Administration and Leadership, Columns

Striving Toward Evidence-Based EMS Performance Measures

Issue 4 and Volume 42.

The concept of customer satisfaction in medicine has largely been borrowed from the corporate world, but exactly how well it reflects quality in healthcare is a matter of debate.

Patient Satisfaction

For those who work in hospitals, patient satisfaction isn’t just some kind of nicety for physicians, nurses and other staff to strive for; it’s now become a compelling focus for hospital administrators as well.

Like financial penalties for 30-day readmissions, current hospital reimbursements from Medicare, Medicaid and third-party insurance payers are directly tied to these scores.

The underlying principle is that hospitals should be paid more for higher patient satisfaction, presumably because these scores reflect better outcomes.

Presumably.

We also must be careful how we use patient satisfaction to drive performance. ED doctors’ salaries, for instance, are often directly tied to these scores, and it’s one of the reasons many physicians say they have given opiate painkillers to patients when they might otherwise have preferred not to. Though perhaps not the cause of the current epidemic of narcotics use or drug seeking in the ED, ensuring patient “satisfaction” in these cases may not have helped either.

Quality in EMS

Although customer satisfaction doesn’t currently pose the kind of financial bottom line for EMS that it does for hospitals, many of our systems create their own patient surveys, the results of which are often shared with city leaders or boards of directors, or even the media, as evidence of how well we are doing.

How well a patient’s perception of their EMS experience matches the actual quality of care they receive is also a source of debate.

Thus, a five-minute response time from a truly kind, compassionate and highly experienced EMS crew might not accurately predict if a patient eventually dies in the back of the ambulance say as a result of delayed airway management or inappropriate use of CPAP, or following an unrecognized misplaced tube.

This, by the way, isn’t a potshot at EMS professionals who are doing the best job they can, especially given the wide range in quality of classroom training, field preceptor programs and ride time that is available to them. Some of our crews’ unfortunate clinical outcomes may also reflect quality assurance (QA) processes that we put in place to ensure patient care.

We don’t go out and buy ambulances and fire trucks that aren’t equipped with speedometers or pressure gauges, so what’s the logic to placing supraglottic or endotracheal tubes without end-tidal carbon dioxide (EtCO2) capability, regardless of the complexity of the airway or of the individual provider’s skill level and experience?

Another Path

As we develop quality measures for EMS, what if we don’t just look at process measures (e.g., time to aspirin administration) or subjective measures of success (e.g., the number of IV attempts or endotracheal tube placement)?

What if we hold ourselves instead to objective measures of quality, like oxygen saturation and four-phase waveform EtCO2 for every airway; and 90% time-on-the-chest and minimal frequency and duration of pauses during CPR?

If we’re still going to be held to process measures like response times, then how about evidence-based ones that actually matter: Four to five minutes for a responder to arrive on-scene who can perform CPR, defibrillate and manage an airway.

And what about 9-1-1 call processing times? How important is it to rush to the scene of a call if it only gets dispatched after going through one, two or even three separate 9-1-1 public safety answering points?

EMS Agenda for the Future

What if, in the future, our budgets and even our leaders’ salaries depended on systems having the necessary processes, personnel and tools in place to measure true quality, and to report on it in transparent fashion? Then there would be no more excuses that we don’t have the financial resources, staff or technology to support these critical functions.

Word has it that we’re about to develop another EMS Agenda for the Future. That’s good, but how about the last one we haven’t fully translated and operationalized yet? Maybe it’s time to try and finish implementing this one first.