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Quality Improvement Part 3: Prospective Review


   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.


   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.


   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?

   Every EMS agency has a collection of EMS-related publications lying around on desks, shelves and on or under end tables in the duty crew room. All current and relevant publications should be gathered up and placed in a common area. At a minimum, a current ACLS and PALS or PEPP provider manual, the most up-to-date treatment protocols for your service, and any additional local, county or regional operations manuals should be readily available to your providers. While there's no guarantee they'll be read from cover to cover, making them available dramatically increases the likelihood that providers will reference them from time to time.

   Perhaps your agency could purchase some additional reference books and manuals like Rosen's Emergency Medicine or Harrison's Principles of Internal Medicine. The idea is not to try to make doctors out of medics, but rather encourage them to do call research and learn more about emergency medicine. The more providers know about their medical discipline, the better they will become. Management has a moral obligation to assist EMS providers with improving their knowledge. The perfect time to do call research is immediately after a question is encountered on a call, and the chances are much greater they'll do this if reference material is readily available.

   Most medical books are now available in downloadable electronic format. There are also many free excellent medical resources available online: has an excellent medical dictionary and encyclopedia; is good for quick drug look-up; and is an excellent source for emergency medicine literature. To make it more convenient for our providers, we added a shortcut icon for each of these websites on all computer desktops at both agencies.


   Another tool in call-based education is the newsletter or bulletin. Identify an area in need of improvement, such as the inequity in how various medics treat chest pain. Write a one-page review on the highlights of assessment and treatment of ischemic chest pain. Emphasize the importance of early aspirin administration and 12-lead acquisition, if applicable to your service, as well as the fact that sublingual nitroglycerin and analgesia may help prevent or limit myocardial injury. Stress the importance of a thoughtful working diagnosis; not all chest pain is ischemic and therefore should not receive cardiac meds, but all chest pain patients at a minimum should probably be hooked up to a cardiac monitor and receive a 12-lead EKG, if possible. Emphasize the importance of every patient receiving the same standard of care, no matter which provider responds.

   When writing for a newsletter or bulletin, reference multiple sources and include interesting evidence-based information. (An example could be that early administration of aspirin in AMIs has shown a survival rate comparable to that of tPA, the primary clot-busting drug used for treatment of AMI in hospitals.) It is extremely important to keep the newsletter or bulletin article short and to the point--no more than one page of medium to large print--to encourage providers to read it. Use bolding and underlining to emphasize key points so someone who does not read the whole page might still learn something just by glancing at it. There's also the possibility that bold or underlined items may grab the resistant reader's attention and draw him or her into reading the rest of article. Print the newsletter or bulletin on the brightest colored paper you can find. I used the traditional EMS colors on steroids with international orange and electric blue.

   Finally, display and distribution are critical. At one agency, I distributed them in each provider's mailbox. At the other, I scattered a few newsletters around tables, computer work stations, or anywhere providers tended to congregate. One of my most imaginative and effective ideas by far was posting the newsletter in the men's and ladies' restrooms. This took full advantage of a captive audience, and they were learning where they least expected it. Several people told me they learned more in the bathroom than they did in some classrooms.

   Once the newsletter or bulletin is established, invite others to write. One thing I realized after doing several newsletters was that I ended up learning more by researching and writing than just reading them. This validates the old axiom, "The best way to learn something is to teach it," so why not share the wealth? An especially good source is a provider who had an interesting call or one who had problems with a call. This is the concept behind the M&M (morbidity and mortality) conferences medical residents are subjected to after a fatal or serious error. Education on the heels of a tragedy or near-tragedy is very effective.


   Simple, specific issues uncovered by the QI process that do not require a lot of background information or supportive material may be handled by memo or posted notice. Likewise, any critical issue that requires immediate action should be written up and distributed immediately. For example, we discovered that medical command was not being called for patient refusal authorization for syncope, aspirin was being administered inconsistently for ischemic chest pain, and copies of EKGs were not being included with the PCRs.

   As with the newsletter or bulletin, we used bright-colored paper to get attention. One general announcement was placed in each provider's mailbox to ensure everyone was notified, and, as a last-minute reminder, we also posted it on all doors leading to the apparatus room so it was literally the last thing everyone saw before taking a call. As a general rule, no more than three issues or five to six sentences should be included in a general announcement or flash memo.


The importance of acknowledging an error cannot be overstated. The first step in fixing any problem is admitting there was a better way of doing something and making the psychological commitment to incorporate that improvement into your patient care moving forward.

Historically, there is an undercurrent of inferiority complex in EMS whereby we have convinced ourselves that because of the high stakes of our profession, mistakes are not permitted, and admitting to them is a sign of weakness. Such an unrealistic and unhealthy attitude does nothing but perpetuate patient risk. Any comprehensive QI program must attempt to remove the stigma of human error in EMS and emphasize the importance and moral obligation of error reporting. Anyone can and will make an error. Confidential, non-punitive error reporting must become a standard of quality improvement if the ultimate goal of improved patient safety is ever to be achieved.


   The more closely you can link your QI program with your training program, the better and quicker you can improve your standard of care. QI and training are the two most important components of EMS with regard to the actual service we provide. Unfortunately, they are all too often totally separate and distinct entities that never communicate. For maximum efficiency, the quality improvement and training departments should be partners with the same goal: improving the quality of patient care.

   Joe Hayes, NREMT-P, is deputy chief of the Bucks County Rescue Squad in Bristol, PA, and a staff medic at Central Bucks Ambulance in Doylestown, PA. Contact him at


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