A National Assessment of EMS Performance at the Response and Agency Level.

BACKGROUND: In 2019, the National EMS Quality Alliance (NEMSQA) established a suite of 11 evidence-based EMS quality measures, yet little is known regarding EMS performance on a national level. Our objective was to describe EMS performance at a response and agency level using the National EMS Information System (NEMSIS) dataset. METHODS: The 2019 NEMSIS research dataset of all EMS 9-1-1 responses in the United States was utilized to calculate 10 of 11 NEMSQA quality measures. Measure criteria and pseudocode was implemented to calculate the proportion meeting measure criteria and 95% confidence intervals across all encounters and for each anonymized agency. We omitted Pediatrics-03b because the NEMSIS national dataset does not report patient weight. Agency level analysis was subsequently stratified by call volume and urbanicity. RESULTS: Records from 9,679 agencies responding to 26,502,968 9-1-1 events were analyzed. Run-level average performance ranged from 12% for Safety-01 (encounter documented as initial response without the use of lights and siren to 82% for Pediatrics-02 (documented respiratory assessment in pediatric patients with respiratory distress) At the agency level, significant variation in measure performance existed by agency size and by urbanicity. At the individual agency performance analysis, Trauma-04 (trauma patients transported to trauma center) had the lowest agency-level performance with 47% of agencies reporting 0% of eligible runs with documented transport to a trauma center. CONCLUSION: There is a wide range of performance in key EMS quality measures across the United States that demonstrate a need to identify strategies to improve quality and equity of care in the prehospital environment, system performance and data collection.

Quality Management of Prehospital Airway Programs: An NAEMSP Position Statement and Resource Document.

Prehospital airway management encompasses a multitude of complex decision-making processes, techniques, and interventions. Quality management (encompassing quality assurance and quality improvement activities) in EMS is dynamic, evidence-based, and most of all, patient-centric. Long a mainstay of the EMS clinician skillset, airway management deserves specific focus and attention and dedicated quality management processes to ensure the delivery of high-quality clinical care.It is the position of NAEMSP that:All EMS agencies should dedicate sufficient resources to patient-centric, comprehensive prehospital airway quality management program. These quality management programs should consist of prospective, concurrent, and retrospective activities. Quality management programs should be developed and operated with the close involvement of the medical director.Quality improvement and quality assurance efforts should operate in an educational, non-disciplinary, non-punitive, evidence-based medicine culture focused on patient safety. The highest quality of care is only achieved when the quality management program rewards those who identify and seek to prevent errors before they occur.Information evaluated in prehospital airway quality management programs should include both subjective and objective data elements with uniform reporting and operational definitions.EMS systems should regularly measure and report process, outcome, and balancing airway management measures.Quality management activities require large-scale bidirectional information sharing between EMS agencies and receiving facilities. Hospital outcome information should be shared with agencies and the involved EMS clinicians.Findings from quality management programs should be used to guide and develop initial education and continued training.Quality improvement programs must continually undergo evaluation and assessment to identify strengths and shortcomings with a focus on continuous improvement.

Discharge in Pandemic: Suspected Covid-19 patients returning to the Emergency Department within 72 hours for admission.

INTRODUCTION: Coronavirus disease 2019 (Covid-19) has led to unprecedented healthcare demand. This study seeks to characterize Emergency Department (ED) discharges suspected of Covid-19 that are admitted within 72 h. METHODS: We abstracted all adult discharges with suspected Covid-19 from five New York City EDs between March 2nd and April 15th. Those admitted within 72 h were then compared against those who were not using descriptive and regression analysis of background and clinical characteristics. RESULTS: Discharged ED patients returning within 72 h were more often admitted if suspected of Covid-19 (32.9% vs 12.1%, p < .0001). Of 7433 suspected Covid-19 discharges, the 139 (1.9%) admitted within 72 h were older (55.4 vs. 45.6 years, OR 1.03) and more often male (1.32) or with a history of obstructive lung disease (2.77) or diabetes (1.58) than those who were not admitted (p < .05). Additional associations included non-English preference, cancer, heart failure, hypertension, renal disease, ambulance arrival, higher triage acuity, longer ED stay or time from symptom onset, fever, tachycardia, dyspnea, gastrointestinal symptoms, x-ray abnormalities, and decreased platelets and lymphocytes (p < .05 for all). On 72-h return, 91 (65.5%) subjects required oxygen, and 7 (5.0%) required mechanical ventilation in the ED. Twenty-two (15.8%) of the study group have since died. CONCLUSION: Several factors emerge as associated with 72-h ED return admission in subjects suspected of Covid-19. These should be considered when assessing discharge risk in clinical practice.

Recording Out-of-Hospital Cardiac Arrest Treatment via a Mobile Smartphone Application: A Feasibility Simulation Study.

BACKGROUND: Given the demanding nature of out-of-hospital cardiac arrest (OHCA) resuscitations, recordings of the times of interventions in EMS patient care reports (PCRs) are often inaccurate. The American Heart Association developed Full Code Pro (FCP), a smartphone application designed to assist EMS personnel in recording the timing of interventions performed. Through OHCA simulations, this study assessed the group size necessary to use the FCP recording functions accurately and safely without compromising patient care. Program evaluation was based on participant feedback surveys, data accuracy, delays between recording and performing interventions, and delays in care attributed to using the application, stratified by group size. METHODS: Simulations of a standard OHCA scenario using the Gaumard TraumaHal mannequin and a dedicated iPhone 5 preloaded with FCP version 3.4 were run with group sizes of 2-6 participants, with group sizes determined by participant availability. Participants included Connecticut certified paramedics and paramedic students who had completed the appropriate coursework. A 7-item feedback survey using a Likert scale established participant feedback on the application. Videos of the simulations were analyzed to assess for delays. One-way analysis of variance with trend analysis was used to test whether outcomes differed by group size and whether differences tended in one direction in parallel with group size. RESULTS: There were 37 simulations, including 142 participants. The feedback survey questions achieved a Cronbach's alpha of 0.91, signifying high reliability, and demonstrated a linear trend supporting greater satisfaction with FCP as group size increases (p < 0.001). Similarly, increasing group size displayed linear trends with greater numbers of interventions recorded (p = 0.009) and fewer missed and false recordings (p = 0.002). Delays revealed significant linear trends (p = 0.018 for delays in recording and p < 0.001 for delays in care), as increasing group size corresponded with lesser delays. Greatest improvement was noted to be between groups of 3 and 4 participants. CONCLUSIONS: OHCA simulations using FCP demonstrate increased provider comfort, increased recording accuracy, and decreased delays as the group size increased. While the application may improve recordings for PCRs and future research, the data suggest a sufficient number of EMS personnel (>3) should be present to achieve reliable data without compromising patient care.

Governance Practices in an Era of Healthcare Transformation: Achieving a Successful Turnaround.

EXECUTIVE SUMMARY: This article illustrates the successful application of principles established by the American Hospital Association (AHA) to foster hospital transformations (). We examined a small community hospital's successful transition from one emergency care center (ECC) physician group to another and the methods by which significant improvements in outcomes were achieved. The foundation of this transformation included a generative governance style at the board level, a shared governance model at the employee level, a renewed sense of employee and physician engagement, and a sense of individual accountability. Outcomes included improved communication, a more unified vision throughout the ECC (which led to improved efficiency and accountability among staff), improved metrics, and a positive impact on the community's perception of care. Press Ganey scores and ECC operational metrics demonstrated significant increases in patient satisfaction and decreases in wait times for seven operational metrics. These data serve as a proxy for the transformation's success. Structured interviews revealed an increase in employee satisfaction associated with the transition. The positive outcomes demonstrate the importance of the AHA-articulated governance principles. The AHA recommendations for a superior value-based care model closely align with the methods illustrated through Bristol Hospital's successful transformation. Other institutions can apply the lessons from this case study to drive positive change and improve patient care.

Correlation between hospital rating agencies' data: An analysis and recommendation.

Hospital rating agencies exist to inform consumers through publicly available patient safety data. The large number of rating agencies, the variability in their methodologies and data presentations leave few consumers considering these data in making healthcare decisions. The objective of this study was to analyze the comparability of data from four different healthcare rating agencies to understand whether there exists a correlation among the rating agencies' published data. Four well-known rating agencies' data were gathered for 30 Connecticut hospitals and analyzed using correlation methods. The overall rating score was used for comparison accounting for patients' probability of referencing this score in determining a hospital's safety. The results indicate little or no correlation between ratings of Connecticut hospitals among the reviewed rating agencies. The only statistically significant correlation was between CMS and Leapfrog. The lack of correlation among rating agencies' publicly available data identified in this study leads to consumer confusion. This research provides support for the need for a valid, reliable, and transparent healthcare rating system to inform patient decision making. These findings can be used to advocate for a legislatively mandated national reporting system that focuses on user understanding of the data.

Simulation-Based Orientation for Emergency Medicine Residents Participating in EMS Ride-Alongs.

Introduction: Emergency medicine resident physicians are required to complete observational ride-alongs with emergency medical services (EMS) units as part of their curriculum as per the ACGME. We created this curriculum to expose emergency medicine residents to the equipment they will encounter in the prehospital setting, discuss basic EMS operations and the challenges of working in the prehospital environment, and review the limitations that restrict care provided by EMS professionals. Methods: We created a series of five simulation cases for resident physicians participating in an EMS ride-along rotation. Each case was implemented with three to four residents at a time. A critical action checklist was used to assess participants during the scenarios. Following each simulation, a debriefing was conducted to discuss EMS operations and the impact on providers. At the conclusion of the session, participants completed a course evaluation survey. Results: Thirteen emergency medicine resident physicians took part in this curriculum from October 2020 through January 2021. Results indicated that the participants gained insight into the prehospital environment, felt more prepared to complete their ride-alongs, and were engaged and satisfied with the introduction to EMS program. Discussion: Simulation allowed emergency medicine residents to be exposed to the complex nature of prehospital care and prepared them for their ride-along sessions. The five cases provided significant breadth and depth of potential prehospital care issues, and the residents were able to discuss the medical, policy, and operational challenges presented as part of each case.