Evidence-Based Performance Measures for Emergency Medical Services Systems: A Model for Expanded EMS BenchmarkingA Statement Developed by the 2007 Consortium U.S. Metropolitan Municipalities' EMS Medical Directors (Appendix)
Section of EMF Homeland Security & Disaster Medicine, The University of Texas Southwestern Medical Center, Dallas, TX 75390-8579, USA. Prehospital Emergency Care
(Impact Factor: 1.76).
07/2009; 12(2). DOI: 10.1080/10903120801903793
There are few evidence-based measures of emergency medical services (EMS) system performance. In many jurisdictions, response-time intervals for advanced life support units andresuscitation rates for victims of cardiac arrest are the primary measures of EMS system performance. The association of the former with patient outcomes is not supported explicitly by the medical literature, while the latter focuses on a very small proportion of the EMS patient population andthus does not represent a sufficiently broad selection of patients. While these metrics have their place in performance measurement, a more robust method to measure andbenchmark EMS performance is needed. The 2007 U.S. Metropolitan Municipalties' EMS Medical Directors' Consortium has developed the following model that encompasses a broader range of clinical situations, including myocardial infarction, pulmonary edema, bronchospasm, status epilepticus, andtrauma. Where possible, the benefit conferred by EMS interventions is presented in the number needed to treat format. It is hoped that utilization of this model will serve to improve EMS system design anddeployment strategies while enhancing the benchmarking andsharing of best practices among EMS systems.
Available from: Pat Croskerry
- "The ACP scope of practice has traditionally included advanced airway management, intravenous (IV) access, IV drug administration, and other skills . Across Canada, recent changes have seen ACPs provide additional interventions, such as 12-lead electrocardiogram interpretation, administration of thrombolytics for acute myocardial infarction and application of continuous positive airway pressure ventilation for acute shortness of breath [6,7]. "
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ABSTRACT: The scope of practice of paramedics in Canada has steadily evolved to include increasingly complex interventions in the prehospital setting, which likely have repercussions on clinical outcome and patient safety. Clinical decision making has been evaluated in several health professions, but there is a paucity of work in this area on paramedics. This study will utilize the Delphi technique to establish consensus on the most important instances of paramedic clinical decision making during high acuity emergency calls, as they relate to clinical outcome and patient safety.
Participants in this multi-round survey study will be paramedic leaders and emergency medical services medical directors/physicians from across Canada. In the first round, participants will identify instances of clinical decision making they feel are important for patient outcome and safety. On the second round, the panel will rank each instance of clinical decision making in terms of its importance. On the third and potentially fourth round, participants will have the opportunity to revise the ranking they assigned to each instance of clinical decision making. Consensus will be considered achieved for the most important instances if 80% of the panel ranks it as important or extremely important. The most important instances of clinical decision making will be plotted on a process analysis map.
The process analysis map that results from this Delphi study will enable the gaps in research, knowledge and practice to be identified.
Available from: dalspace.library.dal.ca
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ABSTRACT: Few developed emergency medical services (EMS) systems operate without dedicated medical direction. We describe the experience of Hamad Medical Corporation (HMC) EMS, which in 2007 first engaged an EMS medical director to develop and implement medical direction and quality assurance programs. We report subsequent changes to system performance over time.
Over one year, changes to the service's clinical infrastructure were made: Policies were revised, paramedic scopes of practice were adjusted, evidence-based clinical protocols were developed, and skills maintenance and education programs were implemented. Credentialing, physician chart auditing, clinical remediation, and online medical command/hospital notification systems were introduced.
Following these interventions, we report associated improvements to key indicators: Chart reviews revealed significant improvements in clinical quality. A comparison of pre- and post-intervention audited charts reveals a decrease in cases requiring remediation (11% to 5%, odds ratio [OR] 0.43 [95% confidence interval (CI) 0.20-0.85], p = 0.01). The proportion of charts rated as clinically acceptable rose from 48% to 84% (OR 6 [95% CI 3.9-9.1], p < 0.001). The proportion of misplaced endotracheal tubes fell (3.8% baseline to 0.6%, OR 0.16 [95% CI 0.004-1.06], (exact) p = 0.05), corresponding to improved adherence to an airway placement policy mandating use of airway confirmation devices and securing devices (0.7% compliance to 98%, OR 714 [95% CI 64-29,334], (exact) p < 0.001). Intravenous catheter insertion in unstable cases increased from 67% of cases to 92% (OR 1.31 [95% CI 1.09-1.71], p = 0.004). EMS administration of aspirin to patients with suspected ischemic chest pain improved from 2% to 77% (OR 178 [95% CI 35-1,604], p < 0.001).
We suggest that implementation of a physician medical direction is associated with improved clinical indicators and overall quality of care at an established EMS system.
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