A national database examining five metrics in evidence-based care gives EMS a framework to improve tactics, efficiency, outcomes and resource allocation
By Brent Myers, EMS1 Contributor
Everywhere we look, EMS is undergoing subtle and not-so-subtle changes, with an increased emphasis on how and when dollars are spent, what results are being measured, how to best serve rural areas and the increasing opioid crisis. The smarter use of data continues to emerge as a critical need to help us make more informed decisions, share important information from multiple sources, and improve interoperability between departments and other systems to ensure positive outcomes for both patients and the organizations that serve them.
Data will be particularly valuable in the financial realm, particularly as EMS plays a more vital role in the transition from volume-to-value payment methodologies. In other words, as the EMS evaluation tools in the field become more sophisticated, treatment and transport decisions will have increasing influence regarding assurance of the most positive outcome possible.
For example, if a patient presents with acute ischemic stroke symptoms, do we take them to the nearest stroke-capable hospital that is 10 minutes away or the thrombectomy-capable or comprehensive stroke center that may be 30 minutes away?
The ongoing move from quantity of services provided to quality of services provided will have a ripple effect across all agencies, especially as financing and payments are tied to those decisions. Access to the right data at the right time will play a key role in those decisions and will help agencies properly evaluate and measure performance.
Evaluating evidence-based metrics
The appropriate metrics for evaluating the success of any EMS organization will vary depending upon a number of factors, including the size of population served and geographic location. However, an objective review of aggregate data may give EMS providers a good idea how they are performing compared to their peers.
To that end, we extracted data to provide an objective look at five minimally controversial metrics that are evidence-based. We utilized our national database of encounters for the complete calendar year of 2017, which includes 5.02 million patient encounters, to create our 2018 EMS Index. The five metrics are:
- Stroke assessment performance.
- Proportion of patients suffering from overdose.
- ETCO2 after advanced airway procedure.
- 12-lead performance in adult chest pain.
- Aspirin administration in adult chest pain.
The purpose of the Index is to serve as a point of reference for EMS organizations to identify which areas are in alignment and which areas represent opportunity for improvement – or at least further assessment and evaluation. This quantitative approach to measuring performance gives EMS organizations a framework to continually refine tactics, improve efficiency and outcomes, and allocate resources appropriately.
Here is what we found:
1. Stroke Assessment
Any patient record with a primary EMS impression of stroke in the electronic health record was included. Stroke encounters accounted for approximately 75,000 of the 5 million encounters in our dataset. What we discovered is that a complete stroke assessment is not documented in nearly 50 percent of those 75,000 encounters, meaning there is significant room for improvement in light of new literature around stroke.
This is an important measure, and one that has received lots of press recently, since appropriate hospital destination more and more is determined not only based on the presence of stroke but also on the severity of stroke. The best tool to evaluate the severity of stroke has yet to be determined; thus, completion of currently used tools with adequate documentation is essential both to assure optimal care for the patients EMS encounters and to help the industry determine the best tool or tools to use in the future.
Inclusion criteria for overdose was any patient with a primary EMS impression of overdose, including opioids. Overdose encounters accounted for approximately 83,000 of the 5 million encounters in our dataset, about 1.65 percent. As the opioid epidemic continues, this allows EMS to communicate effectively with external stakeholders about the magnitude of this type of response versus other types of response, as well as help internal stakeholders understand the magnitude of impact in their community.
As a side note, EMS responses to overdose make up a greater proportion of responses than cardiac arrest, stroke or STEMI at a national level.
3. ETCO2 After Advanced Airway
Inclusion criteria is at least one value of ETCO2 documented for any patient with advanced airway (BIAD/Supraglottic/ETT/Surgical). There are approximately 30,000 cases in our dataset, with capnography monitoring in place 94.5 percent of the time. This is phenomenal.
One of the greatest risks associated with critical patients requiring advanced airway management is unrecognized decompensation, either due to worsening disease/injury or to misplaced or dislodged airway. Evidence suggests that quantitative ETCO2 monitoring is the best intervention to minimize these risks.
4. 12-Lead Performance
Inclusion criteria for 12-lead performance is any patient 35 years of age or older with a primary impression of chest pain. Of the approximately 209,000 documented cases, an EKG was performed in nearly 76 percent of the cases.
The EKG is the most powerful study in the EMS scope to evaluate patients for the presence of acute myocardial ischemia that is likely to be improved with percutaneous interventions. Measureable and reproducible reductions in mortality are associated with appropriate acquisition and interpretation of EMS EKGs. The 76 percent raises a couple of questions, including why nearly 25 percent of the patients in the dataset that met the inclusion criteria did not receive an EKG (or an EKG was performed and not documented).
5. Aspirin Administration
Inclusion criteria for aspirin administration is any patient 35 years of age or older with a primary impression of chest pain (essentially, the same criteria for 12-lead performance). Aspirin administration encounters accounted for approximately 182,312 of the 5 million encounters in our dataset. Aspirin was administered in just more than 55 percent of cases, which means that in nearly 45 percent of cases aspirin was not administered.
Anecdotally, many of the “missing” aspirin administrations were actually situations in which the medication was self-administered prior to any EMS arrival or was provided by a first-response agency and not documented in the transport EMR. That said, if EMS is to truly be evaluated based upon quality rather than quantity, it is imperative upon us to assure appropriate documentation in all of these circumstances.
Our healthcare partners at receiving hospitals have been documenting EMS administration of ASA for many years – we can do the same with respect to utilization of aspirin prior to transport arrival on-scene.
Gauge opportunities for improvement in EMS
So, what do we do with all this data and what does it mean? The Index we created is simply a start and a way for organizations to look at their own performance and gauge where opportunities exist for improvement and where agencies should be applauded for the great work they are doing.
This is simply meant to start the conversation – and we look forward to continuing it with you.
Take a look at the full Index here.
About the author
Dr. Brent Myers is the chief medical officer for ESO and one of the authors of the EMS Index. He is also the president of the National Association of EMS Physicians. He can be reached at firstname.lastname@example.org.