Rural Challenges in EMS

Outcomes and
Performance
Improvement

Jeffrey Coughenour MD FACS
Assistant Professor of Surgery and
Emergency Medicine
Medical Director, Mitchell Trauma Center
Disclosures
Industry supported research
Reflectance Medical, Inc. and ZOLL Medical
Content expert, not legal expert
Objectives
Define tenets of a successful patient safety
and performance improvement (PIPS)
program
Prohibitions
Legal protection
Health Care Risk
Complex technology
Constantly changing medications and best-
practice
Individual competence
System constraints
Patient variation, co-morbid conditions
Optimal Outcomes
Mitigate risk
Performance improvement and patient
safety (PIPS) process and outcome
Depends on your perspective
Historical Definitions
Quality assurance retrospective chart
review
Total quality management
Continuous quality improvement
Performance improvement

PIPS Defined
A continuous, multidisciplinary effort to
measure, evaluate, and improve the process
of care and its outcome

Major objectives
Reduce inappropriate variations in care
Improve patient safety
PIPS
Supported by reliable method of data
collection, valid and objective
Multidisciplinary review defines corrective
strategy
Effect of change documented as cycle
repeats
Intubation
success rates
Intubation success rates
by provider, location
Targeted education,
equipment
Didactic and practical
skills, scenarios
Participants
Multidisciplinary Committee
Input from several disciplines
System issues
Peer Review Committee
Experienced providers, objective review
Individual, case-specific issues
Systems Hospital
Trauma surgeons
Specialty service
liaisons
OR services
Intensivists/ICU
leadership
Rehabilitation
services
EMS

Hospital
administration
Nursing leadership
Prevention
Education
Trauma registry
Respiratory therapy
Transfusion services

Systems EMS
Medical director
Service administrator
Board representation
Service representative
(EMT, EMT-P)

Hospital
representation (TCD
disciplines)
Mutual aid services
Fire
Law enforcement
Air service

Peer Review Hospital
Trauma medical
director
Trauma surgeons
Orthopedic surgery
Neurological surgery
Anesthesia
Emergency medicine

Trauma program
manager
PI coordinator
Radiology*
Intensivists*
Pediatrics*
Obstretics*

Peer Review EMS
Medical director
Service administrator
Board representation
Service employees
(EMT, EMT-P)

Administrator and/or
representation from
adjacent services
Hospital TCD
representation*
Leadership
Medical direction
Champion, defines data dictionary, categories
of review, leads multidisciplinary discussion to
formulate corrective action
Program manager
Logistics
Accountability
Empower the program to address issues
that involve multiple disciplines
Approval, governing body
Adequate administrative support
Define lines of authority and responsibility
Committee
Membership
Opportunity for Improvement
Eliminate language that places blame
Not punitive
Constructive and all-inclusive
Issue Identification
Event
Error, mistake, incident, accident or deviation,
regardless of patient harm
Patient safety
Avoidance of injury or AE resulting from
processes of health care delivery


The Joint Commission, 2008
Issue Identification
Concurrent process best
Data dictionary
Medical record
Referrals, feedback
External audit filters
Validation
Systematic approach
Real issues that require multidisciplinary
input and potential for system change
Necessary for completion of the cycle
Levels of Review
Primary
Program management
Secondary
Program-level PI staff
Tertiary
System, Peer Review Committees
Quaternary
Hospital process, regional/state EMS
Documentation
Issue identification
Case summary
Corrective actions
Documentation of resolution, re-
evaluation, loop closure
TJC Taxonomy
Impact
Outcome or effect of the issue, harm, etc.
Type
Implied or visible processes that were flawed
or failed
Domain
Characteristics of the setting where the issue
occurred, individuals involved
TJC Taxonomy
Cause
Factors that led to the issue/incident
Prevention and Mitigation
Corrective action plan
Case 1
54, MVC, transfer from NTC in evening 8
hours after injury
Initially hypotensive, now stable after 6L
crystalloid, 4 PRBCs
Pulmonary contusions, rib fxs, open tib/fib,
brain injury GCS 13
Suspicion of lower thoracic spine fracture
Case 1
Ortho requests spine clearance prior to OR
NS recommends MRI for thoracic spine
Develops cyanosis despite good rhythm on
MRI monitor
Removed from MRI, asystolic
CPR instituted, resuscitated, severe anoxic
injury
Case 1
Support withdrawn 5 days later
Further review indicted significant base
deficit with near collapse of vena cava on
arrival
Case 1
Impact
Medical: Death
Non-medical: Potential legal consequences
Type
Communication: Questionable advice
Patient management: Questionable delegation,
correct study but untimely
Case 1
Domain
Setting: Diagnostic procedures
Staff: Resident, nursing
Cause
Organization: Culture
Human: Provider knowledge
Prevention and Mitigation ?
Case 2
Adult female, missed BCVI caused
alteration in screening guidelines
Case 3
Difficult airway in the ED, several
opportunities for improvement
Case 4
Difficult field intubation, fatal injuries
No immediate action necessary
Referral to ground EMS for education?
Case 5
Inefficient evaluation leads to change in
practice
Prohibition
Lack of buy-in from medical staff and/or
administrative leadership
Punitive, not constructive
Amount of effort
Fear
Protection
Chapter 537, Torts and Actions for
Damages
Section 537.035 Defines health care
professional
Physician/surgeon, dentist, podiatrist,
optometrist, pharmacist, chiropractor,
psychologist, nurse, social worker, professional
counselor, mental health professional

Protection
permitted or required to disclose any information
acquired in connection with or in the course of such
proceeding, or to disclose any opinion, recommendation,
or evaluation of the committee or board, or any member
thereof; provided, however, that information otherwise
discoverable or admissible from original sources is not to
be construed as immune from discovery or use in any
proceeding merely because it was presented during
proceedings before a peer review committee nor is a
member, employee, or agent of such committee
Protection
19 CSR 30-40.375 Uniform Data Collection
19 CSR 30-40.430 TC Designation Standard
4(B) 3. A regular multidisciplinary trauma conference
that includes representation of all members of the
trauma team, with minutes of the conferences to
include attendance and findings.
PSO Protection
Patient Safety and Quality Improvement
Act, 2005
Patient Safety Evaluation System required
part of the ACA
Patient safety work product may still be
discoverable if required reporting

Kentucky Supreme Court; Tibbs, et al. v. Bunnell (2012-SC-000603-MR)
Fancher v. Shields (Jefferson Circuit Court Div. 2 10-CI-4219)
Summary Points
Measure, evaluate, improve the process of
care and outcomes
Valid, objective data collection
Honest inspection, multidisciplinary input
CAP focused and obtainable
Summary Points
Document to your needs and comfort level
Peer review protection difficult topic
Not easy but immeasurable benefit to
your program and patients

Why are you here?