Performance
Improvement and
Patient Safety in EMS
Jeffrey Coughenour, MD, FACS
Assistant Professor of Surgery
Associate Medical Director
Staff for Life Helicopter Service
Objectives
• Define performance improvement and patient
safety (PIPS)
• What are the components of a successful
system?
• What prohibits development?
• Demonstrate the positive impact a mature PI
process can have on patient care
Health Care
• “...More with less and doing it better and
faster”
• Pay for performance initiatives gaining ground
but lacking detail
• EMS as a component of the continuum of care
Health Care
PIPS Defined
A continuous, multidisciplinary effort to
measure, evaluate, and improve the process
of care and its outcome.
A major objective is to reduce inappropriate
variation in care and to improve patient safety.
PIPS Defined
• Quality (PI)
– Indications for early transfusion in transient
responder after trauma
• Safety (PS)
– Accurate type and crossmatch
• Combined elements (PIPS)
– Transfusion-related acute lung injury (TRALI)
Historical Perspective
•
•
•
•
Quality assurance – retrospective chart review
Total quality management…
Continuous quality improvement…
Performance improvement
“Bureaucratic pencil-pushing peckerheads”
—P. Kearney
Modern PIPS
• Continuous cycle of monitoring
• Support by reliable method of data collection,
obtains valid and objective information
• Multidisciplinary review defines corrective
strategies
• Effect of change is documented as cycle
repeats
Program Configuration
• Administrative accountability
– Empower the program to address issues that
involve multiple disciplines
– Approval from governing body
– Adequate administrative support
– Defined lines of authority or responsibility
Program Configuration
• Medical direction
– Leadership
– Title 202 KAR Chapter 7, Section 801: Developing,
implementing, and maintaining a quality
improvement program for continuous system and
patient care improvement
• Program manager
– Critical component, logistics
Outcome Measurement?
• Patient
– Complete and rapid recovery
• Administrator and payer
– Cost of care
• Service director or regional physicians
– Quality of care
“Value Equation” Concept
• System variables to individual performance
• Increase value by: Improved process or
outcome, decrease cost
Quality of Process+Quality of Outcome
Value =
Cost
Process Measures
• Consensus, local or regional guidelines, or,
ideally… nationally derived, evidence-based
guidelines
Compliance with guidelines, appropriateness of destination
determination, delay in assessment, delay in diagnosis, delay
in treatment, error in judgment, error in treatment, error in
communication, appropriateness of documentation, insurance
carrier denials, dispatch time, chute time, response time,
scene time, transport time, system skill performance,
individual skill proficiency
Outcome Measures
• Are care processes adequate to achieve the
desired outcome?
Mortality, morbidity (any derivation from normal health that
may be result of a complication or may be pre-existing), pain
control, tranfusion-related acute lung injury, ARDS,
coagulopathy, hypothermia, did patients whose complaint
warranted ALS services receive it, did patients with a
breathing problem or respiratory distress receive
supplemental oxygen in a timely fashion
Data Collection
• Should be valid and objective
• Participation in a regional trauma registry, at a
minimum
• State trauma registry preferred
• Develop occurrence tracking form
– Concerns brought forth from variety of sources
Review
• Review performance and safety of your EMS
system
• Is the issue open or closed?
• System or individual?
• Preventable or not?
• Now what?
Corrective Action
•
•
•
•
•
•
Develop or revise a guideline
Targeted education
Enhanced resources, communication
Counseling
Change in provider privileges or credentials
External review
Results
• Demonstrate that a corrective action has the
desired effect by continued evaluation
• Continuous use of your new PIPS process is
more important than “loop closure”
Chapter 16, Performance Improvement and Patient Safety,
Resources for the Optimal Care of the Injured Patient 2006
Copyright © 2006 American College of Surgeons, Chicago, IL
Missouri
• 19 CSR 30-40.375
– Uniform Data Collection System and Ambulance
Reporting Requirements for Ambulance Services
– “Emergency, life-threatening runs”
• 19 CSR 30-41.010
– Head and Spinal Cord Injury Reporting
Requirements
Missouri Protection?
• Missouri Revised Statutes, Chapter 537
– 537.035 Peer Review Committees
– Physician/surgeon, dentist, podiatrist,
optometrist, pharmacist, chiropractor,
psychologist, nurse, social worker, professional
counselor, mental health professional
• EMS… no
• Strong opposition
Kentucky Law
• State statutes with protection
– Protect participants with immunity and preserve
the confidentiality of peer review documents and
information
• McGuffy v. Hall (1977) “AN ACT relating to
health care malpractice claims or insurance”
• 1980, “AN ACT relating to the establishment
of certificate of need, licensing and regulation
of health facilities and health services”
Kentucky Law
• 1988, “AN ACT relating to health care” and
“AN ACT relating to civil actions”
• Sweasy v. King’s Daughters Memorial Hospital
(1989)
• 1990, …”the lack of such protection inhibits
open and candid peer review; and there is an
urgent need to promote effective peer review
for the protection and welfare of the public…”
Kentucky Law
• Sisters of Charity Health Systems v. Raikes
(1999)
– Intended only for physicians who sue over poor
peer review results
– Not for plaintiffs, unfair advantage
Kentucky Revised Statutes
• Chapter 211.494 Statewide Trauma Care
– Section 4. The statewide trauma care director and
the advisory committee shall develop and
implement… a statewide trauma care program,
including but not limited to… (f) Continuing
quality assurance and peer review programs
Kentucky Revised Statutes
• Chapter 211.494 Statewide Trauma Care
– Section 6. Data obtained through a trauma
registry or other data collected pursuant to KRS
211.490 to 211.496 shall be confidential…
Personal identifying information… shall not be
subject to discovery…
Bottom Line
• There is NO peer review protection in
Kentucky
• Utilization of attorney client privilege
• Perform all PIPS work with the collaboration
of a recognized patient safety organization
Patient Safety Organizations
• Established under the “Patient Safety and
Quality Improvement Act of 2005”
• Organization of peer review activities in
concert with a PSO provides protection
• Under the doctrine of pre-emption, federal
law "trumps" state law
• Federal law has yet to be challenged in
malpractice actions in Kentucky courts
Patient Safety Organizations
• Missouri Center for Patient Safety
– Collaboration with the Missouri Ambulance
Association, funding from the Missouri
Foundation for Health (private)
• 16 EMS agencies participating in pilot program
www.mocps.org
• Destination determination
• Cardiac arrest resuscitation
• Mass casualty incidents
Impact of PIPS
• Extension of early blood product
administration and contemporary shock
resuscitation
• Failed airway management
Resuscitation Practice
• Outdated
• “… after 2 liters of crystalloid, consider use of
uncrossmatched packed red cells in transient
or non-responders.”
• Average 2.79 liters LR/NS
– Average scene and flight time of under 1 hour
Pattern Recognition
• Exam findings
– Decreased mental status from injury or shock
– Suspected TBI
– Clinical coagulopathy
• Laboratory values
–
–
–
–
INR > 1.5
Base deficit > 6
Hemoglobin < 11
Hypothermia (<96) or hypotension (SBP <90)
Pattern Recognition
• Trunk, axillary, groin, or neck wounds not
controlled by local wound care
– Direct pressure
– Tourniquet
– Hemostatic dressings
• Proximal amputation or mangled extremity
• Hemoperitoneum with shock
• Massive hemothorax
– >2000 mL initially or >200 mL per hour for 4 hours
Massive Transfusion
• April—December
– 9 patients
– 3 deaths
– 1 inappropriate activation
– Total product: 116 PRBCs, 65 FFP, 14 platelet
pheresis packs, 13 pre-pooled cryo
– Average ratio 1.78-2:1
– Only 3 activations occurred within 1 hour of
patient arrival
Massive Transfusion
• Current 8 Jun
– 12 patients
– 7 deaths
– 1 inappropriate data set inclusion
– Total product: 229 PRBCs, 158 FFP, 23 platelet
pheresis packs, 29 pre-pooled cryo
– Average ratio 1.45:1
– Excluding 1 outlier of 144 minutes, average
activation time 0:29 (0:10-2:24)
What’s Next?
• Additional evidence to determine safety,
efficacy, optimal PRBC:FFP ratio
• Replace crystalloid with non-albumin colloids?
• Lyophalized plasma
• POC testing for early MTP activation
• Expanded use of ultrasound – IRB application
for pneumothorax/ETT position evaluation
Airway Management
• Increasing number of failed field intubations
• Reasonable use of rescue devices
• Single 3 month period
– Facial fractures, no surgical airway attempt
– Failed intubation, poor function of rescue device
– Unrecognized esophageal intubation
– Occluded ETT
– Tracheal injury
Airway Management
• Targeted outreach education
– Ground and flight services
• Increased use of simulation
– Problem recognition
– Review of indications for failed airway algorithm
– “3-Step Cricothyroidotomy”
3-Step Cricothyroidotomy
Summary Points
• PIPS is a labor intensive process
• Obtain administrative support
• Medical director leadership, which may
require partnering with a regional referral
center
• Logistics is local
Summary Points
•
•
•
•
•
Data collection can be difficult
Participate in regional or statewide registry
Review and make corrective actions
Continuous cycle evaluates effectiveness
Utilize attorney client privilege or PSOs for
legal protection
PIPS
References
• Resources for the Optimal Care of the Injured
Patient 2006, Copyright © 2006, American
College of Surgeons, Chicago, IL
• Missouri State Legislature, www.moga.mo.gov
• Kentucky State Legislature, www.lrc.ky.gov
• Paula Holbrook, RN, BHS, JD, Clinical Risk
Manager, UK Health Care
• Richard A. Setterberg Co., LPA