Successful EMS systems don't happen by chance or accident. They exist within their community to serve an important need. This need may be a reliable, timely emergency response to any given location in the community; a dependable, well-trained EMS professional to care for the acutely ill or injured; or a local resource for the mitigation of a natural or manmade disaster. Each of these EMS system components requires ongoing resources, knowledge, expertise and, most importantly, funding.
If your EMS system is like most, you've noticed changes in accepted benchmarks locally and within the industry. First, your community's size and the number of EMS events each day has increased. Along with this increased volume, the patients you care for are more complex, more likely to be geriatric and require an increased amount of care and resources. Regionalization requires that systems mature, because there's an expectation that the right patient gets to the right location in the right time.
Along with this increase in volume and complexity has come an increased cost in supplies, resources, personnel and training. This comes at the same time as the economic and health-care crisis in the U.S. Those who are billing for their services are seeing their percentages for unreimbursed care rise. Those who don't bill for their services soon will. The endpoint is more volume and a higher level of service, with less funding.
So how does an EMS system survive and even thrive in this world of health-care crisis and reform? How do we hold our own with the city council or county commissioners when additional ambulances, 12-lead ECGs, capnography or paramedic staffing are needed? How does a community decide between a new school bus and an ambulance? If your government or community is unable to provide these resources, is that the end of the game? What other resources can be called upon to meet your needs?
We believe the answer is in data. By using EMS data, agencies can describe and advocate for their community and patients' needs. Through the relationships an EMS system maintains within its community, the knowledge an EMS data system provides can be the power to control its destiny.
To make our point, let's express data as an acronym for Dollars, Application, Time and Advocacy. We will address each as it relates to our story about Acme EMS and the way they successfully used data to meet systemƒand ultimately communityƒneeds.
"A" Is for Application
John always wanted a sports car. He worked extra shifts, saved as much as he could and finally, after two years, he was able to purchase a brand-new red convertible. As soon as he drove it home, he quickly pulled into the garage, placed a protective cover over it and closed the door. From that point on, he drove the car only when he had a friend over, or for routine maintenance needs.
Does this describe the EMS data system you've worked to build and maintain? EMS data is not something you collect and hide; it should be something you apply to daily EMS operations. Within an EMS data system, there's vast information on how service delivery, professional performance and patient care are provided. It's through an EMS data system that you determine how your volume is increasing. Is it on a specific day of the week, or only during certain hours of the day? Is it only in a certain geographic location within your service area? Is this increased demand beyond your current staffing configuration?
Let's say Acme EMS System has noted an increase in their emergent response times over the past year. Using benchmarking data from their state EMS data system, their response time was noted to be on average three to four minutes longer than similar EMS systems. They operate within a rural environment with three in-service ambulances staffed by EMS crews working 24-hour shifts at all times. Using the EMS data system, it was noted that the number of events experienced by Acme EMS peaked in the late afternoon, with three to five events per hour (see Figure 1). The average total call time for Acme was noted to be 60 minutes.
This information identified a scenario where demand exceeded existing resources. The solution would require an additional ambulance to be brought into service late in the afternoon. The data also revealed that the demand does not require a fourth ambulance for a full 24 hours. The demand was noted only for eight to 10 hours. It was determined that staffing requirements would best interface with current operations by implementing an additional 12-hour ambulance beginning at noon and operated until midnight each day.
"A" Is also for Advocacy
Acme EMS System is a governmental service provided by Acme County. Each year, it must go through a budget process with all other county divisions. This budget process serves to evaluate all county budget and resource requests, ultimately ranking them by their importance to the county and its citizens. Projects that rank highly based on their need and value will be funded.
Acme EMS leaders felt comfortable with their justification for an additional peak-time ambulance. However, to be successful in the county budget process, they knew this new resource would have to be translated into value for the community. Going back to the data, Acme was able to identify five time-dependent illness and injury patient types that could benefit from this additional ambulance and improved emergent EMS response times. These were cardiac arrest, trauma, ST-elevation myocardial infarction (STEMI), acute stroke and respiratory distress.
Over the previous 12 months, it was noted that 60 patients had experienced these conditions during the 12 hours each day this new ambulance would be in service. To show how this three-to-four-minute improvement in response time could improve outcomes, information from the American Heart Association's ACLS manual was used. This information illustrated a 10% decrease in survival for each minute a patient was in cardiac arrest prior to CPR and defibrillation.
Ultimately, Acme EMS provided a budget plan to the county requesting funds for an additional 12-hour staffed ambulance to decrease EMS emergent response times by an average of four minutes. In the plan, Acme was able to advocate for this additional ambulance and for the improved care and outcomes of their patients because it provided care to at least one time-dependent ill or injured patient each week whose outcome could be impacted by this improved response time. As an example, each cardiac arrest patient would have a 30Ï40% improved chance of survival with this additional ambulance.
'D' Is for Dollars
Acme EMS System's budget plan and proposal were successful and fully funded by Acme County. This was a great victory for Acme EMS. The data system was able to provide information to document the need, justify the additional resources and describe the value to the community.
During this process, one other need was noted but unable to be funded in the budget process. The budget provided for an ambulance, staff and basic operational supplies, but to adequately care for the acutely ill and injured patients within the community, the ambulance also needed an advanced monitor/defibrillator with 12-lead ECG and capnography capabilities. This device would provide Acme EMS with the tools to quickly identify STEMI patients, better care for cardiac arrest patients, and more accurately monitor the respiratory and cardiac function of all acute patients.
Using the state EMS data system, Acme EMS was able to obtain aggregate and benchmarked information on the five time-dependent patient types (cardiac arrest, trauma, STEMI, stroke and respiratory distress), including their outcomes for each of the state's counties. The state EMS data system provides outcome information back to Acme EMS via a linkage between the agency's EMS data system, emergency department (ED) data system and hospital inpatient data system. This linkage allows the state EMS office to obtain the outcomes of all EMS patients in these five categories.
Based on this outcome information and the results of each county across the state, it was determined that there was a disparity in the outcomes of patients within Acme County. STEMI patients were not being rapidly identified because identification requires 12-lead ECG capability. This inability to identify STEMI patients caused a delay in the definitive treatment of these patients and, ultimately, a worse outcome compared with other counties. Similarly, airway emergencies were not being monitored by Acme EMS, also due to a lack of capnography equipment.
Armed with the EMS data associated with the newly funded ambulance, impact of response times on the outcomes, and identified disparity in care for STEMI and airway emergency patients, Acme decided to approach a private endowment for funding. The Best Foundation strives to improve community health and education in the region by funding initiatives in health care with a focus on the underserved. Acme EMS completed an application to the Best Foundation requesting the monitor/defibrillator with 12-lead ECG and capnography capability for the new ambulance and upgrades to their existing equipment to provide this capability systemwide.
The application was based on their history and success in obtaining resources through the county as well as an objective description of this additional need supported by outcomes measured through the state EMS data system. Along with this need for the equipment, the numbers of patients with STEMI and airway emergencies were described to add value to the proposed solution to the identified STEMI care and airway management disparity. Objective measures used to evaluate the impact of the Best Foundation investment would be the outcomes of future patients pulled from the state EMS database managed by Acme EMS after this equipment was in place.
The Best Foundation funded the initiative for Acme EMS, enabling it to purchase the essential equipment. Acme EMS used the data system to provide an objective evaluation of the project and show an improvement in their STEMI care and airway management to the Best Foundation.
"T" Is for Time
This example illustrates how EMS systems can take control of their destiny through use of data. But Acme EMS' success didn't happen overnight. Change toward a data model requires a belief in EMS data systems. The system must be as much a part of the organization as each ambulance or EMS crew, and that takes time.
To be able to use data, it must be complete and collected in an accurate manner that reflects the service delivery and patient care provided. The power and value of an EMS data system is directly proportional to the time and value it's given by EMS administration and staff. EMS data systems require time to build, time for data collection, and time for data analysis and application. The decision of which EMS data system to use is as important as who you hire, what ambulance you drive and what drugs you carry.
The ability for EMS data systems to provide meaningful information on patient outcomes requires a maturity of health-care data systemsƒincluding EMS. Many states either have or are building EMS, ED, hospital inpatient (often referred to as discharge), trauma, stroke, STEMI, airway and other data systems. EMS data systems should be linked to these other data systems to provide an overall picture of each patient's journey through the health-care system. This will permit EMS to evaluate the impact of their care and decisions on the overall outcome of the patient. Ultimately, this can allow data to be moved between data systems, decreasing the documentation time and improving data quality and, overall, patient care and outcomes.
Relationships are built on trust and communication. Our health-care environment is moving to a regionalized, connected model. Every patient's outcome is a sum of the care provided by all. This is especially true with the time-dependent illness and injury types described in this example. To get the right patient to the right place at the right time, there must be constant communication before and after each event. Relationships combined with data systems are the currency of the future. JEMS
The following staff of the EMS Performance Improvement Center (EMSPIC) contributed to this article: Cindy Raisor, Brian Barrier, Melissa Black and Joe Fraser. EMSPIC is a division of the Department of Emergency Medicine at the University of North Carolina at Chapel Hill.
The names used in the preceding examples are fictitious and do not represent a real individual, EMS system, county, state or foundation.
For more on data collection, read "Avoid Information Overload" at www.jems.com/documentation