A Child Is Dead. What Did Your Crew Do?

Cases in Quality

 

 
 
 

James J. Augustine, MD, FACEP | | Wednesday, December 5, 2007


The world is obsessed with quality. In every corner of the globe, people seek to provide consistent products or services that completely fulfill customer expectations. What is "quality" in the field of EMS? Can we help achieve a definition by understanding what quality is not?

A case study

As the quality director for your service, you receive and process patient care reports. These arewritten notes of satisfaction or dissatisfaction that come from patients, families or the EMTs themselves. Often more difficult to handle are the verbal reports, especially the ones that come directly to you from a reliable source that requires an immediate response on an unsatisfactory patient care encounter.

It_s a peaceful Friday afternoon when the phone rings; the ED manager of your favorite local hospital is on the other end. She asks if you could help her review a case. A 10-year-old patient is dead. According to his mother, he was seen byEMS. What did your crew do?

You feel the first wave of nausea as you ask quietly, "Any details available?"

The child and his mother were eating at a restaurant. EMS was called because the child was choking. Non-removal. Came to the hospital later that night. Admitted. A toothpick was stuck in the esophagus. Complications. Death. Devastated parents. The hospital has already received a request for records. They're probably going to ask for EMS records also.

Would you trust what you find in your file of patient care reports? How about what you'd find in the computer if the EMS service documents patient encounters using electrons? Then there's the dreaded word "non-removal."

Patient documentation is critical, for so many reasons. Yet we're probably at the point of most discomfort in the performance of this duty. A variety of parties -- including hospitals, states, billing companies, department quality directors, department chiefs and risk managers -- are interested in documentation. The many documentation options vary from paper reports to "bubble sheets," laptop to desktop computers. Some states or regions require all individual reports to be routed to a central collection point. Others want reports to provide a snapshot of the agency's patient care activities.

As the quality director, it's your opportunity to guide the agency's documentation and reporting decisions, improve the providers' work processes and simultaneously grab the information needed to report to the agency_s "customers" of the agency, whether they're politicians, members of the public or shareholders.

How do we know quality?

Can all quality be measured? Some would say quality is meeting or exceeding expectations. A variety of data models offer measures quality in terms of timeliness of response, reliable delivery of a service and customer satisfaction. Upcoming columns will look at those statistical elements. But the choking case described above, and many others, is not about numbers. A child is dead.

What's the best method for documenting that is timely, durable and able to provide information on the nature of the care delivered? Is it completed checkboxes? Certainly it's not a "bubble sheet." Many would still say the narrative patient care report -- describing what happened, the evaluation, the assessment and the disposition. -- proves a great patient care report. A few software/hardware systems may offer the ability to provide excellent documentation, quickly and reliably. Most present systems cannot.

How can an agency report its quality to an oversight organization at the state or regional level? Should quality be measured at the state level? I firmly believe that quality work and agency reporting canonly be done at the local level. When performed at the local level, by a quality director and reported to the agency chief, there is the greatest opportunity to capture accurate data, report it correctly and allow it to drive improvement efforts with the agency's EMTs. The agency can then develop trend lines and prepare reports for the city or county leaders responsible to the citizens served by the agency. The agency can even collaborate with a comparable agency to develop comparison reports.

The state (or region) certainly needs data, and it should receive it in the form of an agency report outlining the important elements of service: how many patient runs, how many cardiac arrests, how successful were intubation attempts, how often were backboards used and what was response time. The state or region can then report to its customers with the input of complete reports from all response agencies.

But back at work, the quality director still has to identify any issues related to the untimely death of a child. The quality director finds the patient care record in the agency's record system. It's a bubble sheet, filled out in detail -- name, address, normal vital signs, clear lungs, released with mom. There's a signature on a piece of paper. The run occurred one month ago, and the crew has absolutely no recollection of the incident. The computer input sheet doesn't help them remember, either.

It will be difficult to give the ED manager, or the parents, an answer about what theEMS crew found on their assessment. The potential for a lawsuit that names the EMS agency and crew members is very high. The potential for a settlement against the agency and the crew may also be high.

The quality director wanted to immediately address the issue and provide relevant training for all EMTs working with the agency. Bubble report sheets were removed. To get insight on patient care reports, the director queried all paramedics, emergency nurses, emergency physicians and EMS chiefs in the region. What follows are10 good documentation practicesthese experienced providers would offer:

  1. Document neatly and spell correctly.
  2. Record each patient encounter appropriate to the service provider's responsibility. First responders document what they find; transport crews document a full evaluation, assessment and results of treatment and disposition.
  3. Ask someone to review it with you. If the patient was very difficult or the encounter resulted in an unexpected negative outcome, audio record the report.
  4. Don't use bubble documents for patient documentation.
  5. Don't lie or make judgmental statements.
  6. Quote the patient or appropriate bystanders.
  7. Ensure consistency in the report, and explain any inconsistencies.
  8. Remember it's even more important to document non-transports.
  9. Know that the signature doesn't protect you when the patient isn't transported.
  10. Let the patient and bystanders know you care.

Case discussion

The family was unhappy. They still have two more years to decide whether to pursue a lawsuit

Learning point:Quality directors have great opportunities to develop documentation and reporting systems. System design begins with great patient care reports.

James J. Augustine,MD, FACEP, is an emergency physician from Washington, DC. He serves as deputy chief-assistant medical director for Washington, D.C. Fire & EMS Department. He's a clinical associate professor in the department of emergency medicine at Wright State University in Dayton, Ohio. Contact him atJames.Augustine@dc.gov.




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