EMS Imperatives

“Better a Railing at the Top of the Cliff than a Hospital at the Bottom!” – Edward Lear
Several truisms in patient care.
  1. Proactive rather than reactive
  2. Function over anatomy
  3. Doctoring over doctors
  4. Subjective experience over objective
  5. Findings coupled with outcomes
  6. True measures over substitutes and proxies
  7. Experience over certifications

To be continued…

Recommendations to Reduce the Misuse of EMS and Delays in Patient Transfers

The ER is for Emergencies.” – State of Washington

The following recommendations were proposed by the District of Columbia Task Force on Emergency Medical Services in its report released on September 27, 2007.  The Task Force, known as the “Rosenbaum Task Force,” which was created in response to the January 6, 2006 death of New York Times journalist David E. Rosenbaum following an assault on Gramercy Street in Northwest, Washington, D.C., released recommendations almost eight years ago that are just as relevant yesterday, today and tomorrow. The recommendations transcend service-type, geography and demographics. Each has scaled applicability and represents some of the best ideas for reducing the misuse of EMS and delays in patient transfers. The recommendations were as follows:

  1. Develop and implement and outreach program for patients with chronic needs.
  2. Develop and implement a public education program regarding appropriate use of 911 systems.
  3. Improve the 911 dispatch process so that call takers and dispatchers have improved training and enhanced ability to distinguish between emergency and non-emergency calls.
  4. Establish and clarify roles and responsibilities for EMS and police for the treatment of uninjured intoxicated patients and for transport of patients to a detoxification facility.
  5. Medical Director to use authority to require hospitals to accept the transfer of care of a patient or patients within a specified period of time.
  6. Develop standards for drop times, diversion, and closure, and to improve procedures for tracking patient outcomes.
  7. Authorize patients to be transported to a pre-approved clinic or other non-emergency medical facility, appropriate to the patient’s need (or consider the use of remote, i.e. telemedicine, consultation).
  8. Develop and implement a system of alternative transportation options (such as scheduled van service, taxi vouchers, or MetroAccess vouchers).
  9. Develop and implement protocols to refuse transport for non-urgent patients, when appropriate, subject to authorization of a medical supervisor.

Every EMS provider in a busy urban system can appreciate the goals of these recommendations and can think of first hand instances where they would have prevented or reduced unnecessary utilization of EMS resources. Just like EMD became an integrated part of the EMS system, hopefully one day these recommendations will become common practice as well.

Competitive Advantage

“Strategy is about making choices, trade-offs; it’s about deliberately choosing to be different.” – Michael Porter

During business school, the professors often discussed the successful companies and organizations in terms of “competitive advantage” – the attributes that allow an organization to outperform its competitors – usually in terms of cost advantage or differentiation. For Amazon, it’s the online retailers ability to inventory, warehouse and ship goods quickly and efficiently anywhere in the world. For Apple, it’s the technology company’s ability to design and build easy to use products that function within its entire ecosystem of stores, apps and devices. When it comes to the debate over pre-hospital care and the role of community paramedics, its increasingly becoming necessary to consider our own competitive advantage and advocate EMS’s value proposition – the attributes that differentiate the delivery of care by EMS providers from other healthcare providers. However, outside of EMS’s historical role of “you call, we haul,” it is difficult to clearly articulate what distinguishes paramedics and EMTs from visiting nurses, social workers, care coordinators and community volunteers. As a thought experiment, I’ve found myself wondering if paramedics and EMTs desiring to fill the community paramedic role should just get their RN and save themselves the hassle of petitioning to change reimbursement policies and state licensing regimes…

One of the difficulties in defining our competitive advantage stems from the varied forms that EMS can take, from non-profits to for-profits, from fire-based services to hospital-based services, operating in super rural geographies to dense urban cities. These differences seem to overwhelm the ability to find commonality. Fortunately, Dr. Gregg Margolis, Director of the Division of Health Systems and Health Policy at the Department of Health and Human Services, has found a way to cut through the differences and describe the core attributes that define EMS’s competitive advantage. Paraphrasing, they are the following:

  1. Mobile – Able to go to where the patient is
  2. Available 24/7 – When the care is needed
  3. Integrated into the Community – Cognizant of differences in culture, access to care and needs
  4. Structured – Able to function using guidelines while still employing critical decision-making
  5. Autonomous – Capable of delivering care in austere environments with limited resources

The transformation of healthcare is already seeing providers expanding beyond their traditional roles.  Scopes of practice are increasingly porous and skills are more distributed. Paramedics and EMTs definitely have a role in performing scheduled, in-the-home, non-emergent care. Yet, in searching to evolve EMS, we shouldn’t just look to see what gaps paramedics and EMTs can fill, but also consider where these providers can be most effective and successful given their competitive advantage or we risk the ire of other vested healthcare interests and the risk of setback from unconvinced payors.

Measuring Performance

EMS was established in 1966 by the US Department of Transportation through the Highway Safety Act to reduce death and disability in the pre-hospital setting. EMS executes this objective through ex ante steps, such as training and community education, and ex post steps, such as patient stabilization and transport. With such an important mission, we all have an obligation to hold ourselves accountable, but how do we measure the effectiveness of our agency’s interventions?

Given the variability of EMS delivery and community needs, it has been difficult to develop a uniform body of standards. Evaluation is further complicated by a dual nature system where the majority of responses are for low acuity, time irrelevant conditions and a very small minority are for high acuity, time dependent conditions (e.g. cardiac arrest, uncontrolled hemorrhage and anaphylaxis). Many historical benchmarks, such as response times less than 9 minutes or need for ALS, are a legacy of a previous era (where only paramedics could defibrillate and lay rescuers did not know CPR) or reflect biased, non-evidence based agendas. Fortunately, a hierarchy of performance measures supported by a growing body of research is emerging. The measures are focused on EMS’s core mission (categorized by system design and structure, clinical care and outcomes, and response) and have been expanding to include EMS’s larger role in community health (human resources, finance/funding, quality management and community demographics).

The Hierarchy of EMS Performance

“Just Showing Up” – Transportation Measures

The minimum tools to evaluate an EMS agency.

  • Established emergency medical dispatch that can impact response mode and level
  • Timely arrival of care
  • Statutorily credentialed providers
  • Prescribed equipment
  • Delivery to appropriate, definitive care
  • Delay causing crash rate

“Doing a Good Job” – Clinical Indicators

It is difficult to separate EMS’s contribution to a patient’s clinical outcome from the rest of the healthcare system. The following is an approach developed by the 2007 Consortium of U.S. Metropolitan Municipalities’ EMS Medical Directors’ and is based on tracer conditions designed as a surrogate to measure clinical performance. Tracer conditions are clinical conditions where EMS has a high impact on mortality, morbidity, cost and frequency. The following evidence based treatment bundles have been shown to reduce harm. (Keep in mind that these interventions have been evaluated in bundles, it is not clear which individual interventions contribute to (or detract from) positive survival rates. Further, it is important to recognize that the effectiveness of the interventions do not depend on the credential level of the provider, but are contingent upon being performed correctly in appropriate circumstances. See R. Davis, “Inverse Lifesaving Function? More Paramedics Does Not Equal More Lives Saved,” USA Today, 2 March 2005, D-1.)

  • ST-Segment Elevation Myocardial Infarction (1 in 15 patients treated will avoid a stroke, a second MI or death)
    • Early Administration of Aspirin unless Contraindication
    • 12 Lead EKG Acquisition and Pre-Hospital Notification
    • Interval from EKG to PCI < 90 Minutes
  • Seizure (1 in 4 patients treated will avoid persistent seizure activity)
    • Blood Glucose Evaluation
    • Administration of Benzodiazepines for Status Epilepticus (seizure greater than 15 minutes)
  • Pulmonary Edema (1 in 6 patients treated will avoid the need to be intubated)
    • Nitroglycerin unless Contraindication
    • Non-Invasive Positive Pressure Ventilation
  • Trauma (1 in 11 patients treated will avoid death)
    • Transport to a Trauma Center for Patients Meeting Criteria
  • Cardiac Arrest (1 in 8 patients treated will avoid death)
    • Initiation of Chest Compression and Defibrillation < 5 Minutes from 911 Call
  • Intubation
    • Verification with ETCO2

“Excelling” – Whole-System Measures

Finally, it is important to account for all of the externalities that are produced by showing up and taking care of patients.

  • Rate of Adverse Events
  • Incidence of Occupational Injuries and Illnesses
  • Healthcare Cost per Capita
  • Satisfaction with Care Score
  • Pain Relief Rate
  • Annual Staff Turnover
  • Call Complaint Rate

It is possible to come up with many more proxies for quality, such as percentage of providers seeking advanced credentialing or number of community members taught CPR, however additional research is needed to provide the evidence to support their application even if common sense seems to dictate their persuasiveness.

All measures contain inherent disadvantages. Independent from the quality of care, outcomes will always vary due to patient characteristics, differences in measurement, and chance (random variation). Measuring the wrong things can produce perverse incentives such as increased costs, greater injuries, and less skilled providers. Ultimately, all measures should evaluate what the US National Highway Traffic Safety Administration has dubbed in its 1994 EMS Outcomes Project the “6D’s”: survival (death), impaired physiology (disease), disability, discomfort, satisfaction (dissatisfaction), and cost-effectiveness (destitution). Hopefully the above will serve as a starting point to begin our own self-evaluation.

Please see the following for further reference:

Evidence-Based Performance Measures

Measuring Quality in Emergency Medical Services

Emergency Medical Services Performance Measures

EMS as a Referral Service

Patient Navigation in the Setting of Unscheduled Care

I used to ask my patients “if they would like to go to the hospital?” Now I ask them “what hospital would you like to go to?” Imagine if we were no longer limited in patient transport destinations to hospitals, but could help navigate patients to the most appropriate care, providing each patient with shorter wait times, stronger care coordination and a reduction in costs. That day may not be too far away.

According to some forward thinkers at HHS and DOT, there is a future where not all patients who call 911 end up at a hospital. A draft white paper sets out an innovative vision for the range of dispositions of patient encounters that is premised on what EMTs and Paramedics do best, triage patients between sick and not sick, as well as provide supportive care until the patient reaches definitive care.

Innovative Triage, Treatment and Transport Strategies:

  1. Triage 911 calls without dispatch of an ambulance,
  2. Treatment  without transport,
  3. Transport to an non-hospital receiving facility (urgent care, primary care, substance abuse counseling),
  4. Transport to a hospital, and, maybe,
  5. Scheduled non-acute assessments and treatments.

Innovation Opportunities in EMS

These strategies are predicated on prospectively being able to determine which disposition is applicable to each patient. Academics at NYU have already put in a lot of work toward this goal with the following analysis.

Billing Algorithm:

  1. Non-Emergent – Care not required within 12 hours
  2. Emergent / Primary Care Treatable – Complaint did not require continuous observation, and no procedures were performed or resources used that are not available in a primary care setting
  3. Emergent ED Care (Preventable / Avoidable) – Visit potentially unnecessary if timely and effective ambulatory care received during episode of illness
  4. Emergent ED Care – Emergency department care was required and ambulatory care could not have prevented condition

ED Utilization Analysis Algorithm

Ultimately, the problem is that diverting non-emergent and primary care treatable patients away from the ED does not produce significant cost savings. These patients still require treatment, albeit this treatment would be at a reduced rate. The greater savings can be achieved by avoiding admissions and improved care coordination. It is not clear yet how EMS can play a role in achieving these objectives.

Regardless, it does not mean that pursuing these strategies is not a worthy goal. Providing more transport options would have a cultural effect on patients and providers and, certainly provide creative flexibility in a currently straitjacketed industry.

As a postscript, this post’s title comes from a Trauma Residence who once told me ambulance services were the best referral services for his/her department.

EMS Innovation

“If you can’t fly then run, if you can’t run then walk, if you can’t walk then crawl, but whatever you do you have to keep moving forward.”

Driven mostly by the needs of the community, EMS, in its roughly 40 years of existence in the United States, has evolved substantially. From Cadillac ambulances and the famous TV show Emergency to pre-hospital ultrasound and community paramedics, the profession continues the march of progress. As before, EMS once again finds itself at a crossroad, attempting to navigate a sea change within the health care and societal landscape.

Everyday providers find themselves having to straddle the gap between public safety officers and agents of the health care system.  Along these lines, it seems more and more like ambulance services are morphing into one of three models of EMS delivery – large commercial services, fire-based services and hospital-based services. Each model wishes to fulfill the goal of providing high quality pre-hospital care but has its own nuances, difficulties and considerations. In many areas of the country there currently exists a tug-of-war between different models for dominance. Areas that have not seen this conflict directly, certainly will in the future as pressure on the health care system mounts. This lack of solidarity makes it difficult to imagine and shape future models of health care delivery.

One group attempting to lead the transformation are the EM and EMS leaders at Mount Sinai Health System and UC San Diego, who have partnered together to identify and address “the regulatory, financial and technological obstacles to improving our nation’s EMS systems.” Through their collaboration, the group hopes to “create a pathway for the widespread implementation of best practices and delivery system reforms in emergency medical services across the U.S.” What this is likely to look like is a consensus document that expounds best practices and a role for EMS within the health care ecosystem. It would be hubris not to recognize that one of the greatest features of EMS is its flexibility to adapt to the vagaries of every local. Still the profession desperately needs a vision of where to grow towards and this group is uniquely positioned to produce that vision. Their efforts would not be possible without a grant from HHS. Importantly, the folks running the project want your input (survey). Only by participating can we not just improve the lives of others, but our own lives as well.

A few things are for sure. EMS in the future will be proactive rather than reactive. Much as the fire service has done in reducing the number of fires through new building codes and better education, EMS will play a role in reducing pain and suffering by targeting likely candidates for readmission, helping patients understand their medical conditions, and providing preventative care. Providers, from EMTs to paramedics, will be expected to have greater knowledge, perform more sophisticated procedures, work as part of complex medical teams and handle a larger scope of responsibilities. (This is on top of all the hats EMTs and paramedics normally wear.) And last but not least, the path forward will be difficult, as it should be, as nothing that isn’t worthwhile is ever easy.

EMS Innovations Grant Website

UC San Diego Press Release (Jan. 7, 2015)

Mount Sinai Health System Press Release (Jan. 7, 2015)

Welcome

Whether it’s 3 pm or 3 am, complete strangers open up their doors and invite us into their homes. We’re supposed to be there to aid the sick, provide comfort, and help solve medical problems.  However, more often than not, you’re really there because the situation is outside of the scope of what that person can handle or he or she has exhausted all other options. So you take that situation, put it on your back, become the calm center of the universe and start a return to normalcy. Pre-hospital care truly is a life in the service of others.

This site is dedicated to instilling clinical excellence and accelerating the maturation of pre-hospital care profession. The hope is that through collaboration and the transmission of tacit knowledge, we can all become better providers.  This EMS community is filled with enthusiastic and passionate people. My goal is for all of us to consistently improve, together raising the floor and removing the ceiling.