Missouri EMS Central Region

March 2012 WebinarPerformance Improvement

Jeffrey Coughenour, MD, FACS

Assistant Professor of SurgeryMedical Director, Missouri EMS Central Region

Objectives

• Define performance improvement and patient safety (PIPS)

• What are the components of a successful system?

• What prohibits development?• Demonstrate the positive impact a mature PI

process can have on patient care

Health Care

• “...More with less and doing it better and faster”

• Pay for performance initiatives gaining ground but lacking detail

• EMS as a component of the continuum of care

Health Care

PIPS Defined

A continuous, multidisciplinary effort to measure, evaluate, and improve the process

of care and its outcome.

A major objective is to reduce inappropriate variation in care and to improve patient

safety.

PIPS Defined

• Quality (PI)– Indications for early transfusion in transient

responder after trauma

• Safety (PS)– Accurate type and crossmatch

• Combined elements (PIPS)– Transfusion-related acute lung injury (TRALI)

Historical Definitions

• Quality assurance – retrospective chart review• Total quality management…• Continuous quality improvement…• Performance improvement

“Bureaucratic pencil-pushing peckerheads”

—P. Kearney

Modern PIPS

• Continuous cycle of monitoring• Support by reliable method of data collection,

obtains valid and objective information• Multidisciplinary review defines corrective

strategies• Effect of change is documented as cycle

repeats

Program Configuration

• Administrative accountability– Empower the program to address issues that

involve multiple disciplines– Approval from governing body– Adequate administrative support– Defined lines of authority or responsibility

Program Configuration

• Medical direction– Leadership– Title 202 KAR Chapter 7, Section 801: Developing,

implementing, and maintaining a quality improvement program for continuous system and patient care improvement (MO 190.103)

• Program manager– Critical component, logistics

Outcome Measurement?

• Patient– Complete and rapid recovery

• Administrator and payer– Cost of care

• Service director or regional physicians– Quality of care

“Value Equation” Concept

• System variables to individual performance• Increase value by: Improved process or

outcome, decrease cost

Quality of Process+Quality of OutcomeCost

Value =

Process Measures

• Consensus, local or regional guidelines, or, ideally… nationally derived, evidence-based guidelines

Compliance with guidelines, appropriateness of destination determination, delay in assessment, delay in diagnosis, delay in treatment, error in judgment, error in treatment, error in

communication, appropriateness of documentation, insurance carrier denials, dispatch time, chute time, response time,

scene time, transport time, system skill performance, individual skill proficiency

Outcome Measures

• Are care processes adequate to achieve the desired outcome?

Mortality, morbidity (any derivation from normal health that may be result of a complication or may be pre-existing), pain

control, tranfusion-related acute lung injury, ARDS, coagulopathy, hypothermia, did patients whose complaint

warranted ALS services receive it, did patients with a breathing problem or respiratory distress receive

supplemental oxygen in a timely fashion

Data Collection

• Should be valid and objective• Participation in a regional trauma registry, at a

minimum• State trauma registry preferred• Develop occurrence tracking form– Concerns brought forth from variety of sources

Review

• Review performance and safety of your EMS system

• Is the issue open or closed?• System or individual?• Preventable or not?• Now what?

Corrective Action

• Develop or revise a guideline• Targeted education• Enhanced resources, communication• Counseling• Change in provider privileges or credentials• External review

Results

• Demonstrate that a corrective action has the desired effect by continued evaluation

• Continuous use of your new PIPS process is more important than “loop closure”

Chapter 16, Performance Improvement and Patient Safety, Resources for the Optimal Care of the Injured Patient 2006 Copyright © 2006 American College of Surgeons, Chicago, IL

Missouri

• 19 CSR 30-40.375– Uniform Data Collection System and Ambulance

Reporting Requirements for Ambulance Services– “Emergency, life-threatening runs”

• 19 CSR 30-41.010– Head and Spinal Cord Injury Reporting

Requirements

Missouri Protection?

• Missouri Revised Statutes, Chapter 537– 537.035 Peer Review Committees– Physician/surgeon, dentist, podiatrist,

optometrist, pharmacist, chiropractor, psychologist, nurse, social worker, professional counselor, mental health professional

• EMS… no• Strong opposition

Bottom Line

• Many states lack peer review protection• Utilization of attorney client privilege• Perform all PIPS work with the collaboration

of a recognized patient safety organization

Patient Safety Organizations

• Established under the “Patient Safety and Quality Improvement Act of 2005”

• Organization of peer review activities in concert with a PSO provides protection

• Under the doctrine of pre-emption, federal law "trumps" state law

• Federal law has yet to be challenged in malpractice actions in Kentucky courts

Patient Safety Organizations

• Missouri Center for Patient Safety– Collaboration with the Missouri Ambulance

Association, funding from the Missouri Foundation for Health (private)

• 16 EMS agencies participating in pilot program

www.mocps.org

Impact of PIPS

• Extension of early blood product administration and contemporary shock resuscitation

• Failed airway management

Resuscitation Practice

• Outdated• “… after 2 liters of crystalloid, consider use of

uncrossmatched packed red cells in transient or non-responders.”

• Average 2.79 liters LR/NS– Average scene and flight time of under 1 hour

Pattern Recognition

• Exam findings– Decreased mental status from injury or shock– Suspected TBI– Clinical coagulopathy

• Laboratory values– INR > 1.5– Base deficit > 6– Hemoglobin < 11– Hypothermia (<96) or hypotension (SBP <90)

Pattern Recognition

• Trunk, axillary, groin, or neck wounds not controlled by local wound care– Direct pressure– Tourniquet– Hemostatic dressings

• Proximal amputation or mangled extremity• Hemoperitoneum with shock• Massive hemothorax– >2000 mL initially or >200 mL per hour for 4 hours

Massive Transfusion

• April—December – 9 patients– 3 deaths– 1 inappropriate activation– Total product: 116 PRBCs, 65 FFP, 14 platelet

pheresis packs, 13 pre-pooled cryo– Average ratio 1.78-2:1– Only 3 activations occurred within 1 hour of

patient arrival

Massive Transfusion

• Current 8 Jun– 12 patients– 7 deaths– 1 inappropriate data set inclusion– Total product: 229 PRBCs, 158 FFP, 23 platelet

pheresis packs, 29 pre-pooled cryo– Average ratio 1.45:1– Excluding 1 outlier of 144 minutes, average

activation time 0:29 (0:10-2:24)

What’s Next?

• Additional evidence to determine safety, efficacy, optimal PRBC:FFP ratio

• Replace crystalloid with non-albumin colloids?• Lyophalized plasma• POC testing for early MTP activation• Expanded use of ultrasound – IRB application

for pneumothorax/ETT position evaluation

Airway Management

• Increasing number of failed field intubations• Reasonable use of rescue devices• Single 3 month period– Facial fractures, no surgical airway attempt– Failed intubation, poor function of rescue device– Unrecognized esophageal intubation– Occluded ETT– Tracheal injury

Airway Management

• Targeted outreach education– Ground and flight services

• Increased use of simulation– Problem recognition– Review of indications for failed airway algorithm– “3-Step Cricothyroidotomy”

3-Step Cricothyroidotomy

Summary Points

• Medical director leadership, which may require partnering with a regional referral center

• Logistics is local• Data collection can be difficult• Participation in regional/state registry key• Review and make corrective actions

Summary Points

• Continuous cycle evaluates effectiveness• Utilize attorney client privilege or PSOs for

legal protection• Development of an inclusive PIPS program

may be the single, most important component of the TCD system

References

• Resources for the Optimal Care of the Injured Patient 2006, Copyright © 2006, American College of Surgeons, Chicago, IL

• Missouri State Legislature, www.moga.mo.gov• Kentucky State Legislature, www.lrc.ky.gov• Paula Holbrook, RN, BHS, JD, Clinical Risk

Manager, UK Health Care• Richard A. Setterberg Co., LPA