Reviewed this Month: Ho JD, et al. Effect of Body-Worn Cameras on EMS Documentation Accuracy: A Pilot Study. Prehosp Emerg Care, 2017 Mar–Apr; 21(2): 263–71.
This month we’ll discuss EMS research that evaluates data and technology. While we use both in our field more each year, there isn’t a lot of research specifically evaluating both. Luckily, Dr. Jeffrey Ho and his coauthors recently published a novel study evaluating if the use of body-worn cameras can improve documentation accuracy on a prehospital care report. Although body cameras are currently used by some law enforcement officers, they are not typically worn by EMS professionals.
Because this topic has not been widely studied before, the authors wisely chose to start with a pilot study. A pilot study is a preliminary study, almost like a practice run. It’s typically used to determine if the study is feasible prior to embarking on a large-scale research project. Pilot studies are used to identify issues, solidify study methods and help determine the sample size needed to conduct the full-scale study.
One great thing about a pilot study is that you don’t need a huge, representative number of participants. You can use what’s called a convenience sample. Basically that means anyone you, as an investigator, can convince to participate (friends, family, coworkers, etc.). This can of course introduce bias into a large-scale study, but it’s not a major concern for the preliminary results obtained from a pilot study.
The authors here justifiably expressed some concerns with current documentation practices in healthcare. They used this pilot study to specifically examine documentation practices in EMS. One of the biggest concerns expressed was recall bias. Since documentation is typically completed after care is transferred, the EMS professional may not accurately remember everything that happened and in what order. The authors conducted this pilot study with the objective of evaluating the accuracy of current EMS documentation practices and exploring whether body cameras could affect accuracy.
They selected 10 paramedics to participate in this study, not telling them about its goals. All paramedics worked for the same EMS agency in Minneapolis. Their age ranged from 22 to 43, with an average of 33.3 years. Their experience ranged from 2 months to 20 years, with an average of 7.7 years. The paramedics were asked to wear cameras attached to clear safety glasses and participate in a simulated EMS call.
The authors took many steps to ensure they were solely assessing documentation habits. First, to reduce any chance the documentation was impacted by sleep deprivation, they made sure all the paramedics in their convenience sample weren’t coming off night shifts. The simulated call was a narcotic overdose, and we all know these don’t always go as planned. Even on a simulated call, depending on the scenario, things might get out of hand. So the authors had a safety officer monitoring the simulations to keep the paramedics and simulated patients safe. The 10 paramedics worked with a “role player” partner who did only what they were directed to do and would not help with documentation.
The scenario was constructed so the most important things that needed to be documented occurred in the first of four scenes. The four scenes were:
In an apartment;
Exiting the apartment;
The ambulance transport; and
Arrival at the emergency department.
The scenarios appeared to be very well done. The apartment was a mess! There were discarded syringes, open alcohol containers, discarded condoms, firearms and bags of illegal drugs everywhere. There were four role-players in the apartment, all dressed as commercial sex workers. Two of the four were minors. The simulated patient had vital signs consistent with a narcotic overdose, and the paramedic should have simulated the administration of IV naloxone. But the chaos didn’t end there: The patient woke up combative and wanted to refuse further care. The police (simulated) had to be called to compel the patient to be transported, and restraints were needed. And as providers exited the apartment, the patient’s simulated brother appeared and started to argue with the patient. He informed the paramedic that the patient was HIV-positive and taking methadone.
Then, during transport, the patient threatened suicide and tried to bribe the paramedic with drugs and sexual favors. Finally the paramedic arrived at the ED and gave the report to the nurse, and the scenario ended with completion of the PCR.
Yes, this was a difficult call to document accurately, but it certainly wasn’t an impossible scenario. In fact, some of you reading this might have been on a similar call!
Now came the part of the study where research data were actually collected. The paramedics completed a PCR similar to what they typically completed in the field. This was important because it attempted to remove the possibility that documentation was inaccurate due to a lack of familiarity with the ePCR. So the initial/baseline data came from the paramedic’s recollection of the call, much like how most PCRs are completed.
Then the paramedic was allowed to watch the video from the body camera and make any changes to the PCR they saw fit. They were neither mandated nor instructed on how to change the PCR, and there was no time limit for viewing the simulated call. The authors then evaluated all the changes made to the initial PCRs. These are the main results of the study.
Every paramedic made at least some changes to the original PCR. The authors developed an a priori (a priori means they came up with it before they began the study) definition to categorize each change. In total there were 71 changes made. Of these 7 were categorized as minor, 51 were classified as moderate, and 13 were classified as major. The authors indicated that most of the moderate changes were related to missing or erroneous medications and vital signs on the original PCR or issues that enhanced liability, such as not mentioning that the patient tried to bribe the paramedic. The major errors mostly related to failing to record things that could put the patient or paramedic in danger (weapons on scene, patient mentioning suicide, etc.).
The authors also reported some secondary results obtained from two survey questions they asked the paramedics. First they asked if the body cameras increased each medic’s confidence in the accuracy of their report, and 8 of the 10 medics had increased confidence. They also asked about the ease of use/functionality of the body camera, and that was rated overall as an 8.6 out of 10. Interestingly, the authors note that no paramedic took longer than 45 minutes to review the video and complete their report. However, in their agency they are required to complete their report within 20 minutes.
Overall this pilot study seems to suggest that adding body cameras can improve documentation accuracy, and that does seem reasonable. The authors also specifically stated that privacy laws related to the patient care setting should not be an issue because these body cameras were designed for law enforcement and meet or exceed custodial chain-of-evidence requirements. The authors indicate these requirements exceed those related to patient confidentiality and data privacy. Before I used one, though, I’d like to have a HIPAA lawyer verify this.
While the results of this study seem compelling, let’s remember that this is a pilot study of 10 paramedics who work in the same department. All we can really take from this is that it seems reasonable to pursue a full-scale research study. To the authors’ credit, they did not appear to overstate their results, even though they seem very promising.
It should also be mentioned that the company that makes these body cameras provided them for the study and contributed funding to complete it. The principal investigator is the medical director for this company, another author is a consultant, and both of these authors own stock in the company. This was disclosed on the first page of the study. It is extremely important to know who funds and conducts any study, and while this doesn’t change the results, it may help put them into context a bit more.
There are likely a lot of barriers to bringing body cameras to every paramedic in the country, but this pilot study seems to suggest it’s worthwhile to investigate further. The potential benefits include better documentation, which can lead to better EMS research. I’m looking forward to the full study, and I bet you are too.
Antonio R. Fernandez, PhD, NRP, FAHA, is the research director at the EMS Performance Improvement Center and an assistant professor in the Department of Emergency Medicine at the University of North Carolina–Chapel Hill. He has been a nationally certified paramedic since 2005 and completed the EMS Research Fellowship at the National Registry of Emergency Medical Technicians.