Acres of QA

In May 2007, the Queensland (Australia) Ambulance Service (QAS) hosted a brief visit by Edward T. Dickinson, MD, FACEP, NREMT-P, the medical editor of JEMS. QAS paramedics appreciated his ability to relay his experiences as a firefighter/paramedic, emergency physician and medical director during his presentation on penetrating trauma. Although we found more similarities than differences,”žDickinson noted the particular challenges for quality assurance (QA) across a large”žEMS agencyÆ’both in number of paramedics and by geography.

System Specs

The QAS is a large EMS provider with approximately 2,000 operational paramedics who provide care across 286 ambulance stations over 1.7 million square kilometers. Paramedics respond through seven regional communications centers, employing approximately 300 emergency medical dispatchers who are assisted in rural areas by another 350 volunteers, including drivers, hospital-based and honorary-based ambulance officers, and community first responders.

Helicopters aid outer-urban and rural responses. In extremely isolated areas of the state, a primary fixed-wing response may be used, often landing at the nearest airstrip on a cattle station or in rare instances on the road.

The level of providers involves a two-tiered approach. Entry into the ambulance service occurs after completion of a three-year undergraduate degree or vocational entry for the same duration. These baseline crews are termed Ë™advanced care paramedicsà“ and provide care comparable to a North American EMT level, as well as additional procedures, such as laryngeal mask airway, laryngoscopy, IV access, IV narcotics, adrenaline and dextrose, intramuscular midazolam, naloxone, glucagon and adrenaline. Aspirin, nitrates, acetaminophen, salbutamol and methoxyflurane are also administered.

Second-tier providers, or Ë™intensive care paramedics,à“ undertake all ATLS, PALS and ACLS procedures, including transcutaneous pacing. To progress to this clinical level, the paramedic must have five years EMS experience and then successfully complete a 12-month graduation program. We recently introduced procedural sedation and thrombolysis as new clinical enhancements. By late 2007, we_ll introduce IV ketamine to provide an advanced analgesic optionÆ’this is particularly relevant for markedly displaced fractures, severe burns and entrapped patients with difficult extrication options.

Our aim is for all paramedics to practice with autonomy within a defined scope of practice, and we offer no on-line medical control.”ž”ž As the medical director, I provide clinical governance for prehospital response, which includes the direction of QA activities. My position is half-time and supported by a number of physicians in regional care centers, approximately four hours per week.

To a certain extent, North America has provided added impetus to QA activities in all aspects of health-care delivery in Australia. One surgeon, who was registered in the U.S. and contracted to a hospital position in Australia, had a number of allegations that his care contributed to fatal outcomes for 11 patients. Criminal proceedings are pending successful extradition from the U.S. These cases have both governmental and non-governmental organizations focused on safety and quality within health-care delivery organizationsÆ’that is, real-time monitoring and quality improvement.

Monitoring Performance

We divided our approach to this issue into clinical and patient safety activities. Patient safety requires investment to achieve the goals of the clinical governance program. Our particular program utilizes seven staff members (including a part-time attorney) who report to the medical director.

The audit and clinical governance of cases begin on scene where clinical support officers conduct local and regional audits. Randomly selected cases are referred to a mandatory audit program. Each case is classified, and any variance from the current scope of practice is stratified against a standing audit matrix. This classification allows a standardized response to clinical audit, reporting and, ultimately, the interventions to prevent recurrence.

This reporting allows early identification of trends, which is particularly important for an organization of our size and the geography of our country. High-risk events are immediately reported centrally. In these cases, the medical director_s office staff assists with the regional investigation and response. Examples of high-level events include suboptimal clinical care that results in death or disability, or when there_s significant equipment failure.

Suspicious deaths are reported to the coroner, similar to jurisdictions in North America. Any case that specifically targets the level of care provided by QAS paramedics is addressed centrally within the medical director_s office. In these circumstances, it_s beneficial to have on-site legal assistance. Comprehensive preparation of the brief for the coroner will not only support the paramedics and service but may also prevent further action because it provides a transparent account by individuals who understand the prehospital environment. Early notification of adverse clinical outcomes also prepares the organization and paramedics involved for potential litigation.

The QAS has also implemented a process called root cause analysis (RCA). Systemic error is implicated in most adverse clinical events; therefore, it_s important to identify these contributing factors as part of any review. Full participation of any review process by paramedics and communications staff is a prerequisite for successful outcomes.

In Queensland, we_ve undertaken legislative review at a state level to ensure participants in RCA processes have Ë™privilegeà“ regarding any information provided. Although the systemic recommendations of an RCA review are made available to the public, the analysis and individual testimony aren_t accessible.

The departments of Emergency Services and Health are covered under the same legislation. The QAS must annually publish the results of all QA activities, including RCA investigations. A governing body has been established by the state to ensure that individual agencies conform to this standard.

Additionally, the QAS recently converted to an electronic patient care record (ePCR) system that has processed more than 450,000 cases. This system provides a robust audit tool that serves as an excellent platform to interface with receiving hospital clinical information systems. The advanced auditing system is currently being developed, and although it_s in the embryonic stages, the potential for such a system is almost limitless.

Because prehospital care is always under scrutiny from our hospital colleagues, the wider community, including funding agencies, has also embraced this ongoing review. The aim is to place the service in a position to monitor system performance and respond appropriately. The primary goal is to ensure quality patient care; after all, that_s why paramedics undertake such difficult roles.

Cardiac arrest survival and response times are often reported as surrogate markers of system performance. Most frontline providers recognize a poor correlation between response times and actual patient care. Other measurements of care, such as rates of aspirin administration or the provision of adequate analgesia, are also important and reflect on the quality of service. EMS providers must continue to progress in the development of other reproducible measures of quality.

Like most modern EMS systems, QAS is well equipped to face the challenges that robust QA activities bring. We feel it_s vital for each paramedic to embrace these concepts for system-wide success. For more, visit”ž


Dr. Stephen Rashford, MBBS, FACEM, is the medical director of Queensland Ambulance Service in”žAustralia. Contact him at”ž

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