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