ACS Care Quality Improvement for Winnipeg Fire Paramedic Service
Problem: Low rates of 12 lead acquisition in patients presenting with atypical symptoms of ACS.
Aim(s): Improve outcomes for patients seen and treated by WFPS who are suffering from Acute Coronary Syndromes. Increase the percent of patients who present with typical and atypical symptoms of ACS that receive a 12 lead Acquisition from 21- 50% in 12 months. Reduce outliers in FMC to 12 lead acquisition time intervals in 12 months.
Intervention: Change language and design of ACS protocol and bring it up to date to decrease time from FMC to 12 lead acquisition and also to cast a broader net of patients who would apply to this new protocol. Developed training programs regarding ACS care for paramedics and different methods of reminders of the new changes in practice.
Results: See below graph.
Contact: Nikki Little
Use of a Checklist to Reduce Post-Intubation Hypoxia Among Initially Hypoxic Patients Who Underwent Rapid Sequence Intubation (RSI) by a Helicopter EMS Crew
Problem: Hypoxia is a common reason for intubation and may be a surrogate outcome measure as hypoxia is associated with morbidity and mortality. A checklist for aeromedical RSI was developed by a large aeromedical vendor and included strategies to mitigate hypoxia. These include preparation of equipment, patient positioning, preoxygenation, apneic oxygenation, laryngoscopic techniques, placement, confirmation, etc.
Aim: For patients who are initially hypoxic (SpO2 <90%), use RSI Checklist as a bundle to reduce by 10% the incidence of post-intubation desaturation (SpO2<90%) by 11/1/18.
Results: In process
Contact: Brad Weir
Improving Ambulance Offload Times in an Under-Resourced Community
Problem: 90th percentile APOT (ambulance patient offload time) were very high in our county. They reached a peak of 115.02 minutes in July of 2017. The community has two hospitals but only one in the county seat. This hospital is the highest volume and highest acuity hospital in the community. High wall times at this facility affects the entire emergency system, including ED wait times, ambulance response times, and quality of patient care.
Aim: This project aims to decrease APOT to the state goal of a 90th percentile of 20 minutes or less.
Intervention: A monthly meeting of stakeholders (EMS, hospital, ambulance provider, behavioral health, law enforcement) was established to brainstorm and discuss potential interventions. A variety of interventions have been tested through a PDSA cycle. These include: a BLS/ALS tiered ambulance response to keep more ambulances in the field; allowing a single paramedic to monitor 4 patients on the wall, allowing ambulances to return to the field in a more timely fashion; creating a discharge lounge in a hospital Mercy Merced (biggest offender and improver), so that boarded patients in ED can be moved faster to acute Care hospital beds,; and mobile crisis response teams who meet clients in the field, preventing purely psych patients from entering the ED, to name a few of the most successful.
Results: One year after the height of 115.02 minutes, the July 2018 90th percentile APOT time was 31.96 minutes, a 72.2% decrease. APOT times have creeped back up subsequently, but remain well under the height of summer 2017.
Improving Rates of Bystander CPR Using DA-CPR Metrics and Feedback
Problem: Bystander CPR in New Castle County lags behind our peers in CARES. We have exceeded the median among CARES participants for all other metrics but have not seen improvement in CPR rates despite community education and other attempts at improvement. Our initial rates of CPR in the community were 30-33% for all cardiac arrests dating back 5 years. Our rates of CPR for witnessed cardiac arrest were measured at 40%.
Aim(s): OVERALL RATE OF CPR increase from 30% to 45% within one year. RATE OF CPR ON WITNESSED ARRESTS increase from current 40% to 55% within one year. STRETCH GOAL increase rate of CPR on witnessed arrests to 70% by 2020.
Intervention: Enlist support of Communications Leadership and create a project team. Education of Supervisors on how to review DA-CPR calls. Education of all telecommunicators by the EMS Medical Director. Provision of feedback by email/graph after preliminary intervention period. Direct education at 6 months with information on improvement and guidance to overcome identified barriers.
Results: CPR recognition rates have improved from baseline median of 66.7% to current median of 78.9%. This is above the 75% goal of AHA for DA-CPR. Data from August to present show a run above the baseline median and current data are showing a positive trend. Median time to recognition of OHCA has decreased from baseline 108 seconds to 70 seconds. Earlier delivery of first compression with baseline 160 seconds now improved to 146 seconds. Improved CPR rates for witnessed cardiac arrests; baseline data for 2018 began at 45%. Preceding years showed bystander CPR rates at 38-42%. Currently, Median CPR rate for bystander witnessed OHCA are 50.6% with AIM of 55% by April of 2019.
Contact: Rob Rosenbaum
Problem: DEA accountability is a major liability for EMS medical directors. The DEA registrant is personally liable for the activities of controlled substances acquired under his or her DEA license. Despite good policies and procedures, our front-line compliance with controlled substance documentation standards averages about 87%.
Aim: Reduce the liability exposure of the medical director by improving compliance with documentation of administration and waste of controlled substances to 90% by November 1, 2018.
Intervention: Add electronic checks in the various ePCR systems used by our affiliated agencies to enforce the requirement for 2 signatures with controlled substance use. Utilize FirstWatch notification triggers to alert staff in realtime regarding charts which are out of compliance, to allow immediate follow-up with the crew for corrective action.
Results: Still in progress. Several agencies changed PCR vendors which required re-creating the FirstWatch triggers, data is not complete at this time.
Contact: Bjorn Peterson, MD
Improving Stroke Care through Greater Compliance and Documentation of CSTAT
Problem: Currently, 27% of stroke activations have CSAT documented in the chart, but only 21% reported on radio to receiving facility.
Aim: Improve compliance in reporting and documentation of CSTAT findings by 48% by Sept. 1, 2018
Intervention: Added fields to stroke interventions in the ePCR system. Provided education to crews in quarterly allhands meeting as well as email via clinical updates to all crews. Met with hospital stroke coordinator on project plans so they could communicate to their staff to be aware and assist in documentating recieved radio reports.
Results: Achieved a 40% increase in documentation of a CSTAT radio report given between June and July. Hospital data showed only a 12% increase of radio reports revived. However, the hospital reported an increase in positive CSTAT reporting of 50%.
Contact: Ben Sorenson and Shawn Wood
EMS Acute Stroke Care Improvement Project
Problem: Acute stroke is a time-dependent emergency condition requiring a system of care involving at least the public, PSAPs, EMS and hospitals. EMS can significantly influence the quality of patient care by determining the time last known normal (hh:mm), performance of the Cincinnati Prehospital Stroke Scale (CPSS), obtaining a blood glucose and notifying the stroke hospital.
Aim: Develop a reporting system for EMS elements of stroke care utilizing the current e-PCR (electronic patient care report), and track e-PCR compliance with acute stroke elements of care.
Intervention: The first step was to update the e-PCR to the NEMSIS 3 compliant version which provided for tracking of time last known normal, blood glucose, stroke scale and stroke hospital notification. The second step was to track e-PCR compliance over time and see how this could be improved by interventions. Data would be analyzed quarterly and reported on a monthly basis.
Results: Low e-PCR compliance for 3 or the 4 measures based on early results. Working with the e-PCR database is a complex and time-consuming process.
Early Detection of Sepsis in the Prehospital Setting
Problem: At Mercy Merced the monthly average for sepsis admits through ER is approx 120 patients per month. Riggs ambulance transport approximately 50 % to Mercy ER per month, more during flu season. Prior to this intervention there was no protocol for sepsis recognition or prehospital notification of a sepsis alert.
Aim: Increase recognition of potential sepsis to 80% by prehospital providers within 4 months through the use of a new prehospital sepsis protocol.
Intervention: Developing a new Merced County treatment protocol focusing on suspicion of infections and SIRS criteria and notifying the hospital of a SEPSIS ALERT.
Results: In Process—pending data from hospital
Contact: Dave Murphy