Quality Improvement Part 3: Prospective Review

EMS agencies must embrace continuous quality improvement as part of their daily operations


   This is the final part of a three-part series of articles that reviews the three components of a QI program and shows how each was successfully administered at Bucks County Rescue Squad and Central Bucks Ambulance--two midsized EMS agencies in southeastern Pennsylvania. Parts 1 and 2 discussed retrospective and concurrent review. This month, we look at prospective review.

   Prospective quality improvement is anything done prior to call dispatch that can improve the quality of patient care, such as continuing education courses, in-service training, counseling sessions, skills review or clinical memoranda.

   Continuing education is a fact of EMS life. It's the minimum CE credits required to maintain active status, with the emphasis on minimum. But who holds a job involving life-and-death decisions on a regular basis and is satisfied with the bare-bones minimum? We all get to choose our primary care provider, but no one gets to choose their EMS provider. Patients end up with whoever happens to be on duty at the time, and we owe it to them to always be at our best. We need to strengthen our commitment to lifelong learning in an attempt to become better emergency medicine providers.

   In many cases, continuing education in EMS has become nothing more than the constant rehashing of ACLS and PALS. These classes are a great foundation on which to build, but after a time or two, they are just refreshers that offer little new educational value.

CALL-BASED EDUCATION

   A concept that is frequently lacking in EMS training is "call-based" education. Grand rounds come close, but, just as with retrospective and concurrent quality improvement, they most often end up concentrating on high-profile cases. Grand rounds also all too frequently focus on calls with excellent to acceptable management. We have the potential to learn a lot more by reviewing calls that are poorly managed.

   One perfect example is how generalized weakness is frequently under-appreciated and undertreated. As mentioned in Part 1 of this series, generalized weakness is not always a critical emergency, but it is in the case of stroke, sepsis, cardiac dysrhythmia, MI, hypoglycemia, etc. Some underlying causes can be confirmed or ruled out in the field by glucometer or cardiac monitor, but most cannot. In EMS, you don't win points by guessing right when there's no serious illness or injury. You win points by maintaining a high index of suspicion, looking for problems that aren't so obvious and always erring on the side of caution.

   Because weakness as a symptom is so nonspecific and may be lacking a specific treatment or protocol, these patients are frequently just given a ride to the hospital without the provider ever considering the underlying cause. Effective training on this issue might include reviewing some cases of generalized weakness or similar complaints where the patient had a bad outcome. Focusing training on inappropriately managed calls identified through the quality improvement process has the potential to quickly and dramatically improve your providers' quality of care as soon as the very next shift. That's effective quality improvement.

MEDICAL REFERENCE RESOURCES

   It is a universal but sometimes forgotten concept in EMS that employers have the right to dictate how their employees should perform the job they're being paid to do. It is therefore appropriate for an employer or his agent to mandate additional in-house, on-the-clock education, which may include some of the many online EMS education sites. In Pennsylvania, the state Department of Health hosts a free online LMS (learning management system) for use by certified EMS providers. Although this has been available for a few years, it was only within the last year or so that Central Bucks Ambulance mandated completion of a certain selection of these courses. What's easier than a half-hour of online training to be completed monthly between calls, at your convenience, while you're being paid to learn how to perform your job better?

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