Review of:Vrostos KM, Pirrallo RG, Guse CE, et al: “Does the number of system paramedics affect clinical benchmark thresholds?” Prehospital Emergency Care. 12(3): 302-306, 2008.
The Science
What’s the impact of the number of paramedics in a system on their ability to meet clinical benchmarks? This was the question these researches from Milwaukee, Wis. addressed through a retrospective review of patient care records (PCRs) completed by their paramedics. The researchers compared all PCRs completed between 1987-1996 (1997 study period) with those from 2001-2005 (current study period). They recorded the number of times the paramedics were engaged in the following; patient contacts: being a team leader, starting adult and pediatric intubations and IV, treating adult and pediatric cardiac arrests, treating hypotensive trauma, acquiring ECGs, and administering medications.
“Over the five-year study period, 1,215 paramedic profiles gleaned from 107,524 PCRs documented a total of 297,900 patient contacts,” the researchers wrote. “Annual means standard deviations [ranges] were as follows: patient contacts 245 133 [12 788]; team leader: 106 119 [0 739]; intubations: adult 2.57 2.54 [0 20], pediatric 0.1 0.3 [0 3]; IV starts: adult 44 37 [0 267], pediatric 0.34 0.77 [0 5]; treated cardiac arrests: adult 8 6 [0 34], pediatric 0.26 0.61 [0 4]; treated hypotensive trauma: 5 6 [0 42]; and ECGs acquired: 31 19 [0 144]. The 1997 analysis (1987 1996 data) included 1,450 paramedic profiles representing 467,559 patient contacts generated from 172,131 filed PCRs. All comparable experiences decreased significantly between the 1997 analysis and the current study, except medication administration, which increased 25%”
Their conclusion states, “These data show a decreased opportunity and a wide variability in the frequency of successfully completed paramedic technical skills and experiences in this EMS system. Limited exposure to critically ill adult and pediatric patients reaffirms that high-risk skills are performed infrequently. A multifaceted approach should be considered for maintaining provider competency.”
The Street
This study raises more questions than it answers. Clearly there were drastic changes in the system between the two different periods. In 1987 the Milwaukee County EMS system had 150 paramedics in 1987, compared with 250 paramedics in 2005. Even with the growth in total run volume the patient contacts per medic dropped significantly. Another significant change was the addition of paramedics as ALS first responding fire engines. This further diluted the opportunity for paramedics to perform such high acuity procedures as cardiac arrest management and intubation.
The authors note, and I agree, that the ultimate quest is to determine the optimum number of patient contacts and interventions that proves competency. This “Eureka” point has been very elusive. In this study, the competencies were tracked over a two-year period for their biannual renewal cycle. Is there a difference in the competency of the medic who performs one intubation every four months and the medic who performs no intubations for 16 months then gets six tubes in six months? Meaning, is there value to ensuring medics get their clinical exposure at more regular intervals?
What the authors did do — and I recommend others do as well — is to publish their list of recommended benchmarks. The Milwaukee system requires its medics to meet the following annual benchmarks: 160 patient contacts, 35 times as team leader, one adult intubation, 18 IV starts, 37 medication administrations, 17 ECGs, four cardiac arrests, and 1 hypotensive trauma patient.
So let’s hear from you. What are your benchmarks and why?