Michigan Prehospital Pediatric Michigan Prehospital Pediatric Continuous Quality Improvement Continuous Quality Improvement

ProjectProject

William D. Fales, MD, FACEP

Michigan State University

Kalamazoo Center for Medical Studies

Supported in part by MC 00126 01 from the Department of Health and Human Services, Health Resources and Services

Administration, Maternal and Child Health Bureau.

Traditional EMS Quality ImprovementTraditional EMS Quality Improvement

• Typically Retrospective

• Often Case-Focused– Review “fall-out” cases– Negatively focused

• Resolutions often associated with punishment– Not real popular with EMS personnel

Example of Case-Based Retrospective Example of Case-Based Retrospective EMS Quality Improvement ProcessEMS Quality Improvement Process

Medical Director Discovers BadnessMedical Director Discovers Badness

Problem Paramedic ContactedProblem Paramedic Contacted

Search for Additional ProblemsSearch for Additional Problems

Very Thorough SearchVery Thorough Search

Confrontation of ParamedicConfrontation of Paramedic

Get Those Bad Medics Off the StreetGet Those Bad Medics Off the Street

Public FloggingPublic Flogging

Ultimate Penalty Ultimate Penalty Permanent Revocation Permanent Revocation

Michigan Prehospital Pediatric Continuous Quality Improvement Project

• Goal: Create a pediatric-focused CQI Model and determine its impact on protocol compliance.

• Assumption: Protocol Compliance = Quality

MethodologyMethodology

• Created a CQI Model– NHTSA Leadership

Guide to Quality Improvement

– NEDARC Quality Improvement References

– Used MERMaID – Electronic Medical Record

MERMaIDMERMaID

Methodology (con’t) Methodology (con’t)

• Selected 30 agencies– Randomized into Intervention and Control Groups

• Peds vs. Adult Stroke

– CQI Workshops– CQI Software

• Baseline Performance Data Acquired

• Monthly Aggregate Feedback to Agencies / Personnel

Clinical IndicatorsClinical Indicators

• Created by multi-disciplinary panel

• Pediatric Indicators

– Trauma

– Respiratory distress

– Seizure

– Pain management

• Adult-Stroke

ResultsResults

• 30 Agencies Recruited– 21 submitted data– HIPPA “phobia”– Smallest agencies lost

• Diverse Population– 2 MSA’s

• Kalamazoo and Saginaw

– Many rural agencies

Project PopulationProject Population

Pre-CQI

Interv.

Pre-CQI

Control

Post-CQI

Interv.

Post-CQI

ControlTOTAL

Total

Patients24,756 25,679 37,640 40,298 128,373

Ped Patients

(<16 YO)

2,129 2,199 3,237 3,457 11,022

% Peds 8.6% 8.5% 8.6% 8.5% 8.6%

FindingsFindings

• No significant differences between – Pre- and post-CQI– Intervention and control group

• All groups did well (>85%) with documenting– Meds / Allergies– Peds GCS– Vital Signs

TraumaTrauma

• 16 to 19% used a Trauma protocol

• Subset of all trauma patients– w/ Altered LOC = 6-11% of those with trauma– w/ Load and Go = 7-12% of those with trauma

• >97% spinal immobilization (when indicated)

• >92% IV access attempted (when indicated)

• 37-52% “Load and Go” (<10 min. @ scene)

• Rapid trauma management remains a challenge!

Pain ManagementPain Management

• 15 to 20% of all pediatric patients had potentially painful condition

– Pain scores documented 32-40% of time• Pain score >4

– 12-17% of those with likely pain• 3-4% of all ped patients

– Of these 18-36% received analgesia• Prehospital pain management remains an important

challenge!

LimitationsLimitations

• Small numbers within all subgroups• Use of protocol compliance as an indicator of

quality• CQI interventions varied by agency

– Most primarily provided aggregate feedback

• Limitations that could not be controlled– e.g., medical control denied pain medication

request

• These are extremely low frequency events!

ConclusionsConclusions• We were unable to demonstrate improved

protocol compliance using a contemporary CQI model.

• Positive areas of pediatric care– Collection of baseline patient data– Checking blood glucose and attempting IVs– Spinal immobilization in trauma – Bronchodilator use in respiratory distress

• Areas in need of further efforts– Pain management – Rapid trauma management

What is the Next Step?What is the Next Step?

• MI 1st STEPPS– Michigan’s First Simulation Training and

Evaluation of Paramedics in Pediatrics– 2005 EMS-C Targeted Issues Grant

• Evaluate impact of brief training every 4 months

• Compare simulation-based and non-simulation based instruction

ThanksThanks

www.emscqi.orgfales@msu.edu