One of the most important challenges facing EMS systems is getting hospital outcome data, ultimately in the goal of improving patient care. In the following interview, Paul Misasi, Quality Improvement & Patient Safety Manager for Sedgwick County (KS) EMS, explains how they use data and how they were able to use technology to overcome challenges to getting outcome data. Sedgwick County EMS (SCEMS) is a third service agency, and with 64,000 calls per year is the the busiest in the state, using 21 paramedic units to serve 1,000 square miles and 500,000 people.
Q: In general, how is Sedgwick EMS using data to improve clinical care and operations?
A: Our service, like many others, faces the issue of limited resources and high demands both in the field and the office, so we are highly selective in the matters we choose to tackle. When a challenge arises, we first want to identify whether it is a “one-off” issue (special cause variation) or a systemic issue (common cause variation). This is a very important distinction because treating special-cause issues as if they were systemic will have you chasing your tail for many months to come, while systemic issues require a full-blown quality improvement process.
Like everyone, we have many systemic issues and using data is necessary to first validate and investigate the scope of the problem, so we can then begin the prioritization process. Once an issue has risen to this level, we kick-off the quality improvement process, which also requires a careful selection and analysis of the data that will be used to demonstrate that an improvement effort has had the desired effect. We use our data for varying issues including clinical quality improvement, dispatch performance, and public health issues.
Sedgwick County EMS’s vision is to make a measurable difference in the health of its community. Photo courtesy Sedgwick County EMS
Q: Specifically, how are you using data as part of your quality management process?
A: There are three common ways to measure quality in healthcare: outcomes, process, and structure. The literature demonstrating outcome-justified or evidence-based practice in prehospital care is sparse, but there is some, so it was an important place to start. While the strength of the evidence begins to decrease, especially in terms of outcomes, there are many practices and processes that are worth implementing and measuring, such as AHA Mission Lifeline standards for STEMI care, hospital-based metrics that have implications for prehospital care practices and direct to CT, or cath lab for stroke patients. We are also beginning to incorporate the EMS Compass metrics, such that we have mechanisms in place to capture this information should they become compulsory standards of reporting.
Q: How does technology help you manage your data?
We use software called FirstPass, by the creators of FirstWatch, to evaluate our PCRs against quality metrics and highlight the discrepancies for human review and feedback in real-time. Alerts notify specialty teams at each of our major hospitals when a PCR has been completed pertaining to their focus (i.e., STEMI, stroke, etc.). Each alert generates a form within FirstPass that the STEMI or stroke team fills out with follow up information such as occluded vessels, definitive diagnosis and time to intervention; anything we want to collect.
FirstWatch technology helps SCEMS aggregate its data and drill down to team level and/or individual provider level performance along multiple dimensions. Photo courtesy Sedgwick County EMS
Q: Why is having outcome data so critical to the improvement process?
A: In 2012, we re-wrote our mission, vision, and values. Our mission at SCEMS is to provide quality out-of-hospital healthcare and our vision is to make a measurable improvement in the health of the community. Therefore, outcome data is really our only way to prove that we are achieving our mission and vision. Generally speaking, outcomes are the best method we have for evaluating the performance of our greatest assets, the paramedics and their clinical decision making, so that we can create systems that improve or enhance this performance. Outcome data enables our ability to either validate or refine our field impression(s) and allows us to highlight the positive interventions provided by EMS, or to discover if there are deficiencies in assessment and direct further investigation. It also bridges the gap between the continuum of care from dispatch, prehospital care and final diagnosis and discharge. It enables us to identify processes in need of improvement.
Q: What are the obstacles to getting outcome data?
A: HIPAA has created an artificial barrier with some facilities by creating reluctance to share data for fear of violating privacy laws. Even without HIPAA worries, disparate data sources make it difficult to collect information in a consistent manner, and view the data in one place. Now it is even difficult to get demographic and other face-sheet data from hospitals, even immediately after we drop the patient off in the ER. Other barriers include the lack of technological sophistication in navigating the complexities of connecting, mapping, and moving data. We also have to demonstrate to those institutions that provide the data the business need, not just the altruistic reasons, for doing so. This is something we have been able to begin to demonstrate with our new community paramedic program. Finally, there are political and ideological obstacles to navigate; regardless whether we agree or disagree, they must be addressed carefully and with sincerity.
Q: How is Sedgwick able to “connect all the dots” from dispatch to discharge?
A: By using FirstWatch to tie the disparate data sources together, Sedgwick has a unified location for all patient data from their CAD, ProQA, ePCR and Hospital ED final outcome data. We can view the information with one single login and create customized alerts based on any of the data points across the spectrum, which enables analysis of new variables such as first medical contact to hospital intervention(s). This information can be used to further investigate how prehospital care impacts processes and outcomes as an integrated whole, and as it is experienced from the patient’s point of view. Doing so further demonstrates the importance of prehospital care as a critical component of the healthcare system.
Q: What are you doing with your outcome data, in terms of feedback to the medics?
A: Knowing how to use data and understand what it means is what makes that data valuable. Our software is able to do what no other ePCR systems are able to do at this point, pivoting data upon nearly any variable. We are able to aggregate our data and drill down to team level and/or individual provider level performance along multiple dimensions. For example, we may be able to identify that certain crews or groups are able to achieve remarkable door-to-balloon times on STEMI patients. With this information, we can identify the methods the crews use to achieve success, so that it drives new approaches and education to the service.