Quality Improvement Part 2: Concurrent Review

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

   This is the second 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. Last month, we reviewed retrospective review. This month, we look at concurrent review.

   Any truly efficient quality improvement program needs to be active and engaged before, during and after the call.

   While retrospective quality review is an important part of the quality improvement process, it should not be the whole process. Theoretically, you could write a PCR for a totally fictitious call without ever leaving your seat. As long as you didn't document anything too bizarre, probably no one would ever question it. To really understand what's going on in your agency, you have to go beyond reading PCRs after the fact.

   Imagine an EMS crew getting the dreaded "10 minutes before the end of shift call" from a patient who just needs to be picked up off the floor and put back in her chair. The patient denies any complaints, there are no bones sticking through the skin, but department policy states vital signs must be taken on every patient, so what's the problem with just guesstimating them? It'll save a couple of minutes. If you don't look, you won't find anything that could bog you down with time-consuming treatments, so why not?

   To the expert EMS provider's eye, the patient looks like a pulse rate of...oh, say 80, a blood pressure of 120/70 and a respiratory rate of 12, so sign here and away we go. The patient gets exactly what she asked for, the agency is saved the expense of overtime, the providers get out of work on time and everybody's happy. Until the oncoming crew gets dispatched back to the same address an hour later for the same patient who fell again--this time resulting in a life-altering and possibly life-ending hip fracture.

   The new crew, a captive audience for the next 12 hours, has more than enough time to actually check vital signs, especially now that she is an obviously treatable patient. Lo and behold, they discover a pulse rate of 32. Hooking the patient up to a cardiac monitor reveals something unusual: There are P waves before most QRS complexes, but every once in a while, the P wave seems to be missing, along with the rest of the cardiac cycle, resulting in an extended period of asystole, typically followed by a ventricular escape beat. Eventually, but belatedly, a P wave does return. This ultimately ends up being diagnosed as sinus arrest or sick sinus syndrome, most likely resulting in a temporary decrease in level of consciousness and probably causing the several falls the patient has suffered lately. The same decreased perfusion that caused the falls could also affect the patient's sensorium, so she may not have been aware if she had blacked out briefly or suddenly became weak or dizzy. Had the first crew done its job and simply taken a standard set of vital signs, even though it meant getting home a little late, the patient may have been spared her current serious injury.


   Concurrent QI is where the quality coordinator, medical director or other EMS officers get out on the street to see what's going on. One mistaken concept is that there's little reason to do this, since the providers won't do anything wrong if they know they're being watched. Despite the fact that people often do a better job if they know they're being watched, not every deficiency in EMS is malicious. There are many problems or opportunities for improvement in EMS that could be due to lack of objective third-party evaluation and modification. Many real-world issues could not be imagined by supervisors or medical directors sitting in the sanctuary of their offices. The only way to see what's going on in the streets is to get out and observe it first-hand.

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