What? When? Why? How?

While discussing EMS Issues over my first crepe breakfast, the focus of the conversation between Jeramedic, MsParamedic, and myself briefly turned to howEMSis viewed and measured in the prehospital setting.How are we evaluated by the people who monitor our performance?

Jeramedic remarked that, “For a lot of departments, and for a lot of decision makers, if an ambulance gets to somebody’s house in a reasonable amount of time, and they end up at the hospital, that’s a successful, efficientEMSsystem.”All three of us agreed that this was a very poor measure of how good we are at our job.Its like saying that when there is a fire, all that matters is how quickly we get a fire truck there.Once they’re there, they can stand there and watch the place burn to the ground, but it doesn’t matter because they got there!

Police Departments can hang their hats on arrest numbers and crime rates.Fire Departments can measure the number of actual fires they have, and other factors such as inspection results, smoke and CO detector compliance, and loss of life from fire.InEMS, The focus simply on that first ten minutes of a call.Are you making your response time compliance?If so, how far under the bar are you?Whatever happens between the arrival at the scene and arrival at the hospital is mostly overlooked.The reason for this is its very difficult (unless we are talking about ROSC) to measure the performance of anEMSsystem within that time frame.Clinical measurement is based on success rates of skills such as IV attempts and ET attempts, and subjective QA/QI.

A Paramedic friend of mine brought her 4 year old son with her to some of her skill practice session prior to testing for her State certification.She was able to teach her son how to intubate a mannequin, and if she let him play with sharp things, I’m sure he could have learned how to establish an IV as well.Those skills can be taught to anyone, and are a poor measure of the ability of a paramedic.That doesn’t make them unimportant.Those skills are a vital piece of the treatment we provide, and we have to be good at the to be successful.The point is that you can teach a 4 year old how to intubate, but you can’t teach him WHEN to intubate.It takes the knowledge that we all get from our training to understand the when, and the why.

Chart writing is also an extremely important part of our job.Its how we paint our picture of what we do for our patients.Often though, while it is successful in conveying the “what” to the reader, it sometimes fails at conveying the “why” which is an important piece in understanding how effective a paramedic is.Writing a concise and complete chart might keep you out of your Medical Director’s office, and it will definitely save you on the witness stand if you ever end up there, but a chart is only as good as your assessment and treatment as a result of that assessment, and its evaluation is only as strong as the person who is reading it.

The solution to tracking the success of anEMSsystem lies in monitoring clinical outcomes.For example, how much of a difference doesEMScontact make in asthma patients versus patients who walk through an ER door on their own, or land at a clinic?Or how much of a mortality difference do you see in early recognition of a STEMI in the prehospital setting?We need to take those outcomes, and the differences that we make and quantify them to show results.Someone who has had an MI will understand the importance of what was done for them, but the population as a whole has a need to see an impact in the bigger picture.That’s what makes tracking and reporting ROSC so easy for people to understand.Its results can be expressed in a “Yes/No” form.There’s no maybe when it comes to living versus dying.

I had a chance to work with a newer extremely clinically sound paramedic on a street shift the other day, and I was very impressed with how thorough he was.He wasn’t concerned about how much time he spent with a patient, and didn’t rush himself if he didn’t have to.We did have one very critical patient, but even in that setting, he was more concerned about his thorough assessment than anything else.He wanted to know what to treat, and what to fix on this disoriented woman we encountered.He wasn’t concerned about how quickly we got there, and stopping that response time clock.Instead, he was focused on obtaining a better differential diagnosis, a direction to go in his treatment, and a better story to give the ER when we got there.That is something that will not go into any city report.All that they will see is our 5 minute response to the scene.

Once people stop looking at how long it takes us to get to a patient, and starts focusing on the differences we make for those patients once we get there, they will have a better understanding of what we are capable of.This doesn’t magically happen though.Its up to our community as a whole to figure out how to translate this data, and paint a better picture of the difference thatEMSmakes.Everything we need is right here in front of us, we just haven’t figured out how to put it into a more understandable form.

  • jeramedic.com

    Great points SBK. The issue is that what really counts is very subjective. An asthma pt for example Will most likely live weather cared for be EMS and transported, or walked them selves in. So what happen in between is a matter of pt comfort. And that is the pts own opinion. ROSC and response times is easy data to gather. you were on time or not, they lived or died. So what then? hand out comment cards to you pts and try to sell that as research? not gona fly. To get good data, services would have to agree to not provide selected treatments to a "X" number of pts for some amount of time. Track their out comes, and then present the results. I for one do not wont to withhold a medication or treatment to someone who I know needs it, just to see whats happens. I know whats going to happen. Now how to you chart that for when you end up in court?

    Out of hospital medicine works because its based on IN hospital medicine. ya know.. "the real medicine" with research and educated professional providing care… The point is, its still sound medicine. The only difference is where its being preformed. Field providers know what works and what doesn't, we know we make a difference. The individuals we care for know we make a difference. It's the bean counters who need the proof. And the proof is right in front of them. You always hear about when poor care is given and there is a negative outcome. But you never hear anything when good care is given and there is a positive outcome. Why? because 90+% of the time good Prehospital care is being given, and there is naturally a positive result. "We" have become so accustomed to good care and positive outcomes, that we are blind to it…

    One pt at a time, and care for them like it counts. Because it does.

  • Firefighter/Paramedic

    While reading this post (which is excellent by the way) I couldn't help but think of other calls that we go on that would never make into a statistic. The old lady that fell out of her chair and all we do is gently lift her back up. The time spent caring for the family members of the recently deceased. I don't know if the outside world will ever totally appreciate what we do…until we have to do it for them or their family member.

  • AMmedic

    I also think that patient outcome data would be helpful to the providers. In my system its very difficult to track a pt from my stretcher to their discharge from the hospital, and because of this, its sometimes difficult to verify-for my own satisfaction-that my prehospital treatment was the right treatment. There absolutely needs to be a better data collection system so that we can ALL measure the worth and success of prehospital treatment.
    I also disagree with the first comment, I don't think that the idea was to withold treatment so that graphs and charts can be made up, I think it was meant to compare prehospital treatment (immediate at your doorstep meds/intubation-sticking with the asthma pt) outcomes to non ambulance pts. For instance, perhaps in your systems, the severe asthmatics are more likely to end up intubated if they drive themselves to the ED, or to a clinic. Perhaps they're more often discharged from the ED in under 6 hours if you gave them an updraft, say, 45 minutes earlier than they would get one if they were driven in. That's very useful information, not just for prehospital providers, but also for the public.