Let’s be clear about the focus that Paul Paris, MD, FACEP, LLD (Hon.) has on EMS. Paris, professor of emergency medicine at the University of Pittsburgh School of Medicine and medical director for the Center for Emergency for Western Pennsylvania, is all about the health and safety of EMS providers. To prove it, he has spent much of his professional life advocating for the kinds of research that will make their lives safer and easier.
“EMS providers are neglected heroes,” he says. “They are underappreciated, overworked, underpaid, and their safety and wellbeing isn’t well cared for,” he says. Not to mention the potential injuries to backs, shoulders, knees, the stress and the toll on emotions. “We expect so much from folks that we don’t really compensate materially or emotionally,” he says. “It’s a major dilemma that most Americans don’t have a clue about.”
A New Alliance
So when Paris got an opportunity in 2011 to partner with the nationally recognized Jewish Healthcare Foundation (JHF) to address the issues of patient and provider safety in prehospital care, he jumped at the chance. “JHF is a foundation whose mission is largely to improve quality and safety in healthcare,” says Paris. Under his leadership, JHF funded an EMS safety fellowship/quality champions program to help translate the quality improvement and patient safety work they pioneered in the hospital setting to EMS services throughout Western Pennsylvania. JHF has funded similar programs with physicians, pharmacists and nurses.
This past year, the champions program chose 20 EMS fellows to participate in cutting-edge quality improvement and safety training exercises. Many of the participants brought their own ideas for projects and initiatives to work on during the yearlong program. The goal of the program is that the fellows will take both the tools and the insight they have garnered during the program back to their own EMS agencies once their fellowship is complete.
Some of the projects are simple, yet effective. Take, for instance, the flight medic who noticed that, because of logistics, the pre-shift check of the helicopter was only getting completed about 70% of the time.
“What she did was go through and analyze the process, how does it gets done, and what leads to it not getting done,” Paris says. “She changed some very simple things, like where the checklist is located, and putting extra copies in different locations, and now the pre-shift check is completed 95% of the time.”
This kind of logistical need for pre-checks is common, according to Paris. “In our region, for example, when we’ve done unannounced inspections of ambulance, we tend to find things like suction units that don’t work, or vital drugs that are outdated, or equipment that’s just not on the truck,” he says. “We need to pay more attention to the most basic details of a culture of safety.”
In addition to project work, the 20 fellows go through an online educational component, called perfecting patient care, which teaches Lean-based methodology. They also become members of a community of professionals interested in safety through a companion online portal called Tomorrow’s Healthcare (https://tomorrowshealthcare.org). They also do some classroom work, attend a series of quarterly lectures and undergo periodic analysis of their respective projects.
Another student’s project revolves around the question of why patients in extreme pain, say, from an acute fracture, aren’t given adequate analgesia. Paris cites a study where paramedics had standing orders that allowed for the dispensing of morphine or a mixture of oxygen and nitrous oxide without having to call a doctor. If they thought the patient was in pain, they could go ahead and dispense the analgesia.
“So they looked retrospectively at a thousand patients, with suspected extremity fractures, and only 18 out of 1,000—1.8%—got pain medication,” says Paris. “We don’t know why there is this incredible reluctance on the part of paramedics to treat patients who are in obvious pain. So this student has designed a questionnaire that we are sending out anonymously to try to find out the most common factors that paramedics give for not being more proactive, or even reactive, when it comes to treating a patient in pain.”
Another student’s project revolves around the issue of EMS provider health, specifically, in the areas of diet and exercise. “Because of their work schedules, many paramedics and EMTs don’t practice the healthiest patterns,” says Paris. “[The student] analyzed ways that, during their shift, they could routinely stretch, or go on a walk by mapping a customized walking trail around every EMS station or helipad, with distances measured.”
Dozens of EMS personnel applied for the few select spots, so just how were the winning applicants chosen? Paris says they looked for people who might be EMS champions, leaders or future leaders, who either by their position or intense enthusiasm would, after the course, teach the principles they learned to others, and “start to move the tipping point where safety is a consideration.”
“A couple of years ago, if you would have said to 1,000 EMS providers, please describe your understanding of a safety culture, I would say 95% would have been totally clueless,” says Paris. “A safety culture is part of everything you do and plan; it’s always a consideration. This is not only about patient’s safety, but also about provider safety, where we don’t allow our providers to be put in situations where their health and wellbeing is jeopardized or that of their patients.”
Paris is quick to admit that improving the lives of patients and first responders, while much needed and gratifying, also comes with its own dilemma. “We can get national attention to the fact that ambulances and patient care are much less safe than they should be, but I just told you that paramedics are heroes and no one is appreciating them,” Paris says. “The last thing they need is for the public to think it’s unsafe when they call an ambulance, or that these people are not delivering great care.”
He adds, “In EMS, there is a lack of uniformity—different partners, a lack of communications between partners in the hierarchy of authority. Every aspect that could threaten patient safety occurs, but we don’t want the public to start feeling bad about paramedics because they’re already beat upon. I love paramedics. So how do we fix it without embarrassing anyone?”
The answer may lie, in part, in medical error and prevention reporting systems, which encourage anonymous reporting of medical errors for the sole purpose of addressing, and correcting, faulty systems, rather than punishing the offender.
“So, instead of having an environment of blame, which is what we have now[is], let’s have an environment of openness and anonymous reporting, in which we try to figure out where the system’s flaws are, and how we can try to help protect people from making mistakes by designing a safer system,” Paris says.
Paris is hopeful that the projects completed under the JHF partnership will have broad and far-reaching impact. Now that the yearly champions program is coming to a close, he has his sights set on a new initiative, one that again partners with JHF. And with our growing digital age, the program should be popular. Paris envisions an online education program that will be very EMS specific. “We hope to do this next year,” he says. “The content will be interesting, with real-life situations, not talking heads, that will point out the issues and what will be necessary to address those issues to create a culture of safety.”
Some would consider Paris a champion of EMS, but he brushes the compliments aside, preferring to cast the spotlight on the EMS providers who are on the frontline every day caring for patients and saving lives. “I’ve always identified with underdogs, the underappreciated and unrecognized,” he says. “And there is no one in this society more underappreciated than EMS providers. The job is stressful, challenging, and yet they are the ones that sometimes determine whether our loved ones are going to live or die.”
As for the just-completed JHF champions program, Paris hopes some of the findings that come out of the student’s projects will be published, talked about, and, eventually, have a positive effect, although he acknowledges that is sometimes a slow process. Still, he’s hopeful.
“The whole program is going to be described in great detail by one of the students, Daniel Patterson, who is co-editor of this past issue of Prehospital & Disaster Medicine,” he says. “Almost the whole issue is devoted to patient safety. We expect impact that will be a pebble in a pond, slowly emanating waves.” Patterson was named as one of 2010’s EMS 10 innovators.
Paris concludes, “One of the biggest steps that can occur would be for society to begin to recognize the value of EMS providers and ensure that they are treated with the same respect and rewards of other members of the healthcare team.”