included all Saudi Red Crescent Authority (SRCA) general administration branches in 13 regions in Saudi Arabia. The modified version of the emergency medical specialists (EMS) incident response and readiness assessment (EIRRA) tool was used in this study.

Results:

The Makkah region has the largest number of ambulances and medics vehicles, followed by Riyadh.

Makkah and Al Madinah Al Munawarah obtained a median score of 4 and showed substantial preparedness for MCIs. However, Al Madinah Al Munawarah showed higher level of MCI preparedness than Makkah, and a significant difference was found (p=0.019). By contrast, Riyadh and the Eastern region showed limited MCI preparedness. In addition, a moderate positive correlation was observed between the overall median scores and the number of physicians (r=0.656 and p=0.015).

Conclusion:

The SRCA showed substantial preparedness in Makkah and Al Madinah Al Munawarah. The SRCA were highly prepared to face MCIs.

Using a Journal Club Series to Introduce Paramedic Students to Research Fundamentals and Critical Appraisal of Medical Literature

INTRODUCTION

Despite United States national learning objectives referencing research fundamentals and the critical appraisal of medical literature, many paramedic programs are not meeting these objectives with substantive content.

PROBLEM

The objective was to develop and implement a journal club educational module for paramedic training programs, which is all-inclusive and could be distributed to Emergency Medical Services (EMS) educators and EMS medical directors to use as a framework to adapt to their program.

METHODS

Four two-hour long journal club sessions were designed. First, the educator provided students with four types of articles on a student-chosen topic and discussed differences in methodology and structures. Next, after a lecture about peer-review, students used search engines to verify references of a trade magazine article. Third, the educator gave a statistics lecture and critiqued the results section of several articles found by students on a topic. Finally, students found an article on a topic of personal interest and presented it to their classmates, as if telling their paramedic partner about it at work. Before and after the series, students from two cohorts (2017, 2018) completed a survey with questions about demographics and perceptions of research. Students from one cohort (2017) received a follow-up survey one year later.

RESULTS

For the 2016 cohort, 13 students participated and provided qualitative feedback. For the 2017 and 2018 cohorts, 33 students participated. After the series, there was an increased self-reported ability to find, evaluate, and apply medical research articles, as well as overall positive trending opinions of participating in and the importance of prehospital research. This ability was demonstrated by every student during the final journal club session. McNemar's and Related-Samples Cochran's Q testing of questionnaire responses suggested a statistically significant improvement in student approval of exceptions from informed consent.

CONCLUSION

The framework for this paramedic journal club series could be adapted by EMS educators and medical directors to enable paramedics to search for, critically appraise, and discuss the findings of medical literature.

Association Between Emergency Medical Service Response Time and Motor Vehicle Crash Mortality in the United States

Importance

Motor vehicle crashes (MVCs) are a leading public health concern. Emergency medical service (EMS) response time is a modifiable, system-level factor with the potential to influence trauma patient survival. The relationship between EMS response time and MVC mortality is unknown.

Objectives

To measure the association between EMS response times and MVC mortality at the population level across US counties.

Design, Setting, and Study Population

This population-based study included MVC-related deaths in 2268 US counties, representing an estimated population of 239 464 121 people, from January 1, 2013, through December 31, 2015. Data were analyzed from October 1, 2017, through April 30, 2018.

Exposure

The median EMS response time to MVCs within each county (county response time), derived from data collected by the National Emergency Medical Service Information System.

Main Outcomes and Measures

The county rate of MVC-related death, calculated using crash fatality data recorded in the Fatality Analysis Reporting System of the National Highway Traffic Safety Administration.

Results

During the study period, 2 214 480 ambulance responses to MVCs were identified (median, 229 responses per county [interquartile range (IQR), 73-697 responses per county]) in 2268 US counties. The median county response time was 9 minutes (IQR, 7-11) minutes. Longer response times were significantly associated with higher rates of MVC mortality (≥12 vs <7 minutes; mortality rate ratio, 1.46; 95% CI, 1.32-1.61) after adjusting for measures of rurality, on-scene and transport times, access to trauma resources, and traffic safety laws. This finding was consistent in both rural/wilderness and urban/suburban settings, where a significant proportion of MVC fatalities (population attributable fraction: rural/wilderness, 9.9%; urban/suburban, 14.1%) were associated with prolonged response times (defined by the median value, ≥10 minutes and ≥7 minutes, respectively).

Conclusions and Relevance

Among 2268 US counties, longer EMS response times were associated with higher rates of MVC mortality. A significant proportion of MVC-related deaths were associated with prolonged response times in both rural/wilderness and urban/suburban settings. These findings suggest that trauma system-level efforts to address regional disparities in MVC mortality should evaluate EMS response times as a potential contributor.

The Rapid Emergency Medicine Score: A Critical Appraisal of Its Measurement Properties and Applicability to the Air Retrieval Environment

OBJECTIVE

The Rapid Emergency Medicine Score (REMS) was designed to predict in-hospital mortality using variables that are available in the prehospital setting. The objective of this article is to critically appraise the development and summarize the evidence regarding the measurement properties (sensitivity, reliability and validity) of the REMS.

METHODS

A literature search was performed identifying all studies describing the REMS. The original validation study was critically appraised for its development. All other studies that reported any measurement properties of the REMS were also appraised for evidence of calibration, reliability, and validity.

RESULTS

In total, 26 studies reported on the measurement properties of the REMS. Overall, the REMS was developed with robust methodology and has good sensibility with adequate content and face validity. It is easy to understand and feasible to be calculated within minutes of patient assessment. The REMS has the necessary measurement properties to be both a predictive and evaluative clinical index to measure prehospital severity of illness; however, no studies have adequately addressed the intra or inter-rater reliability of the score.

CONCLUSIONS

There is evidence to support the use of the REMS as a predictive or evaluative instrument. In most studies, it performed as well or better than other illness severity scores in predicting mortality.

Teaching improvement science to paramedicine students: protocol for a systematic scoping review

BACKGROUND

It is now more important than ever to equip paramedic students, the likely future managers and leaders of ambulance services, with the knowledge and skills of improvement science. Effective teaching requires a range of teaching methods that will engage students actively in learning. Although the array and effectiveness of methods used for teaching improvement science to clinicians and healthcare students has been systematically reviewed, the evidence regarding the specific sub-group of paramedicine students has yet to be fully explored and synthesized in the literature. The aim of this scoping review is to systematically explore and critically appraise the current state of evidence regarding strategies to teach improvement science to paramedicine students.

METHODS

A number of electronic databases (i.e., PubMed, CINAHL, Embase, Scopus, and ERIC) and gray literature (i.e., ProQuest Dissertations and Theses, Open Thesis, and Networked Digital Library of Theses and Dissertations) will be searched for published and unpublished evidence regarding teaching improvement science to paramedicine students. Included studies will undergo narrative synthesis to examine similarities and differences and to identify patterns, themes, and relationships (e.g., how and why certain teaching strategies or methods have worked in achieving desired learning outcomes (or not) and factors that might have influenced this).

DISCUSSION

To the knowledge of the authors, this is the first review that will systematically explore and critically appraise the current state of research evidence regarding strategies to teach improvement science specifically to paramedicine students. It is anticipated that the findings of this review will help to inform academics, developers of paramedicine teaching curricula, and researchers who are planning projects in this area.

SYSTEMATIC REVIEW REGISTRATION

Scoping reviews are currently not eligible for registration on the international prospective register of systematic reviews (i.e., PROSPERO).

Paramedics' Perspectives on Factors Impacting On-Scene Times for Trauma Calls

IntroductionAccording to Ontario, Canada's Basic Life Support Patient Care Standards, Emergency Medical Services (EMS) on-scene time (OST) for trauma calls should not exceed 10 minutes, unless there are extenuating circumstances. The time to definitive care can have a significant impact on the morbidity and mortality of trauma patients. This is the first Canadian study to investigate why this is the case by giving a voice to those most involved in prehospital care: the paramedics themselves. It is also the first study to explore this issue from a complex, adaptive systems approach which recognizes that OSTs may be impacted by local, contextual features.ProblemResearch addressed the following problem: what are the facilitators and barriers to achieving 10-minute OSTs?

METHODS

This project used a descriptive, qualitative design to examine facilitators and barriers to achieving 10-minute OSTs on trauma calls, from the perspective of paramedics. Paramedics from a regional Emergency Services organization were interviewed extensively over the course of one year, using qualitative interviewing techniques developed by experts in that field. All interviews were recorded, transcribed, and entered into NVivo for Mac (QSR International; Victoria, Australia) software that supports qualitative research, for ease of data analysis. Researcher triangulation was used to ensure credibility of the data.

RESULTS

Thirteen percent of the calls had OSTs that were less than 10 minutes. The following six categories were outlined by the paramedics as impacting the duration of OSTs: (1) scene characteristics; (2) the presence and effectiveness of allied services; (3) communication with dispatch; (4) the paramedics' ability to effectively manage the scene; (5) current policies; and (6) the quantity and design of equipment.

CONCLUSION

These findings demonstrate the complexity of the prehospital environment and bring into question the feasibility of the 10-minute OST standard. LevitanM, LawMP, FerronR, Lutz-GraulK. Paramedics' perspectives on factors impacting on-scene times for trauma calls. Prehosp Disaster Med. 2018;33(3):250-255.

The Evidence Base for the Maternal, Infant, and Early Childhood Home Visiting Program Constructs

OBJECTIVES

The federal Maternal, Infant, and Early Childhood Home Visiting (MIECHV) program requires grantees to demonstrate program improvement as a condition of funding. The MIECHV program monitors grantee progress in federally mandated conceptual areas (ie, benchmarks) that are further subcategorized into related sub-areas or constructs (eg, breastfeeding). Each construct has an associated performance measure that helps MIECHV collect data on program implementation and performance. In 2016, MIECHV modified the constructs and associated performance measures required of grantees. Our objective was to identify whether the constructs were supported by the home visiting literature.

METHODS

We conducted an evaluation of one of the MIECHV program's benchmarks (Benchmark 1: Maternal and Newborn Health) for alignment of the Benchmark 1 constructs (preterm birth, breastfeeding, depression screening, well-child visit, postpartum care, and tobacco cessation referrals) with home visiting evidence. In March 2016, we searched the Home Visiting Evidence of Effectiveness database for all publicly available articles on studies conducted in the United States to determine how well the study findings aligned with the MIECHV program constructs.

RESULTS

Of 59 articles reviewed, only 3 of the 6 MIECHV constructs-preterm birth, breastfeeding, and well-child visits-were supported by home visiting evidence.

CONCLUSIONS

This evaluation highlights a limited evidence base for the MIECHV Benchmark 1 constructs and a need to clarify other criteria, beyond evidence, used to choose constructs and associated performance measures. One implication of not having evidence-based performance measures is a lack of confidence that the program will drive positive outcomes. If performance measures are not evidence based, it is difficult to attribute positive outcomes to the home visiting services.

National Assessment of Quality Programs in Emergency Medical Services

OBJECTIVE

This study aims to understand the adoption of clinical quality measurement throughout the United States on an EMS agency level, the features of agencies that do participate in quality measurement, and the level of physician involvement. It also aims to barriers to implementing quality improvement initiatives in EMS.

METHODS

A 46-question survey was developed to gather agency level data on current quality improvement practices and measurement. The survey was distributed nationally via State EMS Offices to EMS agencies nation-wide using Surveymonkey©. A convenience sample of respondents was enrolled between August and November, 2015. Univariate, bivariate and multiple logistic regression analyses were conducted to describe demographics and relationships between outcomes of interest and their covariates using SAS 9.3©.

RESULTS

A total of 1,733 surveys were initiated and 1,060 surveys had complete or near-complete responses. This includes agencies from 45 states representing over 6.23 million 9-1-1 responses annually. Totals of 70.5% (747) agencies reported dedicated QI personnel, 62.5% (663) follow clinical metrics and 33.3% (353) participate in outside quality or research program. Medical director hours varied, notably, 61.5% (649) of EMS agencies had <5 hours of medical director time per month. Presence of medical director time was correlated with tracking of QI measures. Air medical [OR 9.64 (1.13, 82.16)] and hospital-based EMS agencies [OR 2.49 (1.36, 4.59)] were more likely to track quality measures compared to fire-based agencies. Agencies in rural only environments were less likely to follow clinical quality metrics. (OR 0.47 CI 0.31 -0.72 p < 0.0004). For those that track QI measures, the most common are; Response Time (Emergency) (68.3%), On-Scene Time (66.4%), prehospital stroke screen (64.6%), aspirin administration (64.5%), and 12 lead ECG in chest pain patients (63.0%).

CONCLUSIONS

EMS agencies in the United States have significant practice variability with regard to quality improvement resources, medical direction and specific clinical quality measures. More research is needed to understand the impact of this variation on patient care outcomes.

Policy, Practice, and Research Agenda for Emergency Medical Services Oversight: A Systematic Review and Environmental Scan

Introduction In a 2015 report, the Institute of Medicine (IOM; Washington, DC USA), now the National Academy of Medicine (NAM; Washington, DC USA), stated that the field of Emergency Medical Services (EMS) exhibits signs of fragmentation; an absence of system-wide coordination and planning; and a lack of federal, state, and local accountability. The NAM recommended clarifying what roles the federal government, state governments, and local communities play in the oversight and evaluation of EMS system performance, and how they may better work together to improve care.

OBJECTIVE

This systematic literature review and environmental scan addresses NAM's recommendations by answering two research questions: (1) what aspects of EMS systems are most measured in the peer-reviewed and grey literatures, and (2) what do these measures and studies suggest for high-quality EMS oversight?

METHODS

To answer these questions, a systematic literature review was conducted in the PubMed (National Center for Biotechnology Information, National Institutes of Health; Bethesda, Maryland USA), Web of Science (Thomson Reuters; New York, New York USA), SCOPUS (Elsevier; Amsterdam, Netherlands), and EMBASE (Elsevier; Amsterdam, Netherlands) databases for peer-reviewed literature and for grey literature; targeted web searches of 10 EMS-related government agencies and professional organizations were performed. Inclusion criteria required peer-reviewed literature to be published between 1966-2016 and grey literature to be published between 1996-2016. A total of 1,476 peer-reviewed titles were reviewed, 76 were retrieved for full-text review, and 58 were retained and coded in the qualitative software Dedoose (Manhattan Beach, California USA) using a codebook of themes. Categorizations of measure type and level of application were assigned to the extracted data. Targeted websites were systematically reviewed and 115 relevant grey literature documents were retrieved.

RESULTS

A total of 58 peer-reviewed articles met inclusion criteria; 46 included process, 36 outcomes, and 18 structural measures. Most studies applied quality measures at the personnel level (40), followed by the agency (28) and system of care (28), and few at the oversight level (5). Numerous grey literature articles provided principles for high-quality EMS oversight.

CONCLUSIONS

Limited quality measurement at the oversight level is an important gap in the peer-reviewed literature. The grey literature is ahead in this realm and can guide the policy and research agenda for EMS oversight quality measurement. Taymour RK , Abir M , Chamberlin M , Dunne RB , Lowell M , Wahl K , Scott J . Policy, practice, and research agenda for Emergency Medical Services oversight: a systematic review and environmental scan. Prehosp Disaster Med. 2018;33(1):89-97.

Prehospital Ultrasound in Trauma: A Review of Current and Potential Future Clinical Applications

Ultrasound (US) is an essential tool for evaluating trauma patients in the hospital setting. Many previous in-hospital studies have been extrapolated to out of hospital setting to improve diagnostic accuracy in prehospital and austere environments. This review article presents the role of prehospital US in blunt and penetrating trauma management with emphasis on its current clinical applications, challenges, and future implications of such use.

Quality Indicators for Evaluating Prehospital Emergency Care: A Scoping Review

Introduction Historically, the quality and performance of prehospital emergency care (PEC) has been assessed largely based on surrogate, non-clinical endpoints such as response time intervals or other crude measures of care (eg, stakeholder satisfaction). However, advances in Emergency Medical Services (EMS) systems and services world-wide have seen their scope and reach continue to expand. This has dictated that novel measures of performance be implemented to compliment this growth. Significant progress has been made in this area, largely in the form of the development of evidence-informed quality indicators (QIs) of PEC. Problem Quality indicators represent an increasingly popular component of health care quality and performance measurement. However, little is known about the development of QIs in the PEC environment. The purpose of this study was to assess the development and characteristics of PEC-specific QIs in the literature.

METHODS

A scoping review was conducted through a search of PubMed (National Center for Biotechnology Information, National Institutes of Health; Bethesda, Maryland USA); EMBase (Elsevier; Amsterdam, Netherlands); CINAHL (EBSCO Information Services; Ipswich, Massachusetts USA); Web of Science (Thomson Reuters; New York, New York USA); and the Cochrane Library (The Cochrane Collaboration; Oxford, United Kingdom). To increase the sensitivity of the literature, a search of the grey literature and review of select websites was additionally conducted. Articles were selected that proposed at least one PEC QI and whose aim was to discuss, analyze, or promote quality measurement in the PEC environment.

RESULTS

The majority of research (n=25 articles) was published within the last decade (68.0%) and largely originated within the USA (68.0%). Delphi and observational methodologies were the most commonly employed for QI development (28.0%). A total of 331 QIs were identified via the article review, with an additional 15 QIs identified via the website review. Of all, 42.8% were categorized as primarily Clinical, with Out-of-Hospital Cardiac Arrest contributing the highest number within this domain (30.4%). Of the QIs categorized as Non-Clinical (57.2%), Time-Based Intervals contributed the greatest number (28.8%). Population on Whom the Data Collection was Constructed made up the most commonly reported QI component (79.8%), followed by a Descriptive Statement (63.6%). Least reported were Timing of Data Collection (12.1%) and Timing of Reporting (12.1%). Pilot testing of the QIs was reported on 34.7% of QIs identified in the review.

CONCLUSION

Overall, there is considerable interest in the understanding and development of PEC quality measurement. However, closer attention to the details and reporting of QIs is required for research of this type to be more easily extrapolated and generalized. Howard I , Cameron P , Wallis L , Castren M , Lindstrom V . Quality indicators for evaluating prehospital emergency care: a scoping review. Prehosp Disaster Med. 2018;33(1):43-52.

Prioritizing novel and existing ambulance performance measures through expert and lay consensus: A three-stage multimethod consensus study

Background

Current ambulance quality and performance measures, such as response times, do not reflect the wider scope of care that services now provide. Using a three‐stage consensus process, we aimed to identify new ways of measuring ambulance service quality and performance that represent service provider and public perspectives.

Design

A multistakeholder consensus event, modified Delphi study, and patient and public consensus workshop.

Setting and participants

Representatives from ambulance services, patient and public involvement (PPI) groups, emergency care clinical academics, commissioners and policymakers.

Results

Nine measures/principles were highly prioritized by >75% of consensus event participants, including measures relating to pain, patient experience, accuracy of dispatch decisions and patient safety. Twenty experts participated in two Delphi rounds to further refine and prioritize measures; 20 measures in three domains scored ≥8/9, indicating good consensus, including proportion of calls correctly prioritized, time to definitive care and measures related to pain. Eighteen patient/public representatives attended a consensus workshop, and six measures were identified as important. These include time to definitive care, response time, reduction in pain scores, calls correctly prioritized to appropriate levels of response and survival to hospital discharge for treatable emergency conditions.

Conclusions

Using consensus methods, we identified a shortlist of ambulance outcome and performance measures that are important to ambulance clinicians and service providers, service users, commissioners, and clinical academics, reflecting current pre‐hospital ambulance care and services. The measures can potentially be used to assess pre‐hospital quality or performance over time, with most calculated using routinely available data.

Measuring the impact of emergency medical services (EMS) on out-of-hospital cardiac arrest survival in a developing country: A key metric for EMS systems' performance

Out-of-hospital cardiac arrest (OHCA) can be used to evaluate the overall performance of the emergency medical services' (EMS) system. This study assessed the impact of EMS on OHCA survival rates in a setting where the prehospital system is underdeveloped.A retrospective chart review was carried out over a 5-year period of all adult OHCA patients admitted to the emergency department (ED) of a tertiary care center in Lebanon.A total of 271 patients with OHCA (179 [66.1%] men, mean age of 69.9 [standard deviation = 15.0 years] were enrolled. The most common OHCA location was residence/home (58.7%). The majority of arrests were witnessed (51.7%) with 6.1% witnessed by EMS; 211 patients (75.6%) were transported to the ED by EMS. Prehospital cardiopulmonary resuscitation (CPR) was done by EMS for 43.2% of the patients, whereas only 4.4% received CPR from a family member/bystander. Prehospital automated external defibrillator use was documented in 1.5% of cases in the prehospital setting. Only 2 patients had return of spontaneous circulation prior to ED arrival. Most patients (96.7%) were resuscitated in the ED. Patients presented to the ED mostly in asystole (79.3%). Forty-three patients (15.9%) survived to hospital admission and 13 (4.8%) were discharged alive with over half of them (53.8%) had a good neurological outcome upon discharge (cerebral performance category 1 or 2).Survival of EMS-treated OHCA victims in Lebanon is not as expected. Medical oversight of EMS activities is needed to link EMS activities to clinical outcomes and improve survival from cardiac arrest in Lebanon.

Merger of two dispatch centres: does it improve quality and patient safety?

Background

Dispatch centres (DCs) are considered an essential but expensive component of many highly developed healthcare systems. The number of DCs in a country, region, or state is usually based on local history and often related to highly decentralised healthcare systems. Today, current technology (Global Positioning System or Internet access) abolishes the need for closeness between DCs and the population. Switzerland went from 22 DCs in 2006 to 17 today. This study describes from a quality and patient safety point of view the merger of two DCs.

Methods

The study analysed the performance (over and under-triage) of two medical DCs for 12 months prior to merging and for 12 months again after the merger in 2015. Performance was measured comparing the priority level chosen by dispatcher and the severity of cases assessed by paramedics on site using the National Advisory Committee for Aeronautics (NACA) score. We ruled that NACA score > 3 (injuries/diseases which can possibly lead to deterioration of vital signs) to 7 (lethal injuries/diseases) should require a priority dispatch with lights and siren (L&S). While NACA score < 4 should require a priority dispatch without L&S. Over-triage was defined as the proportion of L&S dispatches with a NACA score < 4, and under-triage as the proportion of dispatches without L&S with a NACA > 3.

Results

Prior to merging, Dispatch A had a sensitivity/specificity regarding the use of lights and sirens and severity of cases of 86%/48% with over- and under-triage rates of 78% and 5%, respectively. Dispatch B had sensitivity and specificity of 92%/20% and over- and under-triage rates of 84% and 7%, respectively. After they merged, global sensitivity/specificity reached 87%/67%, and over- and under-triage rates were 71% and 3%, respectively

Conclusions

A part the potential cost advantage achieved by the merger of two DCs, it can improve the quality of services to the population, reducing over- and under-triage and the use of lights and sirens and therefore, the risk of accidents. This is especially the case when a DC with poor triage performance merges with a high-performing DC.

Association of post-traumatic stress disorder and work performance: A survey from an emergency medical service, Karachi, Pakistan

BACKGROUND

The purpose of the study was to explore the association between post-traumatic stress disorder (PTSD) and work performance of emergency medical services personnel in Karachi, Pakistan.

METHODS

Emergency medical service personnel were screened for potential PTSD using Impact of Event Scale-Revised (IES-R). Work performance was assessed on the basis of five variables: number of late arrivals to work, number of days absent, number of days sick, adherence to protocol, and patient satisfaction over a period of 3 months. In order to model outcomes like the number of late arrivals to work, days absent and days late, negative binomial regression was applied, whereas logistic regression was applied for adherence to protocol and linear for patient satisfaction scores.

RESULTS

Mean scores of PTSD were 24.0±12.2. No association was found between PTSD and work performance measures: number of late arrivals to work (RRadj 0.99; 0.98-1.00), days absent (RRadj 0.98; 0.96-0.99), days sick (RRadj 0.99; 0.98-1.00), adherence to protocol (ORadj 1.01; 0.99-1.04) and patient satisfaction (β 0.001%-0.03%) after adjusting for years of formal schooling, living status, coping mechanism, social support, working hours, years of experience and anxiety or depression.

CONCLUSION

No statistically significant association was found between PTSD and work performance amongst EMS personnel in Karachi, Pakistan.

The Danish quality database for prehospital emergency medical services

AIM OF DATABASE

The aim of the Danish quality database for prehospital emergency medical services (QEMS) is to assess, monitor, and improve the quality of prehospital emergency medical service care in the entire prehospital patient pathway. The aim of this review is to describe the design and the implementation of QEMS.

STUDY POPULATION

The study population consists of all "112 patient contacts" defined as emergency patients, where the entrance to health care is a 112 call forwarded to one of the five regional emergency medical coordination centers in Denmark since January 1, 2014. Estimated annual number of included "112 patients" is 300,000-350,000.

MAIN VARIABLES

We defined nine quality indicators and the following variables: time stamps for emergency calls received at one of the five regional emergency medical coordination centers, dispatch of prehospital unit(s), arrival of first prehospital unit, arrival of first supplemental prehospital unit, and mission completion. Finally, professional level and type of the prehospital resource dispatched to an incident and end-of-mission status (mission completed by phone, on scene, or admission to hospital) are registered.

DESCRIPTIVE DATA

Descriptive data included age, region, and Danish Index for Emergency Care including urgency level.

CONCLUSION

QEMS is a new database under establishment and is expected to provide the basis for quality improvement in the prehospital setting and in the entire patient care pathway, for example, by providing prehospital data for research and other quality databases.

Evaluating clinical care in the prehospital setting: Is Rapid Emergency Medicine Score the missing metric of EMS?

INTRODUCTION

The Rapid Emergency Medicine Score (REMS) was developed to predict emergency department patient mortality. Our objective was to utilize REMS to assess initial patient acuity and evaluate clinical change during prehospital care.

METHODS

All non-cardiac arrest emergency transports from April 1, 2013 to March 31, 2014 were analyzed from a single EMS agency. Using age, pulse rate, mean arterial pressure, respiratory rate, oxygen saturation, and Glasgow Coma Scale, initial and final REMS were calculated. Change in REMS was calculated by initial minus final with a positive number indicating clinical improvement. Descriptive analyses were performed calculating means and 95% confidence intervals.

RESULTS

There were 61,346 patients analyzed with an average initial REMS of 4.3 (95% CI: 4.2-4.3) and an average REMS change of 0.37 (95% CI: 0.36-0.38). Those patients classified with the highest dispatch priority had the highest initial REMS (5.8; 95% CI: 5.5-6.2) and the greatest change (0.95; 95% CI: 0.72-1.17). Patients transported with high priority had greater initial REMS, as well as greater improvement in REMS (high priority 7.3 [95% CI: 7.1-7.4], change 0.61 [95% CI: 0.53-0.69]; middle priority 5.3 [95% CI: 5.2-5.4], change 0.55 [95% CI: 0.51-0.59]; low priority 3.9 [95% CI: 3.8-3.9], change 0.32 [95% CI: 0.31-0.33]).

CONCLUSION

Descriptive analyses indicate that as dispatch and transport priorities increased in severity so too did initial REMS. The largest change in REMS was seen in patients with the highest dispatch and transport priorities. This indicates that REMS may provide system level insight into evaluating clinical changes during care.

Contemporary evidence-based practice in Canadian emergency medical services: a vision for integrating evidence into clinical and policy decision-making

Nationally, emphasis on the importance of evidence-based practice (EBP) in emergency medicine and emergency medical services (EMS) has continuously increased. However, meaningful incorporation of effective and sustainable EBP into clinical and administrative decision-making remains a challenge. We propose a vision for EBP in EMS: Canadian EMS clinicians and leaders will understand and use the best available evidence for clinical and administrative decision-making, to improve patient health outcomes, the capability and quality of EMS systems of care, and safety of patients and EMS professionals. This vision can be implemented with the use of a structure, process, system, and outcome taxonomy to identify current barriers to true EBP, to recognize the opportunities that exist, and propose corresponding recommended strategies for local EMS agencies and at the national level. Framing local and national discussions with this approach will be useful for developing a cohesive and collaborative Canadian EBP strategy.

Emergency Medical Services Utilization in EMS Priority Conditions in Beirut, Lebanon

BACKGROUND

Early activation and use of Emergency Medical Services (EMS) are associated with improved patient outcomes in EMS priority conditions in developed EMS systems. This study describes patterns of EMS use and identifies predictors of EMS utilization in EMS priority conditions in Lebanon METHODS: This was a cross-sectional study of a random sample of adult patients presenting to the emergency department (ED) of a tertiary care center in Beirut with the following EMS priority conditions: chest pain, major trauma, respiratory distress, cardiac arrest, respiratory arrest, and airway obstruction. Patient/proxy survey (20 questions) and chart review were completed. The responses to survey questions were "disagree," "neutral," or "agree" and were scored as one, two, or three with three corresponding to higher likelihood of EMS use. A total scale score ranging from 20 to 60 was created and transformed from 0% to 100%. Data were analyzed based on mode of presentation (EMS vs other).

RESULTS

Among the 481 patients enrolled, only 112 (23.3%) used EMS. Mean age for study population was 63.7 years (SD=18.8 years) with 56.5% males. Mean clinical severity score (Emergency Severity Index [ESI]) was 2.5 (SD=0.7) and mean pain score was 3.1 (SD=3.5) at ED presentation. Over one-half (58.8%) needed admission to hospital with 21.8% to an intensive care unit care level and with a mortality rate of 7.3%. Significant associations were found between EMS use and the following variables: severity of illness, degree of pain, familiarity with EMS activation, previous EMS use, perceived EMS benefit, availability of EMS services, trust in EMS response times and treatment, advice from family, and unavailability of immediate private mode of transport (P≤.05). Functional screening, or requiring full assistance (OR=4.77; 95% CI, 1.85-12.29); acute symptoms onset ≤ one hour (OR=2.14; 95% CI, 1.08-4.26); and higher scale scores (OR=2.99; 95% CI, 2.20-4.07) were significant predictors of EMS use. Patients with lower clinical severity (OR=0.53; 95% CI, 0.35-0.81) and those with chest pain (OR=0.05; 95% CI, 0.02-0.12) or respiratory distress (OR=0.15; 95% CI, 0.07-0.31) using cardiac arrest as a reference were less likely to use EMS.

CONCLUSION

Emergency Medical Services use in EMS priority conditions in Lebanon is low. Several predictors of EMS use were identified. Emergency Medical Services initiatives addressing underutilization should result from this proposed assessment of the perspective of the EMS system's end user. El Sayed M , Tamim H , Al-Hajj Chehadeh A , Kazzi AA . Emergency Medical Services utilization in EMS priority conditions in Beirut, Lebanon. Prehosp Disaster Med. 2016;31(6):621-627.

Developing Program Performance Measures for Rural Emergency Medical Services

BACKGROUND

The development of measures to monitor and evaluate the performance and quality of emergency medical services (EMS) systems has been a focus of attention for many years. The Medicare Rural Hospital Flexibility Program (Flex Program), established by Congress in 1997, provides grants to states to implement initiatives to strengthen rural healthcare delivery systems, including better integration of EMS into those systems of care.

OBJECTIVE

Building on national efforts to develop EMS performance measures, we sought to identify measures relevant to the rural communities and hospitals supported by the Flex Program. The measures are intended for use in monitoring rural EMS performance at the community level as well as for use by State Flex Programs and the Federal Office of Rural Health Policy (FORHP) to demonstrate the impact of the Flex Program.

METHODS

To evaluate the performance of EMS in rural communities, we conducted a literature search, reviewed research on performance measures conducted by key EMS organizations, and recruited a panel of EMS experts to identify and rate rurally-relevant EMS performance measures as well as emergent protocols for episodes of trauma, ST Elevation Myocardial Infarction (STEMI), and stroke. The rated measures were assessed for inclusion in the final measure set.

RESULTS

The Expert Panel identified 17 program performance measures to support EMS services in rural communities. These measures monitor the capacity of local agencies to collect and report quality and financial data, use the data to improve agency performance, and train rural EMS employees in emergent protocols for all age groups.

CONCLUSION

The system of care approach on which this rural EMS measures set is based can support the FORHP's goal of better focusing State Flex Program activity to improve program impact on the performance of rural EMS services in the areas of financial viability, quality improvement, and local/regional health system performance.

Factors Influencing the Timeliness of Emergency Medical Service Response to Time Critical Emergencies

OBJECTIVE

While emergency medical service (EMS) response times (ERT) remain a leading measure of system performance in many developed countries, relatively few studies have explored the factors associated with meeting benchmark performance for potentially time critical incidents. The purpose of this study was to identify system-level and patient-level factors associated with ERT, which are readily available at the time of ambulance dispatch.

METHODS

Between July 2009 and June 2014, we included data from 1,000,458 EMS responses to time critical "lights and sirens" incidents in Melbourne, Australia. The primary outcome measure was ERT, defined as the time from emergency call to the arrival of the first EMS team on scene. Quantile regression models were used to identify system-level and patient-level factors associated with 10-percentile intervals of ERT.

RESULTS

The median ERT was 10.6 minutes (IQR: 8.1-14.0), increasing from 9.6 minutes (IQR: 7.6-12.5) in 2009/10 to 11.0 minutes (IQR: 8.4-14.7) in 2013/14 (p < 0.001). System-level factors independently associated with the 90th percentile ERT were distance to scene, activation time, turnout time, case upgrade, hour of day, day of week, workload in the previous hour, ambulance skill set, priority zero case (e.g., suspected cardiac or respiratory arrest), and average hospital delay time in the previous hour. Patient-level factors such as age, gender, chief medical complaint, and severity of complaint were also significantly associated with ERT.

CONCLUSIONS

System-level and patient-level factors available at the time of ambulance dispatch are useful predictors of ERT performance, which could be used to improve the timeliness of EMS response.

Development of key performance indicators for prehospital emergency care

INTRODUCTION

Key performance indicators (KPIs) are used to monitor and evaluate critical areas of clinical and support functions that influence patient outcome. Traditional prehospital emergency care performance monitoring has focused solely on response time metrics. The landscape of emergency care delivery in Ireland is in the process of significant national reconfiguration. The development of KPIs is therefore considered one of the key priorities in prehospital research.

AIMS

The aim of this study was to develop a suite of KPIs for prehospital emergency care in Ireland.

METHODS

A systematic literature review of prehospital care performance measurement was undertaken followed by a three-round Delphi consensus process facilitated by a broad-based multidisciplinary group of panellists. The consensus process was conducted between June 2012 and October 2013. Each candidate indicator on the Delphi survey questionnaire was rated using a 5-point Likert-type rating scale. Agreement was defined as at least 70% of responders rating an indicator as 'agree' or 'strongly agree' on the rating scale. Data were analysed using descriptive statistics. Sensitivity of the ratings was examined for robustness by bootstrapping the original sample.

RESULTS

Of the 78 citations identified by the systematic review, 5 relevant publications were used to select candidate indicators for the Delphi round 1 questionnaire. Response rates in Delphi rounds 1 and 2 were 89% and 83%, respectively. Following the consensus development conference, 101 KPIs reached consensus. Based on the Donabedian framework for quality-of-care indicators, 7 of the KPIs which reached agreement were structure KPIs, 74 were process KPIs and 20 were outcome KPIs. The highest ranked indicator was a process KPI ('Direct transport of ST-elevation myocardial infarction patients to a primary percutaneous intervention (PCI)-capable facility for ECG to PCI time <90 min').

CONCLUSION

Improving the quality of prehospital care requires the development and implementation of performance measurement using scientifically valid and reliable KPIs. Employing a Delphi panel of key multidisciplinary Emergency Medical Service stakeholders, it was feasible to develop a suite of 101 KPIs for performance monitoring of prehospital emergency care in Ireland. This suite of KPIs may contribute to a framework for achieving safer, better care in the prehospital environment.

The relationship between survival after out-of-hospital cardiac arrest and process measures for emergency medical service ambulance team performance

OBJECTIVE

International institutes have developed their own clinical performance indicators for ambulance services. It is unknown whether these process measures are related to survival of patients after out-of-hospital cardiac arrest (OHCA). We aimed to determine whether Emergency Medical Service (EMS)-related ambulance team process measures correlate with patient survival.

METHODS

Four years of observational data were collected from an urban EMS OHCA registry. The two process measures were achieving an EMS response time ≤4 min and prehospital ROSC (return of spontaneous circulation). The outcome measure was survival to discharge. We used the GLMM (generalised linear mixed model) with stepwise selection to examine this process-outcome link at the patient and EMS team levels, respectively.

RESULTS

We analyzed 3856 OHCA patients distributed across forty-three EMS ambulance teams. Survival to discharge was observed in 193 (5%) patients. The two EMS team process measures were positively associated with an improvement in survival at the patient level after case-mix adjustment. However, they were not associated with improvement in the risk-adjusted survival rate.

CONCLUSIONS

The EMS team-level process measures proposed by international institutes may not predict the risk-adjusted survival rate. Using these measures to motivate EMS teams to improve their quality performance would be questionable. Increased efforts should be devoted to constructing more pivotal EMS team-level process measures that are tightly linked to survival.

The Canadian National EMS Research Agenda: a mixed methods consensus study

Introduction:

Research is essential for the development of evidence-based emergency medical services (EMS) systems of care. When resources are scarce and gaps in evidence are large, a national agenda may inform the growth of EMS research in Canada. This mixed methods consensus study explores current barriers and existing strengths within Canadian EMS research, provides recommendations, and suggests EMS topics for future study.

Methods:

Purposeful sampling was employed to invite EMS research stakeholders from various roles across the country. Study phases consisted of 1) baseline interviews of a subsample, 2) roundtable discussion, and 3) an online Delphi survey, in which participants scored each statement for importance. Consensus was defined a priori and met if 80% scored a statement as “important” or “very important.”

Results:

Fifty-three stakeholders participated, representing researchers (37.7%), EMS administrators (24.6%), clinicians/ providers (20.7%), and educators (17.0%). Participation rates were as follows: interviews, 13 of 13 (100%); roundtable, 47 of 53 (89%); survey round 1, 50 of 53 (94%); survey round 2, 47 of 53 (89%); and survey round 3, 40 of 53 (75%). A total of 141 statements were identified as important: 20 barriers, 54 strengths/opportunities, 31 recommendations, and 36 suggested topics for future research. Like statements were synthesized, resulting in barriers (n 5 10), strengths/opportunities (n 5 24), and recommendations (n 5 19), which were categorized as time, opportunities, and funding; education and mentorship; culture of research and collaboration; structure, process, and outcome of research; EMS and paramedic practice; and the future of the EMS Research Agenda.

Conclusions:

Consensus-based key messages from this agenda should be considered when designing, funding, and publishing EMS research and will advance EMS research locally, regionally, and nationally.

Volume versus outcome: More emergency medical services personnel on-scene and increased survival after out-of-hospital cardiac arrest

BACKGROUND AND AIM

The large regional variation in survival after treatment of out-of-hospital cardiac arrest (OHCA) is incompletely explained. Communities respond to OHCA with differing number of emergency medical services (EMS) personnel who respond to the scene. The effect of different numbers of EMS personnel on-scene upon outcomes is unclear. We sought to evaluate the association between number of EMS personnel on-scene and survival after OHCA.

METHODS

We performed a retrospective review of prospectively collected data on 16,122 EMS-treated OHCA events from December 1, 2005 to May 31, 2007 from a combined population over 21 million people residing in an area of over 33,000 square miles in Canada and the United States. Number of EMS personnel on-scene was defined as the number of EMS personnel who responded to the scene of OHCA within 15 min after 9-1-1 call receipt and prior to patient death or transport away from the scene. Associations with survival to hospital discharge were assessed by using generalized estimating equations to construct multivariable logistic regression models.

RESULTS

Compared to a reference number of EMS personnel on-scene of 5 or 6, 7 or 8 EMS personnel on-scene was associated with a higher rate of survival to hospital discharge, adjusted odds ratio [OR], 1.35 (95% CI: 1.05, 1.73). There was no significant difference in survival between 5 or 6 personnel on-scene versus fewer.

CONCLUSION

More EMS personnel on-scene within 15 min of 9-1-1 call was associated with improved survival of out-of-hospital cardiac arrest. It is unlikely that this finding was mediated solely by earlier CPR or earlier defibrillation.

Paramedic Differentiation of Asthma and COPD in the Prehospital Setting Is Difficult

INTRODUCTION

Separate clinical practice guidelines (CPG) for asthma and chronic obstructive pulmonary disease (COPD) often guide prehospital care. However, having distinct CPGs implies that paramedics can accurately differentiate these conditions. We compared the accuracy of paramedic identification of these two conditions against the emergency department (ED) discharge diagnosis.

METHODS

A retrospective cohort of all patients transported to ED by ambulance in Perth, Western Australia between July 2012 and June 2013; and identified as "asthma" or "COPD" by paramedics. We linked ambulance data to emergency department discharge diagnosis.

RESULTS

Of 1,067 patients identified by paramedics as having asthma, 41% had an ED discharge diagnosis of asthma, i.e., positive predictive value (PPV) = 41% (95% CI 38-44%). Of 1,048 patients recorded as COPD, 57% had an ED discharge diagnosis of COPD (PPV 57%; 95% CI 54-60%). Sensitivity for the paramedic identification of patients diagnosed with asthma or COPD in the ED was 66% for asthma (95% CI 63-70%) and 39% for COPD (95% CI 36-41%). Paramedics reported wheezing in 86% of asthma and 55% of COPD patients.

CONCLUSION

Differentiating between asthma and COPD in the prehospital setting is difficult. A single CPG for respiratory distress would be more useful for the clinical management of these patients by paramedics.

The effect of work shift configurations on emergency medical dispatch center response

OBJECTIVE

It has been proved that emergency medical dispatch centers (EMDC) save lives by promoting an appropriate allocation of emergency medical service resources. Indeed, optimal dispatcher call duration is pivotal to reduce the time gap between the time a call is placed and the delivery of medical care. However, little is known about the impact of work shift configurations (i.e., work shift duration and work shift rotation throughout the day) and dispatcher call duration. Thus, the objective of our study was to assess the effect of work shift configurations on dispatcher call duration.

METHODS

During a 1-year study period, we analyzed the dispatcher call durations for medical and trauma calls during the 4 different work shift rotations (day, morning, evening, and night) and during the 10-hour work shift of each dispatcher in the EMDC of Nantes. We extracted dispatcher call durations from our advanced telephone system, configured with CC Pulse + (Genesys, Alcatel Lucent), and collected them in a custom designed database (Excel, Microsoft). Afterward, we analyzed these data using linear mixed effects models.

RESULTS

During the study period, our EMDC received 408,077 calls. Globally, the mean dispatcher call duration was 107 ± 45 seconds. Based on multivariate linear mixed effects models, the dispatcher call duration was affected by night work shift and work shift duration greater than 8 hours, increasing it by about 10 ± 1 seconds and 4 ± 1 seconds, respectively (both p < 0.001).

CONCLUSION

Our study showed that there was a statistically significant difference in dispatcher call duration over work shift rotation and duration, with longer durations seen over night shifts and shifts over 8 hours. While these differences are small and may not have clinical significance, they may have implications for EMDC efficiency.

Are paramedic students ready to be professional? An international comparison study

INTRODUCTION

The last decade has seen rapid advancement in Australasian paramedic education, clinical practice, and research. Coupled with the movements towards national registration in Australia and New Zealand, these advancements contribute to the paramedic discipline gaining recognition as a health profession.

AIM

The aim of this paper was to explore paramedic students' views on paramedic professionalism in Australia and New Zealand.

METHODS

Using a convenience sample of paramedic students from Whitireia New Zealand, Charles Sturt University and Monash University, attitudes towards paramedic professionalism were measured using the Professionalism at Work Questionnaire. The 77 item questionnaire uses a combination of binary and unipolar Likert scales (1 = Strongly disagree/5 = Strongly agree; Never = 1/Always = 5).

RESULTS

There were 479 students who participated in the study from Charles Sturt University n = 272 (56.8%), Monash University n = 145 (30.3%) and Whitireia New Zealand n = 62 (12.9%). A number of items produced statistically significant differences P < 0.05 between universities, year levels and course type. These included: 'Allow my liking or dislike for patients to affect the way I approach them' and 'Discuss a bad job with family or friends outside work as a way of coping'.

CONCLUSIONS

These results suggest that paramedic students are strong advocates of paramedic professionalism and support the need for regulation. Data also suggest that the next generation of paramedics can be the agents of change for the paramedic discipline as it attempts to achieve full professional status.