Clinical Benchmarks That Matter

Saturday, February 23, 2013
Matt Zavadsky

The following article is an EMS Insider exclusive from the January 2013 issue. The Insider, the premier publication for EMS managers, supervisors, chiefs and medical directors, is a must-have resource for the critical, accurate information EMS leaders need. The monthly publication offers quality investigative reporting, exclusive articles, management tips and the very latest news on legislative issues, grants, current trends and controversies. For more about how to become an Insider, click here.

In a previous column in the EMS Insider, I illustrated the need to deemphasize response times as the defacto quality measure of an EMS system based on the growing body of research appearing in peer-reviewed journals that shows response times greater than five minutes but less than 15 minutes generally make no difference in patient outcomes.

So this leaves us in a bit of a conundrum. Although the “need for speed” generally leads to increased risk, increased expense and little to no demonstrable benefit to patient outcomes, what clinical metrics should we be using to evaluate the quality of an EMS system?

Two potential resources seem to provide some expert guidance on the measures EMS systems should use to track and benchmark clinically effective interventions they believe should be used to evaluate clinical quality in EMS systems.

A position statement published in the April/June 2007 issue of Prehospital Emergency Care, by the U.S. Metropolitan Municipalities’ EMS Medical Directors (aka, the Eagles Consortium), outlines several key performance measures. These were identified by the medical directors of the 50 largest cities in the U.S. for the most common types of emergent medical conditions for which EMS may respond.

ST-segment elevation myocardial infarction (STEMI)
A STEMI is defined as a condition experienced by patients with signs and symptoms consistent, with ischemia with either ST elevation of at least 1 millimeter in two contiguous leads or left bundle branch block not known to have been present previously. The appropriate prehospital treatment includes:

• Administration of aspirin (not enteric-coated), unless a contraindication or a recent previous ingestion is documented;
• Acquisition of a 12-lead ECG with appropriate, training-based interpretation by a paramedic and transmission to a designated emergency physician for interpretation;
• Direct transport to an identified appropriate interventional (PCI) facility for STEMI patients with a written plan to activate the cardiac catheterization team prior to EMS arrival; and
• Elapsed time from acquisition of the diagnostic ECG (STEMI identified) to balloon inflation of less than 90 minutes.

Respiratory distress
The Eagle’s Consortium breaks down respiratory distress into two categories: pulmonary edema and bronchospasm.

Flash pulmonary edema/congestive heart failure (CHF) patients are presumed to be caused by pulmonary edema/left-sided CHF. Prehospital treatment should include:

• Administration of nitroglycerin to patients without contraindications (e.g., a given lower limit of systolic blood pressure, recent sildenafil citrate use); and
• Prehospital provision of noninvasive positive pressure ventilation to avoid endotracheal intubation (both prehospital and in-hospital).
• Bronchospasm patients with respiratory distress are found to have prolonged expiratory phase breathing that’s indicative of wheezing or known history of asthma or reactive airways disease. Provision of beta-agonist by the earliest-arriving, trained and qualified personnel is required.

In addition, patients with status epilepticus are those with seizure activity that persists for more than 15 consecutive minutes, or patients who have two or more seizures without an intervening period of clear mental status. Providers should obtain and measure a blood-glucose level.

Administration of benzodiazepine is recommended (e.g., lorazepam or diazepam) by the best available route (i.e., IV, intramuscular, rectal or intranasal).

Trauma
Trauma is defined by the American College of Surgeons trauma center triage criteria. Transporting paramedics or EMTs should limit on-scene time to less than 10 minutes or document reasons for the exception (entrapment or scene safety). They make the following suggestions:

• Transport should be provided immediately and directly to designated trauma center; and
• If on-scene time is extended while providers await air medical rescue crews, the total presumed ground and transport time intervals for the air crews should not exceed that of the time that would have been required by ground crews to get the patient to the trauma center.

During two recent panel discussions at national conferences, a group of experts identified what they felt were additional useful clinical metrics. This group included New Orleans EMS and Medical Director Jeff Elder, MD; HealthEast (Minn.) Medcal Transportation Medical Director Keith Wesley, MD, FACEP; and American Medical Response National Medical Director Ed Racht, MD. They made the following suggestions for cardiac arrest patients:

• Bystander CPR: Defined as the percent of cardiac arrest cases in which CPR was initiated prior to the first-arriving EMS unit;
• Time from 9-1-1 access to CPR: Defined as the duration of time from the 9-1-1 call being received at the primary public safety answering point and the time chest compressions were initiated; and
• CPR flow time: Defined as the percentage of time during EMS patient contact time in which a non-perfusing patient receives chest compressions.
•  

They made the following suggestions for stroke patients and those with ST-segment elevated myocardial infarction:

• Percentage of STEMI/stroke patients correctly identified as STEMI/stroke and transported to a STEMI/stroke receiving center;
• Percentage of STEMI/stroke patients not identified as STEMI/stroke patients in the prehospital setting;
• Time from symptom onset to 9-1-1 activation; and
• Emergency department (ED) dwell time: The time the patient spends in the ED prior to reperfusion.

Using these criteria, agencies can create a dashboard that provides an easy visual reference and comparable metrics that can be used to benchmark performance over time.

Outside the U.S.
The 12 National Health Service (NHS) Ambulance Trusts in the U.K. develop and publish a quarterly report card they use for tracking clinical performance. This process is used not only to measure performance over time, but also to measure an individual provider level for performance reviews. The chart at the bottom of this page is an actual Cycle 8 Report for compliance by ambulance trust for the STEMI care bundle of ASA administered (M1), NTG administered (M2), two pain scores recorded (M3) and analgesia given (M5).

The NHS system also tracks clinical performance measures for stroke, hypoglycemia and asthma. The results of all the trusts are rolled into one national report card on overall EMS system clinical performance. The chart on p. 10 is the 2012 performance clinical performance report.
Using these types of clinical performance measures that the medical community feels demonstrate clinical quality, we can benchmark our system and even employee performance for clinical metrics that matter. Imagine the day when we, as healthcare professionals operating in the out-of-hospital environment, can track and publish national compliance with medical treatments that the medical community feels makes a difference in patient outcome.

References
1. Myers JB, Slovis CM, Eckstein, M, et al. Evidence-based performance measures for emergency medical services systems: A model for expanded EMS benchmarking. Prehosp Emerg Care. 2008;12(2):
141–151.