Solutions to Provider Safety

John Erich

Original Contribution

Solutions to Provider Safety

John Erich

October 2010

This article appeared in the supplement Ambulance Safety Solutions sponsored by ZOLL Medical Corporation

Expert source: Alan Craig, MS, ACP, Deputy Chief Toronto EMS

EMS rarely lacks for information. Every call brings a chief complaint, vital signs, assessment findings and a history. We differentiate among and intervene against endless combinations of illnesses, injuries and circumstances. Put it all together, and we have a whole lot to keep track of, at moments that aren't exactly tranquil.

And just having that information is only the beginning of the job. What matters for patients--and ultimately for you--is what you do with it.

"There's tons of information available in high-pressure environments like EMS," says Alan Craig, MS, ACP, deputy chief of Toronto EMS, Canada's largest municipal paramedic ambulance service. "There are different ways of making use of that information, and protecting both you and your patients by making sure you're properly processing the information available to you about their condition and the environment you're in."

That's the concept of situational awareness, and it's important for everyone's well-being. And, luckily for everyone, advancing technology is going to make it much easier to keep a handle on.

Situational Awareness

One leading conception of situational awareness breaks it down into three parts:

Perceiving critical elements in the environment;
Understanding the significance of available information;
Projecting what could happen next.

If that sounds familiar, it's because it's precisely what EMS does.

"When we have critical patients, we're not only aware, from our training and experience, of what's happening with them, but we understand why a change in blood pressure, for instance, or a drop in oxygen saturation is important," says Craig, who oversees Toronto EMS' service quality and program development. "Those are the pieces of information we use to make care decisions, and if any of that fails--if you fail to achieve that highest level of not only knowing what to do, but understanding what you're seeing and being able to project into the future--patients can get out from under you. You'll be surprised by what happens, and that can be lethal."

Yet EMS is challenged to practice its situational awareness against the backdrop of uncontrolled environments: on the streets, in homes and businesses, surrounded by bystanders and distractions and dangers. That places a premium on excellent clinical skills--and having a little help, if you can get it.

That's where new technologies come in. We need mechanisms to integrate, contextualize and filter the delivery of the torrent of data and facts coming at us--things that give us what we need to know, when we need it, without bogging down in ancillary details.

"We want smart delivery of information," says Craig. "There's an enormous amount of information available now in the critical-care setting, and it can be overwhelming."

Automation of the process should mitigate that. Through automation, our technologies should be able to package the obvious, display patient progressions, warn you if crisis looms, and promote compliance with protocols and procedures.

Imagine tracking a vital sign over time. Easy enough to measure now, but in the hubbub of an emergency scene, what was it five minutes ago? How about 15? Can you rely on remembering accurately and instantaneously? Then, what's the trend, and what does it mean given your patient's presentation and your other findings?

"Changes in something like a heart rate can tell us a lot about a patient's progression," says Craig. "If they become tachycardic, that's a clue about things. If they're bradycardic, if their blood pressure suddenly drops or increases, if their oxygen saturation drops or there's a change in their end-tidal CO₂ or ECG, that's a tremendous amount of information. So we really want to watch the things that are most predictive, that best describe transitions in the patient's condition. That needs a technology that looks at blocks of time, takes all of that information and then tells us specific things about what's going on, but not about things that are routine or normal."

Of course, a progression or finding that's benign in one circumstance could be a red flag in another. That's where context comes in--the impending leap forward in patient care. Our contemporary monitor systems generally aren't especially context-specific, even with things like alarm settings. The desired EtCO₂ range you'd want for a conscious, breathing patient, for instance, isn't the same you'd look for in an intubated cardiac arrest resuscitatee. Yet with many modern monitors, you're left scrambling to reset the alarm levels while in mid-care--not ideal for patient or provider.

What's necessary to context is integration. That means all the data from all the sources--biometric, and input by humans asking focused questions--is seamlessly combined into an entity that can distinguish and relay what's important now, what's become important in the last few moments, and what else you need to know to help your patient.

"For instance," says Craig, "we now have enough computing power to start to bring in technologies like dysrhythmia software that can tell you, 'Uh-oh, look at this--this guy just threw a string of PVCs.' We don't have that now. Often, the best we can do is watch for a really malignant rhythm like v-tach or VF, and get an alarm that says, 'Check patient.' What we need is the level of sophistication you get in the CCU, where it causes an alarm when certain rhythms or events occur. But that requires an analytical capability in the monitor we don't generally have today."

An exception to that is ZOLL's RescueNet data management suite for EMS and fire, a package of fully integrated fire and EMS software solutions that can manage defibrillator resuscitation data from the time of the call all the way through payment. Monitor data is blended with tablet PCR input for a picture of complete breadth and depth. Linking the entire chain of events this way produces complete clinical and operational overviews that can lead to better and more efficient care.

From there, the big picture can keep growing. Maybe your patient was seen by your service for a similar complaint two weeks ago. How does the ECG from that day compare to today's? If that bundle branch block is new, wouldn't you like to know?

Smart and integrated systems can provide care pathways that lead providers through appropriate interventions, ensuring no step is forgotten.

"A care pathway is a checklist of things we'd expect a paramedic to do, and treatments we'd expect them to consider, for a patient with a particular presentation," says Craig. "For instance, if somebody tells us they're having chest pain, we need to try to determine whether it's ischemic cardiac chest pain or not. That means we have to make certain assessments and apply certain monitors and so forth. They have to have an ECG monitor. They have to be on oxygen. We have to be doing vital signs continuously. They're going to need an IV line. And some other standard treatments we want to make sure they get in the field-- aspirin, if there are no contraindications; in many cases, nitroglycerin. And sometimes we need to remind people to do all those things, so you don't get 15 minutes into the call and realize you've forgotten something."

Safety Benefit

This provides a kind of real-time QA, helping ensure you do everything a reasonable provider with the same training and experience would have done. The safety benefit of that for patients seems obvious. What could it mean for providers in that most dangerous setting, the back of a moving ambulance?

To the extent it can allow caregivers to stay seated and restrained, automation is a huge plus. Imagine no longer needing to stand to deliver chest compressions or acquire another vital.

"If I have to be sitting in a forward- or rear-facing seat, properly belted, all of a sudden I can't be standing up and going over to look at some small monitor screen down by the patient's foot," says Craig. "I can't be getting up to go take a blood pressure manually. I need automated devices to do that, and I need the information that's being collected to be displayed in a way I can see and read from 2, 3, 4 feet away. Maybe I need the ability to communicate with it through a keyboard system or even voice-activated software.

"Safety in the back of the ambulance really requires us to bring sophisticated onboard biometric systems into the back of the ambulance. I don't see any reason why, in five years, a 20-inch touch screen won't be a standard part of the display. I think it's an essential part of promoting provider safety in the back of the vehicle."

Canadian Report Outlines EMS Safety Issues

It goes without saying that ambulance safety issues are not limited to the United States. In June, following an intense three-part research project, the Canadian Patient Safety Institute in Toronto launched a report that it hopes will lead to further research and implementation of current evidence to improve safety in EMS.

Although the project primarily addressed patient safety rather than provider safety, there was definitely an ambulance component to it, says Blair Bigham, MSc, ACPf, prehospital investigator for Rescu, St. Michael's Hospital and principal author of the Patient Safety in Emergency Medical Services report.

"A couple of things came out of the research, the first being whether or not to drive with lights and siren," he says. "There is really no good evidence that can guide us as to when lights and siren use is appropriate, but we do know it can be dangerous and they need to be used appropriately and responsibly."

Some of the study's participants felt that updating dispatch protocols might help cut down the risk of collision while driving at high speeds with lights and sirens. Crew fatigue was also identified as contributing to collisions. According to the study, "Crews work long shifts and experience sleep inertia, characterized by a decline in motor dexterity and a feeling of grogginess after an abrupt awakening." One paramedic also identified lack of driving experience and skill as a contributing factor to ambulance crashes.

For a copy of CPSI's patient safety study, see www.patientsafetyinstitute.ca.

--Marie Nordberg

Situational Awareness for EMS

Perceiving critical elements in the environment: