EMS Quality Improvement Program

Section 1 - ADMINISTRATIVE POLICIES

1.18 EMS QUALITY IMPROVEMENT PROGRAM

PURPOSE:

To establish a system-wide Quality Improvement (QI) program for evaluating the Seminole County Emergency Medical Services (SCEMS) system in order to foster continuous improvement in performance and quality patient care. To identify positive and negative trends in the system, and develop educational programs that will improve or enhance the level of care provided by the system’s EMTs and Paramedics. To assist EMS Providers and Receiving Hospitals in defining standards, evaluating methodologies and utilizing outcome data results for continued system improvement

AUTHORITY:

Florida Administrative Code, Department of Health Rules, 64-J-2.004, Section 4(c)

SCOPE:

The Seminole County EMS (SCEMS) system is comprised of the following agencies under the Medical Direction of the SCEMS Medical Director:

Casselberry Fire Department	Lake Mary Fire Department
Longwood Fire Department	Orlando-Sanford Airport Fire Department
Oviedo Fire Department	Sanford Fire Department
Seminole County Fire Department

The Seminole County EMS Performance Management Bureau adheres to the philosophy of Continuous Quality Improvement (CQI). CQI is a team-based process that conducts a clinical review of selected cases each month. Based on strict confidentiality and a shared commitment to excellent prehospital care, CQI reveals potential areas for improvement of the EMS System, recommends and oversees training, highlights outstanding clinical performance, audits compliance with treatment protocols, and reviews specific illnesses or injuries along with their associated treatments. These efforts contribute to the continued success of our emergency medical services through a systematic process of review, analysis and improvement. Evaluation will be facilitated by use of data derived from the following sources:

EMS reports	Medical Director Meetings
Computer-assisted Dispatch (CAD)	Quality Committees
Hospital Outcome Data	Biomedical devices </ br>(i.e. cardiac monitors)
Direct Field Observation	EMSystem™

PROGRAM OBJECTIVES:

• Establish a mechanism for monitoring EMS Performance.
• Establish performance indicators and benchmarks to identify expected levels of pre-hospital care.
• Establish a mechanism to systematically review data derived from EMS reporting systems.
• Assure all Seminole County EMS providers possess a clear understanding of the EMS Protocols.
• Provide quarterly reports to the EMS Group, Medical Director and Fire Chiefs of Seminole County.
• Establish a method to utilize information received from the program to assist the EMS and Training Group in developing educational programs.
• Establish a Benchmarking relationship with other EMS systems for comparison and competition.

STRUCTURE AND RESPONSIBILITIES:

Medical Director

Responsible for implementation and audit of the CQI Program. Provide medical guidance and leadership to ensure that the techniques and practice parameters meet or exceed local/national standards of care for pre-hospital care. The Medical Director shall perform his/her functions in accordance with the Medical Director Contract and Florida Administrative Code Chapter 64J-2. He shall respond to the direction of and be under the direct authority of the Director of Public Safety.

Senior Coordinator

Responsible for development and implementation of an effective system for continuous monitoring and evaluation of all aspects of patient care. Develop and distribute, as a minimum, quarterly and annual reports of EMS system activities to the EMS Group, Medical Director and Fire Chiefs of Seminole County. Develop and distribute other EMS data/statistics as directed by Director of Public Safety.

Peer Review Committee

Each agency is encouraged to develop an internal review committee for the confidential review of run reports and evaluating the reports and medical care based on the established thresholds for evaluation.

EMS Quality Council:

Composed of the EMS Group, local Hospitals, non-emergency ambulance providers and air medical providers. The Council is chaired by the SCEMS Medical Director and works closely together to identify problems, problem resolution, and to develop standards of care for the EMS system.

ASPECTS OF CARE

Procedures and services delivered by the providers in the Seminole County EMS System may be categorized as high, potential risk, and/or high volume activities for the purposes of measuring performance and benchmarking within the system. Each agency is responsible for the evaluation of these various aspects of care and submitting data monthly as predicated by the Medical Director.

High-Risk

Procedures or interventions in which there is an increased chance of a catastrophic event occurring if the procedure or intervention is performed incorrectly. All high-risk procedures will be monitored on a monthly basis to evaluate the associated risk and benefit of the procedure or intervention. The evaluation includes but is not limited to the review of run reports and data generated by run reporting systems. The following is a dynamic listing of the high-risk procedures that are performed by SCEMS Paramedics:

Endotracheal Intubation	Synchronized Cardioversion
Nasotracheal Intubation	Defibrillation
Surgical Cricothyrotomy	Post-Mortem C-section
Pleural Decompression	Escharotomy

Potential Risk

Procedures, interventions or situations that have a significantly higher than average chance of failure or have been proven to be problematic to the SCEMS system and are not listed as high-risk. Strategic services or procedures shall be reviewed quarterly. The following is a dynamic listing of the strategic procedures that are performed by the agencies of the SCEMS system:

Administration of Controlled Substances	Medical evaluation of tasered patients
Delayed Offload at Emergency Dept.	Wave-form Capnography Compliance
Response time to cardiac arrests > 6 minutes	12-lead EKG for all cardiac & SOB pts.
Questionable transport destination	Absence of IV/IO during cardiac arrest
Appropriate use of Air Medical Resources	Use of Continuous Positive Airway Pressure (CPAP) Device
AMA refusal of incapacitated patient

High-Volume

Procedures or interventions that are performed routinely on a daily basis. These skills will be evaluated monthly with a bi-annual report to be produced to determine the status of the individual procedure. The evaluation of the skill or procedure will include but not limited to the tracking of successes vs. failure of a procedure, the number performed in a specific time period and the benefit to the system in continuing the use of the procedure or service.

• Appropriate use of C-Spine Clearance Protocol
• PCR Documentation
• IV/IO
• Airway Management

CLINICAL INDICATORS

Clinical indicators are tools for measuring compliance with an expected standard. The program shall use clinical indicators to monitor practice parameter compliance. Clinical indicators should be met or the reason it was not met should be documented. On an semi-annual basis, the Program Coordinator, in association with the EMS Group and the Medical Director, will review and revise as necessary clinical indicators.

THRESHOLDS FOR EVALUATION

Thresholds are established for each clinical indicator. They define the acceptable level of performance and may be determined by relevant findings in current literature, National and State standards or past data results. The following is the recommended threshold values for various procedures: (The threshold sets may vary according to call load and other circumstances.)

Airway Management

• Proper airway documentation complete - 100%
• Managed unstable airway with ET tube, King Tube, or BVM – 100%
• ETCO2 utilized on all unstable airway patients being managed with an ET/King Tube – 100%

Trauma Management

• Over-triage of Trauma patients <30%
• On-scene time 10 minutes or less unless extenuating circumstances exist (e.g. entrapment, MCI event, etc.) and are documented - 90%
• Appropriate use of air-medical resources – 95%

Acute Coronary Syndromes (ACS) and Stroke

• Recognition of STEMI – 95%
• ACS patients receive Morphine, Oxygen, Nitro & Aspirin (MONA) or document contraindication - 95%
• 12-Leads performed on all chest pain; congestive heart failure; cardiovascular; pre and post cardioversion; & stroke patients (>35 years of age) – 100%
• 3-Lead ECG performed on all altered mental status; syncope/fainting; respiratory distress; drug/toxic ingestions and abdominal pain patients (>35 years of age) – 100%
• Stroke recognition and transport to an appropriate primary or comprehensive stroke receiving facility -100%

Cardiac Arrest Management

• Total response time (from “dispatch complete” to “with patient”) to Cardiac Arrests <6 minutes – 90% fractile
• IV/IO Access – 90%
• Attain return of spontaneous circulation (ROSC) – 10%
• Survival rate of cardiac arrest patients – 10%
• Code Cool implemented on all patients meeting criteria – 100%

Documentation

• Complete stroke forms for all Stroke/CVA/TIA patients – 100%
• Fax stroke forms to EMS Quality Assurance Office – 100%
• Fax Sepsis forms to EMS Quality Assurance Office – 100%

Data Sources:

Through the use of a variety of data sources, problems or potential problems in patient care can be identified. A yearly evaluation will be performed to determine any outstanding problems with the system and ways to improve. The following are data sources to be used to evaluate the system:

Patient Run Reports	EMSystem data
Computer-assisted Dispatch (CAD)Reports	EMS/Hospital Outcome Data
Random Patient Surveys	Peer Review Committee Feedback
ED staff/Physician feedback	EMS Group Feedback

Field Observations/MD Ride Time

Medical Director shall periodically ride with various units to evaluate crew performance in the pre-hospital setting and interactions with hospital personnel.

Medical Director Review

The Medical Director shall review, on a monthly basis, EMS reports to assure compliance with Seminole County Practice Parameters and Florida Statures. Review may include cardiac arrest, trauma alerts, deviation from protocol and other reports that he may choose. Selected reports shall be forwarded to the Medical Director prior to the 7th of each month for his/her review and comment. Deviations from Practice Parameters shall be forwarded to the Seminole County Medical Director immediately after such a report is completed or upon its discovery during the Q.I. review process.

The Medical Director shall be contacted immediately in the event an alarm occurs which involves questionable medical treatment or if clarification is required regarding patient care.

Specific Incident Resolution and Improvement

Notification of an Incident

An inquiry can be initiated by the Medical Director, Public Safety Director, hospital representative and/or the affected EMS agency representative to determine the severity of the incident and what action may be necessary. If it is determined that further review and/or action may be needed the Medical Director and the EMS Coordinator of the affected agency shall be notified of the alleged incident and related circumstances.

Root Cause Analysis

A root cause analysis (RCA) is a process designed for use in investigating and categorizing the root causes of events with safety, system-design, environmental, quality, reliability and parameter impact. The term “event” is used to generically identify occurrences that produce or have the potential to produce these types of consequences. RCA is a tool designed to help identify not only what and how an event occurred, but also why it happened. Only when investigators are able to determine why an event or failure occurred will they be able to specify workable corrective measures that prevent future events of the type observed. During this phase all information regarding the alleged incident will be obtained to include dispatch records, patient care reports, and hospital records. It may be necessary to interview the individuals involved and document their information. A determination will be made by the Medical Director in cooperation with the affected EMS agency representative to ascertain if the care provided during an incident compromised patient outcome. The Public Safety Director shall be notified in writing of all events falling within the Root Cause Analysis category.

Sentinel Events

A sentinel event is described as an event that has resulted in an unanticipated death or major permanent loss of function, not related to the natural course of the patient’s illness or underlying condition.

Development of an Improvement Plan

Once the RCA has been completed, if the investigation reveals a deviation from procedure or protocol, an Improvement Plan will be developed. The Medical Director in cooperation with the affected agency representative will develop a plan for the involved individuals to follow to alleviate the potential for similar episodes occurring in the future. If the investigation determines that the problem is a system-wide problem, the area of deficiency will be turned over to the Seminole County EMS System Training Group to develop, in conjunction with the Program Manager; a system-wide educational program. The Medical Director shall communicate any recommendations for corrective action to the Fire Chief of the affected agency with a copy to the Public Safety Director for their ultimate determination.

Documentation

The Public Safety Director will maintain, in a secure environment, all reports and information gathered during the investigation. At the conclusion of an investigation the Medical Director will prepare a summary report for the Fire Chief and the EMS representative of the affected agency. The report will provide an overview of the incident and a summary of actions to improve the system.

Confidentiality

All patient care records and reports generated for CQI review purposes are confidential and non-discoverable as outlined in F.S. 401.425.

Medication Errors

There are 5 levels of medication errors based on the type of error and the reaction that the patient has, if any. They are:

• Correct medication / Wrong time of administration
  • No signs or symptoms or physical indicators.
  • No short- or long-term sequelae.
• Correct medication, wrong dose.
  • No signs or symptoms or physical indicators
  • No short- or long-term sequelae.
• Wrong medication or wrong dose, no or limited signs and symptoms or physical indicators
  • No short-term or long-term sequelae.
• Wrong medication or wrong dose.
  • Moderate or severe signs or symptoms or physical indicators.
  • Short-term sequelae, no long-term sequelae.
  • May require monitoring or close observation.
• Wrong medication or wrong dose.
  • Moderate or severe signs or symptoms or physical indicators.
  • Short and long-term sequelae or death.
  • Required intensive monitoring and/or interventions.

In the QI process, levels 1 through 3 do not require intense review. All levels do require some review. All levels require a determination of why the mistake occurred and a determination if there is a way to assure that this does not happen in the future.

Levels 4 and 5 require a detailed review process. These levels will require medical director involvement, including medical director interviews and discussion with the persons involved.

Trend Analysis

The Medical Director shall analyze the data for positive or negative trends with appropriate actions taken to rectify or prevent negative trends in patient care.

Annual Review of the CQI Program

The CQI Program will be evaluated annually by the Seminole County Medical Director and Public Safety Director. The measurable objectives of the program will be compared to the performance in order to determine the effectiveness of the program. The Program will be enhanced as appropriate. The annual report will be presented to the EMS Group, the Medical Director and the Fire Chiefs of Seminole County.