As quality coordinator for Bucks County Rescue Squad—a medium-sized, third service EMS agency in southeastern Pennsylvania—about a year ago I made a major discovery in the realm of concurrent quality improvement when I decided to jump aboard the ambulance and take in a few calls with the duty crew. I told the crew I needed to get out of the office and was going to tag along, adding that I’d be their go-fer and offering my services for whatever they wanted. “Great,” one provider replied, his tone betraying more his sense of resignation than appreciation. I had predetermined that I would resist all temptation to do anything other than observe unless specifically asked.
A little more than an hour into the shift, the medic unit was dispatched for a patient with syncope. Shortly thereafter, we pulled up to the front of a single-family dwelling. The crew grabbed the cardiac monitor, O2 and jump kit, and up the steps and in the front door they went. I trailed behind, posting myself at the doorway to take in the scene. The crew placed their equipment on either side of the 45-year-old female sitting on the sofa, who did not appear to be in any obvious distress. “I was cleaning the house and all of a sudden got very dizzy and weak and felt like I was going to pass out,” she offered.
Medic No. 1 felt for a radial pulse while No. 2 asked if she was having any chest pain or shortness of breath. The patient denied chest pains or any additional complaints other than still “feeling a little shaky.” Medic 2 then asked the patient if she had any past medical history, while Medic 1 took his turn palpating the opposite radial pulse. The patient replied that she had hypertension and high cholesterol, as she handed Medic 2 three prescription bottles of medicine. He wrote down her meds, and he and his partner continued taking turns asking a few additional questions. After several minutes, Medic 1 suggested they move to the ambulance.
The medics collected their unused equipment and escorted the patient outside. We all climbed into the ambulance, and the patient was directed to the litter. Nine minutes after initial patient contact, a full set of vital signs was finally taken. Her pulse rate was 96, BP 138/68, respiratory rate 18, SPO2 96%, and a normal sinus rhythm was displayed on the cardiac monitor. A 12-lead ECG was negative for ischemia or injury. In this case, no critical medical problem was found; however, the inefficiency of the crews’ initial patient assessment, duplication of effort and several minutes of wasted time were striking.
Over the next few weeks, I audited several more calls with our squad and observed some calls with surrounding agencies. Much to my surprise, the inefficiency and lack of any organized effort by EMS crews was more common than I could ever have imagined.
What a great opportunity to improve patient care by way of the first and single most important component of patient care—the initial patient assessment—and all while making the job quicker and easier for the providers. The fix was simple: pre-defined roles and teamwork.
Taking a New Approach
My wonderfully supportive and long-enduring EMT partner Mary Wallover agreed to yet another of my harebrained schemes. This one, however, she quickly recognized had potential. It was decided that for advanced life support calls, Mary would obtain a full set of vital signs and attach the cardiac monitor and pulse ox, while I took a history and performed an exam.
A decade ago, cardiac monitors displayed cardiac rhythms and included a defibrillator, and that was it. Today, most cardiac monitors used by EMS are for all intents and purposes complete patient assessment packages capable of obtaining heart rate, noninvasive blood pressure, pulse oximetry and cardiac rhythm. Some monitors even provide respiratory rate acquired through one of the ECG electrodes.