I am the kind of person that craves numbers. I’l comb the sports section of any website or newspaper looking for the line scores from baseball games, and the statistical leaders for the NFL in a given week. I’ve always spoken in numbers. I think that they are a great way to measure effectiveness in EMS.
We have gotten to be very good at tracking response times. We have defined methods of how to do it, and often when a system decides on a tracking method, we stick with it. The same cannot be said, however, for tracking ROSC rates. While everyone in EMS can agree on what a ROSC is, we struggle in agreeing upon what a ROSC is not. Some systems omit traumatic arrests from their ROSC numbers. Others do not count field pronouncements. Personally, I feel that if a provider puts his or her hands on a patient’s chest with the intention of doing CPR, then that call should count positively or negatively against their ROSC rate depending on the outcome.
I feel, however, that there are a few other statistics that we as EMS systems should be looking at on a regular basis. Here are a few examples:
PMD input vs. paramedic impression – Keeping with the theory that an EMS system is responsible for a patient from the moment the phone is picked up to the moment that they turn the patient over to a higher level provider at a hospital, I feel that tracking the effectiveness of PMD is incredible important. We need to recognized that being as accurate as possible from step one is extremely important in providing the correct resources for a given EMS call.
Last month, I wrote a post about the recoding of shootings and stabbings in Oakland, California and shared my thoughts as to what I felt that the problem was. In the original article I referenced many were critical of Priority Medical Dispatch. Over the years, my opinion of it has fluctuated. I have seen it work tremendously well, and I have seen it be the downfall of an EMS system. The bottom line though is the industry is moving away from sending an ambulance “lights and sirens” to each and every emergency that comes in. Right now, PMD is the best system that we have at our disposal to prioritize calls.
While the paramedic’s opinion of a call is not the “be all, end all” of patient care, taking into consideration their final evaluation of the call and the treatment route the decided to go down can give one a good idea of what was actually going on with the patient. If PMD can correctly identify 3 out of 4 patients correctly, I say that they are doing a fantastic job. As Justin Schorr says “It’s the least informed person (the caller) speaking with the least trained provider (the call taker). ” Giving those call takers the greatest chance at success is key to best providing for our EMS system.
Skills provided in the first five minutes of a call – I have been thinking a lot about the quality of first response that we are providing nation wide. Some places send first responders. Others send paramedics. Systems throughout the country send everything including those two options as well as everything in between. To best understand what would best serve our patients, we need to look at the care that we are providing in the first five minutes of a call. Why the first five minutes? Well, if your ambulance is more than 5 minutes behind your first responders, it might be time to look at your system design.
When I was in Oakland for a week back in 2010, I had my first exposure to ALS first response. While I was only there for a week, I probably made it to 25 scenes, most of which had the fire department arriving at the same time, or just before us. With the exception of one call, I did not see any ALS gear opened up on any scene. It should also be noted though that our response times were pretty stellar while I was there.
Even with the new AHA recommendations for CPR, most of the first five minutes of a cardiac arrest involve skills that revolve around a CPR and an AED. Chest pain patients? The first five minutes is history taking, obtaining a story, and baseline vital signs.
I ate my words a few months ago when I admitted that less paramedics create a system that does not expose itself to as much skill dilution as one that has a paramedic on every truck in every station. Those paramedics need to be properly deployed though to allow them to get to those calls and be utilized properly within their system (see my above comments about PMD). Based on my experiences and the ebb and flow of calls that I have done throughout my career, I would be concerned about skill dilution within the first response community of paramedics if that is their only exposure to EMS.
Systems like Washington, DC could learn a lot from this. Find out what care their providers are doing in the first stages of a call and then take those paramedics that are riding the jump seat of fire engines and redeploy them to a place where they might be better utilized.
While response times, intubation success rates, and IV success rates, and response times are all vital statistics to track, it is time to branch out. They only give a small snapshot of how good we are at our jobs. Tracking these metrics will give us a better idea of how our system is performing. In my next post next week, I will look at some provider level skills that every system should be tracking and the barriers that we need to overcome to best track them.