Mission in Action

   There's a lot that goes into running an EMS system. There's big stuff, like having enough money and equipment and people on hand to answer calls. There's little stuff, like crew configurations and shift schedules and response times to get to calls. And there are calls. Which, you may have noticed, underscore most all other considerations, big and small.

   All that other stuff is important, no doubt, but in a sense it's ancillary to the core mission of EMS, which is the delivery of emergent healthcare services to our communities' ill and injured--that is to say, medicine. Without careful attention, that medicine is a mission that can get subsumed in the day-to-day ballyhoo of operations and logistics and politics that define so many systems' harried existences.

   Noted the architects of the recent Pinnacle EMS leadership and management conference, held this past July in San Diego, CA: "The majority of EMS systems devote a significant amount of their time working to get the right ambulance to each call. Meanwhile, dedicated leaders work diligently to keep staffing numbers up, ambulances in service and response time performance reliable. But when it comes to addressing the reason people call for help in the first place--the medicine--leaders often assume that patient care is just fine, or they relegate a skeleton clinical staff in a back room to monitor it. Imagine if the medicine was a priority that was fully integrated into operations of an EMS agency. What would that look like?"

   No need to imagine; there are some great examples we can consider. Here are two--one profiled at the Pinnacle show, the other intended to be before a last-minute change.

Order From Chaos: Medic's Focused Cardiac Arrest Protocol

   If you're going to zoom down on the medicine in emergency medical services, cardiac arrests are a fine place to start. It's an area where we know EMS, if it does the right things in a right and speedy way, can make a positive difference for many patients. When it comes to outcomes, it's a place where systems can actually demonstrate a return on what they invest.

   What they did in Mecklenburg County was add some hospital-style quality improvement tools to the equation.

   "Our point was to take something that's typically part of a hospital QI program and apply it to the prehospital setting," says Tom Blackwell, MD, FACEP, medical director for Medic, the EMS provider serving Mecklenburg, including the city of Charlotte. "The idea of Reliability Theory, which is used in manufacturing and other industries, is that if you continue to do the same things over and over again, achieving good results, then those results will be sustainable."

   That notion dates to the 19th century, but has been more recently promoted by the Institute for Healthcare Improvement as a way to ensure every patient gets effective, evidence-based care every time, without variations of quality or kind due to location, gender, ethnicity, socioeconomics, etc. As applied to a system's cardiac arrest response, it boils down to doing the right things every time--things like dispatcher coaching, promotion of bystander CPR and delivery of fast, appropriate interventions by practiced responders.

   For a lot of people, appropriate now means deemphasizing ventilations and minimizing interruptions in compressions. And to that point in particular, and to the cause of sustaining good results in general, the theory dovetails neatly with another the IHI extols: the rapid-response or medical emergency team.

   In hospitals, these teams of clinicians bring fast critical care to the bedsides of patients exhibiting precursor signs of crash. Patients who suffer cardiac or respiratory arrest in institutions often show telltale changes in things like subjective complaints, vital signs and nursing documentation beforehand. By recognizing and responding to these, the idea goes, these teams can rescue patients who, postcrash, would have been lost.