JFK Medical Center, a part of the Hackensack Meridian Heath Network, made a bold move in 2011. Based on the insight and actions of staff, the hospital made an investment in EMS.
As a certificate of need holder for ALS, JFK made the decision to expand services. New Jersey mandates a two-tiered system and conveys ALS by certificate of need based on geographic and population delineations.
The model deployed at JFK Medical Center in 2011 was a two-provider fly car ALS response unit. This model has since evolved into a pseudo-high-performance EMS model within the limitations of N.J. regulation that provides ALS, BLS, critical care transport, and a command and control center that coordinates 9-1-1 call screening and response per ProQA guidelines, non-emergency transport, lab specimen pick-up, mobile X-ray dispatch and coordination with Lyft for patient transport.
The evolution of JFK EMS was based the concepts of the Institute for Healthcare Improvement’s Triple Aim, which focuses on access, quality and cost.
The system status management and dynamic deployment provided a means to ensure access and limit expense, but the idea of quality was elusive.
Through long conversations with Jonathan D. Washko, MBA, NRP, AEMD, of Northwell Health Systems, we decided to use the Rapid Emergency Medicine Score (REMS) applied to the first and last set of collected vital signs as a means to measure the difference we make during patient contact, and ultimately to show quality in EMS.
Our goal in employing the REMS score is to prove that the interventions provided in the prehospital arena have an impact not only on the patient’s short-term prognosis but also on a patient’s trajectory within the healthcare system, up to and including the outcome of their care. These claims have historically been difficult for EMS agencies to quantify and prove.
To provide qualitative support for the hypothesis that EMS has an impact on the outcome of the patients we care for, a measure must exist that allows for the empirical measurement of patient condition. REMS may allow for this quantifiable measure in both trauma and medical patients, and has proven to be portable beyond the confines of the EMS encounter alone. Other organizations are already beginning to apply the REMS score during ED stay, and investigating its use as a predictor of appropriate ALS triage.
To start the data collection process, JFK EMS providers were educated on REMS scoring from an operational and clinical perspective, and a laminated card that clipped behind their ID badge as a quick reference memory aid for scoring was distributed.
A customized REMS score was also added to our ZOLL electronic patient care report (ePCR) charting system with the functionality to automatically calculate the score based on a selected set of vital signs. Chart completion rules were also added as a reminder to crews that REMS scores are collected on every patient encounter resulting in transport. The concept of adding another charting field to an already busy day was a concern at first, but ultimately was met with little resistance as the team came to understand the true implications of the data in legitimizing our role in health care.
The Agency for Healthcare Research and Quality (AHRQ) defines quality in healthcare as, “the degree to which healthcare services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”1
To apply this concept to EMS, the desired goal of improving the patient condition had to be proven not only through real-time REMS scoring, but also through linking EMS encounters to outcomes in the medical record. To support this notion, the National Highway Safety and Transportation Authority’s “colloquial” definition of EMS must be established as, “prehospital healthcare for patients with real or perceived emergencies from the time point of emergency telephone access until arrival and transfer of care to the hospital.”2
The concept of demonstrating the impact of prehospital treatments on patient length of stay (LOS), morbidity and mortality are important measures that far outweigh operational metrics such as the response times on which EMS organizations are often judged. But, to prove that EMS care has an impact beyond a ride to the hospital, a reliable, reproducible and valid clinical quality measure must be established.
Thomas Olsson, MD, PhD, from the Hospital of Östersund, Sweden, developed the Rapid Emergency Medicine Score (REMS) as a predictor of in hospital mortality for non-surgical patients. The score was an attenuation of the Rapid Acute Physiology Score (RAPS), which is an abbreviated version of APACHE II scoring system. REMS was shown to be a strong predictor of mortality with limited correlation to length of stay (LOS).3
REMS was also applied to the trauma population in a 2014 study which found REMS to be superior to the Injury Severity Score (ISS) and the Shock Index (SI) in predicting mortality.4
REMS is derived from the sum of scores for six key parameters: patient’s age, mean arterial Pressure (MAP), heart rate, respiratory rate, SpO2 and Glasgow coma scale. Each category is assigned a point value dependent on findings. Points are then added up to calculate the REMS score for the selected set of vital signs, and ultimately within our data collection, the first set of vitals are compared to the last set of vitals and a change in REMS is calculated. (See Table 1.)
The range for REMS is 0–26, with 26 being the most acute. Patients at the higher end of the REMS score have been associated with the greatest risk of in-hospital mortality.3 (See Table 2.)
A 2017 report published in the American Journal of Emergency Medicine shared the results of a prospective study conducted from April 2013 to March 2014 in which all non-cardiac arrest patients transported within the Mecklenburg County (N.C.) EMS agency received REMS scores.5
The results showed that higher acuity patients had greater changes in their calculated REMS, validating that “the Rapid Emergency Medicine Score is associated with other accepted methods of classifying patient severity in the prehospital setting.”5
Results to Date
JFK EMS has been collecting REMS on its patients for the past 18 months. REMS is calculated by providers at the time of initial assessment and the comparative score is collected at the time of transfer to the ED. The score is then recorded in the ePCR and retrospective analysis is performed. Patients received at JFK Medical Center then have their prehospital chart married to an ED chart and eventually, if applicable, to an in-patent chart.
A review of prehospital impression, admitting ICD-10 code and inpatient diagnosis-related group (DRG) was performed on patients that had a positive change (i.e., decrease) in REMS. Patients that had general impressions that matched their admission ICD-10 and their ultimate discharge diagnosis were included in the comparison. The results are shown in Table 3.
Existing literature shows a modest correlation between REMS and LOS, but this conclusion came only from ED scoring. Because of this limitation, the difference that EMS made prior to hospital arrival was outside the scope to the study.3
More research is required, but initial data shows that REMS may be a predictor of positive EMS impact on patient care not only during prehospital treatment but also in regard to hospital LOS. The implications of this concept are beyond the financial realm in that longer hospital stays have been associated with greater incidence of secondary infection, increased risk for medical errors and increased incidence of other iatrogenic harm.
Should REMS become an EMS standard? The potential applications of the score exist across the clinical, operational, and financial arenas of providing prehospital care. JFK currently uses REMS to assist in the validation of shutting off warning devices en route to the hospital, showing which patients gain no benefit through this added risk, and for which patients a few minutes may truly matter.
The ability to provide bundles of care with empirical evidence of efficacy allows the leadership team to focus clinical efforts on improving the less-effective bundles as well as identifying providers in need of added training or supplemental education. The impact of being able to show quality in care also becomes a valid argument to payers or partners regarding reimbursement and competitive service bids.
Ultimately, the idea of working REMS evidence into the dispatch priority algorithm to determine ALS vs. BLS response may also prove to be a plausible strategy in meeting the ever-growing needs of our aging populations.
1. Agency for Healthcare Research and Quality. (n.d.) Topics: Quality. Retrieved Aug. 20, 2018, from www.ahrq.gov/topics/quality.html.
2. National Highway Traffic Safety Administration. (Dec. 31. 2001.) National EMS Research Agenda. Retrieved Aug. 20, 2018, from www.nhtsa.gov/people/injury/ems/ems-agenda/emsresearchagenda.pdf.
3. Olsson T, Terent A, Lind L. Rapid Emergency Medicine score: new prognostic tool for in-hospital mortality in nonsurgical emergency department patients. J Intern Med. 2004;255(5):579–587.
4. Imhoff BF, Thompson NJ, Hastings MA, et al. Rapid Emergency Medicine Score (REMS) in the trauma population: A retrospective study. BMJ Open. 2014;4(5):e004738.
5. Alter SM, Infinger A, Swanson D, et al. Evaluating clinical care in the prehospital setting: Is Rapid Emergency Medicine Score the missing metric of EMS? Am J Emerg Med. 2017;35(2):218–221.