Poor Quality EMS

By Mike McEvoy, Ph.D., RN, CCRN, REMT-P

You’ve probably never met a firefighter whose goal was to be the worst possible emergency responder. It’s not likely that such a person exists; and if he’s out there somewhere, he won’t last for long. Quality is the building block of the fire service. What department would not like to be the all-around best? Enter Quality Improvement (QI) programs. Typically involving EMS operations, QI programs spread from hospitals to virtually all facets of medicine. Today, they are mandated by law for EMS in many parts of the country.

What’s unfortunate is that many QI programs have not been run in an upbeat and constructive manner that would make them helpful to the EMS/fire service. As a result, QI has gotten a black eye from many chiefs and EMS providers who are disillusioned by the destructive results a poorly run QI program churns out. Effective QI programs have been overwhelmingly successful in the fire service, for good reason. The bottom line in QI is quality.

First, a little philosophy of what QI really is. To many of us, QI conjures up images of a crew sitting in some back room reviewing patient care records. In truth, review of run reports is only a small part of the QI process. Or at least it should be only a small part.

QI has three major components: prospective, concurrent, and retrospective. Prospective QI includes activities that ensure quality patient care before the truck rolls. Equipment and staffing standards, checklists, operational policies and SOGs, medical protocols, copies of certifications, and a program for continued EMS education are all examples of prospective QI. Concurrent QI includes activities that monitor and ensure quality at the time the service is being provided. Supervision or oversight by the medical director/advisor is an example of concurrent QI. Retrospective QI involves activities that look back to see if quality service was given. Review of run reports, response surveys mailed to patients and families, interface with other EMS responder agencies, surveys of receiving hospitals, response time studies, and high risk call reviews are all activities reflective of retrospective QI.

A small volunteer fire district providing EMS first response and early defibrillation prior to the arrival of the town advanced life support (ALS) ambulance service initiated a QI program using five simple elements.

First, the department instituted review of 100% of EMS run reports using an Audit Review Sheet obtained from its Regional EMS Program Agency. Monthly, the department posts summary data for all members to review. In exceptional cases, the department medical advisor reviews calls with individual firefighters. Trends in documentation are reviewed at EMS drills. Early on, it was decided that every member of the department would participate in run report review, a move that has improved teamwork and mutual understanding. The entire department quickly became familiar with the data elements that made for a quality report. Within a year, the documentation of first responders and EMTs on EMS calls went from mediocre to exceptional. It remains excellent today.

Second, the department decided to conduct detailed event reviews of every cardiac arrest call. Cardiac arrests are high-risk incidents that warrant individual analysis. Data downloaded from automated external defibrillators (AEDs) are correlated with response times and scene activities to promote optimal patient outcomes. The reviews have focused attention on scene performance benchmarked by data obtained from neighboring fire departments. Through drills and in-service education, as well as changes in equipment configuration, the department reduced its arrival to first shock time by an average of 20 seconds. Last year, the department put AEDs in the hands of its fire police, who often arrive prior to the first piece of fire apparatus, thanks to QI analysis.

Third, the department began mailing a patient satisfaction survey after each EMS call. About 80% of the surveys are returned completed, and these are posted in the fire station. The results of these surveys have been so helpful in improving morale that the department began sending them to fire and rescue customers as well. Frequently, customers send donations with the completed surveys. An issue identified by these surveys helped the department recognize a need to more clearly differentiate its firefighters from ambulance responders. Changes in practice, including large FIRE lettering on work shirts, more traditional firefighter attire, and strategic positioning of the engine-rescue resolved this misidentification. Without a doubt, it is important for taxpayers to see their fire department at work. QI helped the department recognize and fix this problem.

Fourth, the department undertook a review of all EMS equipment and staffing. Support from the Board of Fire Commissioners has allowed the department to keep current with developments in medical equipment and technology. County and state EMS mandates minimum equipment and staffing for each piece of apparatus responding to an EMS call. The department committed to ensuring that all its vehicles exceed these minimum standards. To monitor this, the department developed an EMS equipment checklist in conjunction with standards for maintenance, service, and equipment repair. A computer database was created to track firefighter EMS certifications and a printout of certification levels and expiration dates is routinely generated. The medical advisor works with members to assist in keeping EMS certifications current.

Fifth, a job description was written for the department medical advisor that includes providing medical oversight. This ensures that only qualified people answer EMS calls, that continuing medical education is available, and that EMS training and certification records are maintained. Periodically, the medical advisor evaluates the skills of EMS providers, often by observation on the scene of EMS calls.

This EMS QI program is simple yet comprehensive. It is designed to help firefighters provide the best possible care to patients and prepare the best possible documentation of their actions on calls. From the start, the program endeavored to be not a source of stress but rather a positive and helpful influence to firefighters. The efforts have not only demonstrated improved patient care and better documentation but have also developed greater confidence and provided a good deal of positive feedback from customers directly to the firefighters who cared for them. Another important benefit (somewhat hidden from frontline personnel) is the greater legal protection that improved care and documentation has afforded the department.

Consider your own department. Is your QI program reflective of the desire we all have to be the all around best? Or is it more of an annoyance to firefighters and administration? Quality is a building block of the fire service. A good QI program needs to be at least a stepping stone.

Mike McEvoy, Ph.D., RN, CCRN, REMT-P, is the EMS coordinator for Saratoga County, New York. A former forensic psychologist, he now works in the Cardiac Surgical ICU at Albany Medical Center and teaches at Albany Medical College in New York. He is a paramedic for Clifton Park-Halfmoon Ambulance Corps and medical advisor for the West Crescent (NY) Fire Department. He presently serves as a member of the New York State EMS Council and the State Emergency Medical Advisory Council and is the EMS director on the Board of the New York State Association of Fire Chiefs.

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