While today’s EMS offers significantly more capability than was available just 10 years past, it continues to suffer from severe fragmentation and an absence of system-wide coordination. Further, we suffer from a lack of accountability and caring. Our shortcomings diminish the care provided to emergency patients and often result in worsened medical outcomes. To address these challenges and chart a new direction for emergency care, our communities deserve to be served by well-trained and highly coordinated EMS agencies that are accountable for performance and serve the needs of patients within the system.
To be an effective system, 9-1-1 dispatchers, EMS personnel, EMS directors, and your local governments must be united in an effort to ensure that each patient receives the most appropriate care, at the optimal location, with minimum delay. Does your system do those things? For every single patient? From the patient’s perspective of what they remember from their encounter with you, delivery of services for every type of emergency should appear seamless. We should strive to ensure all care and treatment will also be evidence based, and innovations will be rapidly adopted and adapted to each agency’s needs. A key component in an effective system is the monitoring of system performance. Do you monitor your performance? I don’t mean do you track your out of the chute times or your overall response times; I mean really DIG in to your performance?
Be honest with yourself; you can’t improve if you aren’t. Do you track monthly the number of trauma patients that are under or over triaged? Do you know how many paramedics missed doing a stroke severity scale (RACE) on suspected strokes last quarter? How many times did your medics get a patients vitals, a 12 lead, and appropriate meds within 15 minutes on their suspected STEMI calls? If we aren’t digging into these details and 50 more, we aren’t affecting outcomes.
While these goals will require substantial system-wide change, they are achievable; all well planned goals should be. Efforts to improve are often derailed by deeply entrenched interests and cultural attitudes within an agency, as well as funding cutbacks and other internal impediments to change. Notice I’m being very specific there; INTERNAL impediments. There are very few negative roadblocks EXTERNALLY to improving the continuum of care and truly making a difference in your community’s outcomes. When was the last time the hospital told you they were upset that you got a 12 lead and a good set of labs prior to your arrival in the ED?
What Will it Take to Effect Change for Good?
Good question, I’m glad you asked. As with all change, the state must be onboard; fortunately or unfortunately, we here at the bureau have to approve all scope of practice, transport triage guidelines and new treatment protocols. To date, we have put forth many changes to improve patient outcomes and change how we do business. I could give a laundry list, but you all tell us in the field how much has been improved in the past few years, and we are proud to assist in facilitating that change. Do we still have work to do? Yes. The burden of improving your own systems however falls to you. Our mission has to be global in nature and often doesn’t take in to consideration each and every agency’s goals or capabilities. That, ladies and gentlemen, is in your wheelhouse.
When 9-1-1 is called, responding EMS personnel will have little to no impact until they arrive at the patient’s side. However, the forward-thinking clinician knows the actions that occurred before his or her arrival can have a huge impact on the care they provide, correct?
For example, has the chest pain patient been advised by your dispatch center to take any aspirin or nitroglycerin? How many breathing treatments has a dyspneic patient had, if any, and what were the results? Better, worse, no change? We also know the actions taken, or decisions made, by the patient; family members or bystanders can help or hinder the actions of EMS, such as providing good quality CPR to the patient in cardiac arrest prior to our arrival. Now, flip that over to the Emergency Department.
Now you’ve been at the patient’s side, you’ve gotten the history (maybe) you’ve properly treated the patient (maybe) and your actions are complete. Did your response help or hurt the ED much like your patients and families response to their emergency helped you or hurt you? The response and the impact on the hospital, ED physician, or the anesthesiologist from actions taken by EMS can and do affect patient outcomes, good and bad. I remember many years ago, EMS was treating hypertension with Procardia, we went through several (off label) steps to administer it to the patient sublingually. This practice was later determined to interfere with therapies the hospital may have wanted to administer and could cause harm to the patient, so we abandoned it. Nothing we can do about that, right? It was practice, it isn’t any more, but it affected the patient at the next level of care.
What about the treatments and decisions we make in the field today that is standard practice? We’ll discuss transport decisions in a bit — everyone’s favorite subject — but I mean something as simple as a choice of airways.
EMS can negatively impact the continuum with the insertion of certain types of invasive airway devices. For instance, if the emergency physician wants to intubate the patient and the paramedic has inserted a supraglottic airway device that has to first be removed, the medic may have affected the treatment choice of the physician. Don’t most of our protocols now call for direct insertion of a supraglottic if our first ET attempt is unsuccessful? How do we fix it? That’s right get better at intubation. Adopt the new apneic airway protocol and give yourself more time to get a good shot. Make your first pass your best and only pass.
In this scenario, physicians have several options. They can either elect not to intubate, or they can remove the airway device and assume the risk — and potential liability — of the patient aspirating. Every time a patient’s airway is accessed, the risk of (a) aspiration and (b) a failed airway attempt increases. Patients who aspirate not only have an increased mortality rate, but those who survive have significantly longer hospital stays. See now how we can affect the continuum of care with just one small decision in the field? Need it broken down a bit more? Being on a ventilator can have a significant financial impact on the healthcare system, as one day on a ventilator in the ICU equates to approximately $10,000 in costs.
The physician could also choose to bail on the intubation and let the next physician or RT in the ICU or the OR deal with the problem. However, had you, the EMS provider given careful consideration to the continuum of care when selecting airway equipment and techniques, this issue might have been avoided.
You Can Affect Changes in Outcome, Really!
We all know this was coming so let’s get it out of the way. Transport of a patient to the right facility, in the right amount of time, having intervened appropriately, CHANGES OUTCOMES. Does your system prevent the transport out of county to an appropriate facility? Do you have to take all patients to a central/critical access hospital? Worse yet, do you, as the primary clinician choose to do that because its 45 minutes to the stroke center and you get off in 30? It’s difficult to explain to a parent why their child, a pediatric patient with a critical illness or injury, was taken to the local adult-capable ED only to be flown 20 minutes away to a pediatric ED after incurring the costs of x-rays, CAT scans, and multiple other procedures that may or may not even make it to the next receiving facility. Oh, and we’ve delayed definitive treatment a couple hours too. Why did that stroke patient, who incidentally scores a five on the RACE scale, go to a stroke-capable hospital when there was a comprehensive or comp-capable hospital 20 minutes away only to be transferred — once the ED found an ALS inter-facility unit — three hours later and now falls outside the window for interventional treatment? Think your internal transport guidelines don’t affect patient outcomes? Think again. These are only a few examples but sadly I don’t have to look very far to find them. They literally happen every day.
What Else Can We Do for the Continuum of Care?
So we take everyone to the right place, we diagnose as best we can, and we intervene at every level possible. Or do we? Do you take away your patients pain as best you can or is it too much paperwork? A medic in South Carolina was recently disciplined because they always selected “5” on the pain scale so they never had to administer an analgesic; it was just too much paperwork. No, really. That’s a horror story but what about looking over some other protocols and treatments that make a difference? Have you adopted all you can to affect your patients outcomes? Are you aware (I hope) of the ability for paramedics to administer antibiotics in the field to suspected sepsis patients? We are proud of this program and to date, South Carolina is the only state where this is approved at the field level provider statewide. This program was piloted by the Greenville EMS system a couple years ago and the results there were astounding. It’s common knowledge (Google is your friend) that the earlier a septic patient gets an antibiotic the better the outcome. Serious reductions in mortality occur when we get it on board early; every 15 minutes makes a difference. Want to know how this affects the continuum? You’ll be your receiving ED’s best friend. As there are with all patients there are certain measures that must be met by a hospital to “count” a successful patient and continue to receive funds for them. Stroke, STEMI, trauma, all have core measures. The good news about sepsis patients are if you follow the protocol correctly, you have met the entire EDs core measures for a sepsis patient, sans one! Not only have you done that, but in Greenville’s case study, and now anecdotally across the state where the protocol is being used, you are saving the admitting hospital hundreds of thousands of dollars annually in reduced stay times — about a day in most cases, and that adds up. Wondering how you’ll fund the sepsis kits on the ambulances? Take a copy of Jason Walchok’s manuscript with you to the CMO and ask them nicely for the funding.
EMS providers are under constant scrutiny for the care we render now more than ever. Medical directors, clinical educators, hospitals, and EMS providers must develop strategies to improve the seamless continuity and appropriate care for our patients. The future is NOW and EMS systems must face their role as being part of a “system” and not a “silo” to avoid being a source of treatment complications for our patients. To master this, we all must work in concert to become proactive problem solvers and patient-centered health care agencies.
Rob Wronski is the South Carolina Department of Health and Environmental Control (SC DHEC) Bureau Chief of EMS. He has served in many roles since becoming a firefighter paramedic in 1991, culminating with his selection as Chief of EMS for the state where he has served for nearly three years. He has held several executive positions including Assistant Chief of the St. Andrews Fire Department in Charleston, Medical Officer of the Mt. Pleasant Fire Department, and a Shift Commander in the Beach Park (IL) Fire Department. His experience includes working in fire-based EMS, including ALS and BLS first response as well as fire based and county based ALS transport.