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Operations

Mission in Action

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   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.

   The point in Mecklenburg was to apply these ideas to the resuscitation challenge.

   "We figured we could take the Reliability Theory, the idea of medical emergency teams, and then some of this new dogma on the compressions and ventilations in cardiac arrest," says Blackwell, "and combine it all into a new model focused cardiac arrest protocol that could lead to better outcomes."

You Do Chest (Again)

   Medical emergency teams consist of providers such as physicians, nurses and respiratory therapists, each with distinct roles to play at patients' bedsides. To the end of doing things consistently and well, that's an aspect important to Medic's focused cardiac arrest protocol: Each member of its resuscitation teams has a specific and defined role that remains consistent call to call.

   Putting this concept into action began in Charlotte and fell to the first responders of the Charlotte Fire Department. Each CFD truck has four crew members: a captain, an engineer, and two firefighters. Under the focused cardiac arrest protocol, each one is assigned the same responsibility every time. Firefighter #1 goes immediately to the patient and, establishing pulselessness, begins compressions. Firefighter #2 manages airway and ventilations. The engineer waits outside to assist the arriving Medic ALS crew and help prepare the stretcher and chilled saline for therapeutic hypothermia. The captain applies the AED and oversees his crew's care, providing documentation for the ALS crew. The latter two remain behind for family care and cleanup while the firefighters accompany the patient and Medic crew to the hospital.

   "Each of those individuals has a defined and specific role that never changes," says Blackwell. "I don't care if one person says, 'I did the vents last time. I want to do the compressions this time.' It doesn't work that way. You do the same thing every time. Cardiac arrest scenes are chaotic. Responders need to have an organized approach. We believe this will help improve our return of spontaneous circulation and mortality rates."

   Blackwell and Fire Chief Jon Hannan personally instructed officers, then line personnel on the new protocol, then implemented it in August 2009. Early data, though limited, was encouraging: Live discharges and survivals to hospital admission increased from the five-month period before the protocol's introduction to the five-month period after it, and both measures, along with ROSC, improved over the same period in 2008.

   "We've improved our cardiac arrest survival rates dramatically in this community," says Blackwell. "Whether it's from this or other things, like the induced hypothermia we're doing, I don't know--it's multifactorial, I'm sure. But it's improved our outcomes and, really, the relationship between EMS and the fire service too."

A Big Part of Business

   With the protocol's initial success in Charlotte, it's now expanding to the rest of Mecklenburg, where more than a dozen volunteer rescue squads deliver first response. The framework has been so promising, it may also be extended to other types of patients and calls.

   "I think there are things that can be done for critical injuries," says Blackwell. "I think there are things that can be done for strokes. We have a very easy stroke scale, five parameters, that I think our first responders can use. Building up that first responder tier, and really giving them an expanded scope, is something that can really benefit our patients. Fire calls are down, medical calls are up, and this is a big part of their business now. We want them in tune to that and good at what they do, and really playing a much larger role in patient care than they have in the past."

Ears to the Ground: MedStar's Community Health Outreach

   The greatest advantage EMS providers have is their view from ground level. It often can be left to prehospital providers to tie disparate threads together into an accurate portrait of a patient's condition. That perspective makes EMS a good fit for public health-style outreach types of programs. And before you say you don't have time for such luxuries, consider the case of Ft. Worth's MedStar.

   In 2008, that system identified just 21 callers who collectively accounted for more than 800 transports to emergency departments. That resulted in nearly $1 million in (mostly uncollectable) ambulance charges. In 2009, those callers became the initial focus of MedStar's Community Health Program.

   "We took those frequent users and proactively visited them" to evaluate and help meet their needs, explains Jeff Beeson, DO, RN, LP, now interim medical director for the Emergency Physicians Advisory Board, which provides MedStar's medical oversight. "Now, in one year, by being proactive and helping these people with their problems and not transporting them, we've given back our ERs more than 8,400 hours of bed availability."

   The visits came from advanced-practice paramedics, who worked to develop individual plans that could help each caller get more appropriate healthcare and avoid nonemergency summonses to 9-1-1. Many had problems of psychiatric and mental-health natures. Some had disconnects in care (e.g., unreconciled treatments at different hospitals, lack of understanding instructions) or just couldn't navigate the system. Some just needed someone to talk to.

   "Our system is broken, and we're the only common denominator," Beeson observed earlier this year. "We know we transport Mr. Smith to a different hospital every three days. The hospitals don't know it, because they don't communicate. So we're the ones who need to do something about it."

   Further subjects were identified through call records, employee referral and program-partner suggestions. Visiting medics assess patients and ensure they're taking their medications and following up with their primary care providers. Visits can happen daily or as needed. Those who persist in system abuse may ultimately get transport only to assigned medical facilities, regardless of preference.

   The program is estimated to have saved more than $1.3 million in ED charges, and reduced its patients' 9-1-1 use by nearly 50%. And it's helped bring more appropriate medical care to some of Ft. Worth's neediest citizens.

Hospital Partnerships

   The yang to EMS' yin in this equation is the hospitals. They also pay for system dysfunction, through overstressed EDs, among other tolls. They contribute too, indirectly, when they treat and discharge patients without tapping into underlying problems like those described above. Those patients inevitably call 9-1-1 and reappear on ED doorsteps soon enough. Part of MedStar's focus involves breaking that cycle.

   "We have an obligation to inform that next healthcare provider what kind of environments we're picking people up in," says Beeson. "We need to tell them, 'I went to this guy's house, it's 105°F outside, and he doesn't have an air conditioner. He has vague complaints that have gotten better since he's been in a cool environment. I'm concerned about his heat exposure.' If I don't relay that, they're going to check this guy out, say he's fine, and discharge him right back home into that environment that caused the problem. That leaves us in this perpetual loop."

   For EMS, escaping that loop requires enhancing of partnerships with hospitals and, figuratively, following their patients home to intervene against what they find there. If EMS can be more attuned to the back ends of patients' healthcare experiences, they may help block the front end of the next one. "How about that asthmatic we discharge home from the ED?" says Beeson. "Let's visit him within 24 hours and make sure he's getting better and had his medications filled. Right now we don't do that. We should be making sure what we did really made a difference, and the patients understand their disease processes and what we told them to do."

   That's going to require a bit more of the providers at its interface, not the least being good knowledge of disease processes, community resources and how to recognize and access what patients need. It may, in MedStar's case, mean transport to alternative destinations (better to lose a few Medicare reimbursements than buy and staff a new truck, notes Beeson). It may entail a few new expenses. But there are good reasons for hospitals to want to help. A big one came in healthcare reform.

   "I think we're going to be able to show our hospitals that we're reducing their 90-day bounce-backs," says Beeson. "The government's saying they're not going to pay hospitals for readmitting a person with the same complaint within 90 days--hospitals are going to eat those admissions. So when we show them we're decreasing their bounce-backs, there's a potential source of funding. You're going to pay us to provide better care and keep people out of the hospital. I think that's how an EMS system can sustain it."

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