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EMS Compass

Updatep. 24

ACE Inhibitor-Related

Angioedemap. 41

CommunityParamedics andthe Drug-Seeker

p. 56

Offshore HelicopterEMS OperationsCHI Aviations Sikorsky S-92 is acombination rescue truck and

critical care transport ambulancep. 60

Visit us online at EMSWorld.com JANUARY 2016 | VOL. 45, NO. 1 $7.00
http://www.emsworldexpo.com/http://emsworld.com/

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For More Information Circle 10 on Reader Service Card
http://www.junkinsafety.com/

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3/68For More Information Circle 11 on Reader Service Card
http://www.karlstorz.com/

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PARTNERS

EDITORIAL ADVISORY BOARD

4 JANUARY 2016 | EMSWORLD.com

Peter Antevy, MDCEO & Founder, Pediatric EmergencyStandards

James J. Augustine, MD, FACEPMedical Advisor, Washington Township FireDepartment, Dayton, OH; Clinical AssociateProfessor, Department of Emergency

Medicine, Wright State University, Dayton,OH; Director of Clinical Operations, USAcute Care Solutions

Raphael M. Barishansky, MPH, MS, CPMDirector, Office of Emergency MedicalServices, Conn. Dept. of Public Health

Eric Beck, DO, NREMT-PAssociate Chief Medical Officer, AmericanMedical Response

Bernard Beckerman, MD, FACEPAssociate Profes sor, School of Health andBehavioral Sciences, York College (CUNY),

Jamaica, N Y

Tom Bouthillet, NREMT-PCaptain, Town of Hilton Head Island (SC) Fire& Rescue Division

Kenneth Bouvier, NREMT-PDeputy Chief of Operations, New OrleansEMS; NAEMT President 20042006

Elliot Carhart, EdD, RRT, NRPAssociate Professor, Emergency ServicesProgram, Jefferson College of HealthSciences, Roanoke, VA

Chris Cebollero, NREMT-PSenior Partner, Cebollero & Associates, StLouis, MO

Will Chapleau, EMT-P, RN, TNSDirector of Performance Improvement,American College of Surgeons

Kevin T. Collopy, BA, FP- C, CCEMT-P, NREMT-P,WEMTClinical Education Coordinator, VitaLink/AirLink, Wilmington, NC; Lead Instructor,

Wilderness Medical Associates

Michael W. Dailey, MDAssistant Professor, Dept. of EmergencyMedicine, Albany Medical College, NY

Thom DickEMS Educator, Brighton, CO

William E. Gandy, JD, LPEMS Educator and Consultant, Tucson, AZ

Erik S. Gaull, NREMT-P, CEM, CPPMaster Firefighter/Paramedic, Cabin JohnPark (MD) Volunteer Fire Department

Troy M. Hagen, MBA, NREMT-PCEO, Care Ambulance, Orange, CA;President, National EMS ManagementAssociation

Martin Hellman, MD, FAAP, FACEPAttending Physician, Childrens Hospital ofPittsburgh, Pittsburgh, PA

Tim Hillier, Advanced Care ParamedicDirector of Professional Development, M.D.Ambulance, Saskatoon, SK Canada

Lou JordanPIO, Fire Police Officer, Union Bridge (MD)Fire Department

C.T. Chuck Kearns, MBA, EMT-PEMS Consultant

G. Christopher Kelly, JDAttorney at Law, Atlanta, GA; Chief LegalOfficer, EMS Consultants, Ltd.

Skip Kirkwood, MS, JD, EMT-P, EFO, CMODirector, Durham County (NC) EMS

Sean M. Kivlehan, MD, MPH, NREMT-PInternational Emergency Medicine Fellow,Brigham & Womens Hospital, HarvardMedical School

William S. Krost, MBA, NREMT-PAdjunct Assistant Professor of EmergencyMedicine, The George WashingtonUniversity

Ken Lavelle, MD, FACEP, NREMT-PClinical Instructor and Attending Physician,Thomas Jefferson University Hospital,Philadelphia, PA

Rob Lawrence, MCMIChief Operating Officer, Richmond (VA)Ambulance Authority

Todd J. LeDuc, MS, CFO, CEMAssistant Fire Chief, Broward Sheriff FireRescue, Ft. Lauderdale, FL

Mark D. Levine, MD, FACEPAssistant Professor, Dept. of EmergencyMedicine, Washington University School ofMedicine; Medical Director, St. Louis (MO)Fire Dept.

Tracey Loscar, NRP, FP-CBattalion Chief, Matanuska-Susitna (Mat-Su)Borough EMS, Wasilla, AK

Craig Manifold, DOEMS Medical Director, San Antonio FireDepartment and San Antonio AirLIFE;Assistant Professor, University of TexasHealth Science Center at San Antonio

Paul M. Maniscalco, MPA, EMT-PSenior Research Scientist & PrincipalInvestigator, The George WashingtonUniversity Office of Homeland Security

David Page, MS, NRPDirector, Prehospital Care Research Forumat UCLA; Paramedic, Allina Health EMS;Senior Lecturer, PhD candidate, MonashUniversity

Richard W. Patrick, MS, CFO, EM T-P, FFDirector, Medical First ResponderCoordination, Office of Health Affairs

Medical Readiness, U.S. DHS

Tim Perkins, BS, EMT-PEMS Systems Planner, Virginia Office ofEMS, Virginia DOH, Glen Allen, VA

Michael E. Poynter, EMT-PExecutive Director, Kentucky Board ofEmergency Medical Services

Vincent D. RobbinsPresident & CEO, MONOC, Monmouth-Ocean Hospital Service Corporation,Neptune, NJ

Mike RubinParamedic, Nashville, TN

Angelo Salvucci Jr., MD, FACEPMedical Director, Santa Barbara County &Ventura County EMS, CA

Scott R. Snyder, BS, NREMT-PFaculty, Public Safety Training Center,Emergency Care Program, Santa Rosa Jr.College, CA

Matthew R. Streger, Esq.Executive Director, Mobile Health Services,Robert Wood Johnson University Hospital;Fitch and Associates, LLC, New Brunswick,

NJDan Swayze, DrPH, MBA, MEMSVice President/COO, Center for EmergencyMedicine of Western Pennsylvania, Inc.

Cindy Tait, MICP, RN, PHN, MPHPresident, Center for Healthcare Education,Inc., Riverside, CA

John Todaro, BA, NRP, RN, TNS, NCEEEMS/CME Academic DepartmentCoordinator, St. Petersburg College, St.Petersburg, FL

William F. Toon, EdD, NREMT-PEMS Training Manager, Loudoun County (VA)Fire, Rescue and Emergency Management;Battalion Chief - Training (ret.), JohnsonCounty (KS) EMS: MED-ACT

David Wampler, PhD, LPAssistant Professor, Emergency HealthSciences, University of Texas Health ScienceCenter, San Antonio, TX

Paul A. Werfel, MS, NREMT-PDirector, Paramedic Program, Clinical Asst.Professor of Health Science, School ofHealth Technology & Management, Asst.Professor of Clinical Emergency Medicine,Dept. of Emergency Medicine, HealthScience Center, Stony Brook University, NY

Katherine West, BSN, MSEd, CICInfection-Control Consultant, InfectionControl/Emerging Concepts, VA

Gerald C. Wydro, MD, FAAEMChief, Division of EMS, Temple UniversitySchool of Medicine, Philadelphia, PA

Matt Zavadsky, MS-HSA, EMTDirector of Public Affairs, MedStar MobileHealthcare, Ft. Worth, TX

Published by SouthComm Business Media, IncPO Box 803 1233 Janesville AveFort Atkinson WI 53538920-563-6388 800-547-7377

Vol. 45, No. 1

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EMS World magazine (USPS 947-780; ISSN 2158-7833 print) is publishedmonthly by SouthComm Business Media, LLC. Periodicals postage paidat Fort Atkinson, WI 53538 and additional mailing offices. POSTMA STER:Send address changes to EMS World, PO Box 3257, Northbrook, IL60065-3257. Canada Post PM40612608. Return undeliverable Canadianaddresses to: EMS World, PO Box 25542, London, ON N6C 6B2.

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SouthComm Business Media, LLC does not assume and hereby disclaimsany liability to any person or company for any loss or damage c aused byerrors or omissions in the material herein, regardless of whether sucherrors result from negligence, accident or any other cause whatsoever.The views and opinions in the articles herein are not to be taken as officialexpressions of the publishers, unless so s tated. The publishers do notwarrant, either expressly or by implication, the fac tual accuracy of the

articles herein, nor do they so warrant any views or opinions offered bythe authors of said articles.
mailto:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]://emsworld.com/

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Together, the Pulmodyne O2-MAXwith integrated nebulization and

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60

36

48

56

FEATURES

24 How to Measure and Improve

EMS SystemsEMS Compass is setting the profession on

a path toward performance measurement

and improvement

By Michael Gerber, MPH, NRP

36 Evidence-Based EMS:Out-of-Hospital BiPAP vs. CPAPIs one any better than the other?

By Hawnwan Philip Moy, MD, & Blake Bruton, MD

41 ACE Inhibitor-Related

AngioedemaACEI-RA is a different beast, less than

responsive to standard pharmacological

agents

By Kristin Spencer, MS, NRP

48 Oxygenate and ResuscitateBefore You IntubateCommon pitfalls to avoid when managing

the crashing airway

By Russ Brown, NREMT-P

56 Community Paramedics and theDrug-SeekerBeyond pain, emotional and psychological

needs can help drive pseudoaddictive

behaviors

By Jason R. Berman, EMT-P, & Dan Swayze, DrPH, MBA, MEMS

JANUARY 2016

VOL. 45 | ISSUE 1

COVER REPORT

60 When Size Matters: OffshoreHelicopter EMS OperationsProviding medical and rescue services to the offshore

oil industry is a massive missionBy Barry Smith

COLUMNS

14 GUEST EDITORIALThe Next Great

Tradition

By Dan Swayze, DrPH, MBA,

MEMS

18 CASES WITH A

TWISTRepetitive Risks

By David Page, MS, NRP,

& Will Krost, MBA, NRP

22 LUDWIG ON

LEADERSHIPHow Will You Be

Remembered?

By Gary Ludwig

66 THE MIDLIFE

MEDICFind Your Next

By Tracey Loscar, NRP, FP-C

DEPARTMENTS10 EMS World Online

16 News Network

51 Ad Index

65 Classified Ads

On the CoverCHI SAR crews train an

average of 85 flight hours

per month. Photo by Barry

Smith.

DOWNLOAD our FREEtablet edition app toaccess exclusive EMSWorld content.

LETTERS TO THE EDITOR: Letters may be edited forclarity or space. E-mail [email protected].

SUBMISSIONS: E-mail queries, manuscripts, pressreleases and news items to [email protected].

PERMISSIONS: E-mail requests to [email protected] .

CONTACT USfacebook.com/emsworldfans twitter.com/emsworldnews

linkedin.com/

groups?gid=1853412 youtube.com/EMSWorld
mailto:[email protected]:[email protected]://youtube.com/EMSWorldhttp://linkedin.com/http://twitter.com/emsworldnewshttp://www.facebook.com/emsworldfansmailto:[email protected]:[email protected]://emsworld.com/

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1 In adult patients with cardiac arrest from cardiac etiology. ResQCPR System Summary of Safety and Effectiveness Data submitted to FDA.

2 Lurie et al. J Med Soc Toho Univ 2012;59(6) :305-315.

The ResQCPR System is intended for use as a CPR adjunct to improve the likelihood of survival i n adult patients with non-traumatic cardiac arrest. Risk information: Improper use of the ResQCPR System could cause ineffective chest

compressions and decompressions, leading to suboptimal circulation during CPR and possible serious injury to the patient. The ResQCPR System should only be used by personnel who have been trained in its use. The ResQPUMP

should not be used in patients who have had a recent sternotomy as this may potentially cause serious injur y. Improper positioning of the ResQPUMP suction cup may result in possible injury to the rib cage and/or internal organs,

and may also result in suboptimal circulation during ACD-CPR.

49-0879-000, 01

The ResQCPR TMSystem is a CPR adjunct comprised of two synergistic devices the ResQPODITD 16

and the ResQPUMPACD-CPR Device. Used together, these devices increase blood flow to the brain

and vital organs, as well as increase the likelihood of survival.2

Better Blood Flow.Improved Survival.

For more information, please visit www.zoll.com or call 877-737-7763.

A major clinical study showed a

49%

in one -year survival fromcardiac arrest.1

increase

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Illuminating the Path to Vein AccessVeinlite increases first-stick success, reduces waste and patient discomfort.

One of the most significant complaints among patients is

being stuck too many times when a medical professional is

trying to locate a vein to draw blood or start an IV. Thanks to

Veinlites innovative product line, it does not have to be such a

traumatic experience.

Venipuncture, or vein access, is one of the most routine

invasive procedures medical professionals conduct every day.

Sometimes, however, even the most experienced professionals

have difficulty locating a suitable veindue to age, especially

with elderly and pediatric patients; obesity; or even skin color.

This often results in sticking a patient several times, leading to

patient discomfort, dissatisfaction and delayed treatment.

Veinlite solves that problem by illuminating and isolating a

small portion of the vein for easy needle access. Veinlite deliv-

ers vein imaging in a unique and innovative way that increases

first-stick success while costing a fraction of other similar prod-

ucts.

I have been using the Veinlite in training nurses to start IVs,

primarily in the elderly, says Richard Johnston, of Lifeguard

Ambulance in Texas. Infants and the elderly typically are the

most difficult to gain IV access in. The Veinlite also gives careproviders who are not that experienced in starting IVs more

confidence to attempt an IV.

Johnston says there are several benefits to using the Veinlite.

In addition to reducing the number of attempts to gain IV

access on those with hard-to-access veins, it reduces pain and

stress to the patient, Johnston says. Using the Veinlite can also

reduce the amount of supplies used, thereby reducing costs.

Johnston says dehydration in particular among the elderly,

inhibits the ability to find veins.

With dehydration being a major problem, the ability to start

an IV is typically more difficult, Johnston says. The Veinlite can

help us locate the vein more easily. The Veinlite can also help

inexperienced nurses get needed fluids to patients faster and

reduce hospital admissions.

The Veinlite Vein Finder line of products is sold by TransLite

LLC, a small high-tech company that designs, manufactures

and sells medical devices to help reduce patient pain and

trauma.

Venipuncture is the most performed procedure in the

country, says TransLite President Nizar Mullani. Yet one in five

patients needs another nurse to come in and access the vein

after two attempts at sticking the patient. And theres just an

80% success rate after two sticks.

Clinical Trials Demonstrate Veinlites ValueSeveral clinical trials have been conducted to assess whether

vein finder devices help improve vein access. The results show

that Veinlite improves vein access, while near infrared light

(NIR) devices are no better than the normal standard of care. In

eight clinical trials of devices that use NIR, just oneon neo-

natesshowed improvement in accuracy for sticking veins.

TransLite LLC funded a study at Boston Childrens Hospital to

use Veinlite in a randomized clinical trial to access veins in thehard-to-find vein patients in the emergency department. The

three-year trial showed that the use of the Veinlite improved

the success rate for vein access from 74% to 83% after two

attempts.

In hospital exit surveys, the biggest complaint among

patients is being stuck too many times for drawing blood or

inserting an IV, Mullani says. With Veinlite the medical profes-

sional can see the vein and put the needle right into it. If you

dont see the vein, you dont stick it. Were not a vein finder,

were a vein access device.

Mullani says Veinlite accesses veins without the need for a

tourniquet, which can unnecessarily cut off circulation.

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Veinlite EMS PRO

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Registered Trademark of TransLite, LLC Designed and manufactured in the USA.

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The device accesses and helps hold the vein so it doesnt

roll, Mullani says. It anchors the vein. A whole bunch of devic-

es use near-infrared light, which shines a light on the skin. Then

they use a camera to get the image, but it only shows the vein

on the surface of the skin. The medical professional cant get to

the actual vein. Those devices are vein finders, but they dont

help access or sequester the vein.

The Veinlite ring helps close off the vein, and traction can beapplied to the skin by pushing the ring back from the opening.

This secures the vein and makes it easier to access.

Veinlite creates a local tourniquet that pops the vein up but

doesnt block the entire area of circulation, Mullani says.

Mullani also sought to create a hand-held device that could

operate on a battery. Research showed that orange/amber

light provided the highest contrast for imaging superficial

blood vessels, while red light penetrated deepest for imaging

deeper veins. The two colors of LEDs could produce reason-

able images of veins using only two watts or less of power, and

the portable Veinlite LED was created in 2004.Three variations of the portable devices are available:

Veinlite EMS is a simpler, lower-cost device for use by

prehospital emergency medical services.

Veinlite LEDXis a larger, more powerful version of the

Veinlite LED and effective for use on overweight patients

and for sclerotherapy.

Veinlite PEDIis a tiny device, streamlined for use on

neonates and infants.

And in 2015 the Veinlite EMS PRO was introduced. The

Veinlite EMS PROs new, integrated exam light provides quick,

one-button access to a built-in flashlight mode. Day or night,

this aids in initial patient assessment and reduces the amountof gear required to deliver quality care. The device is suitable

for use on adults and children, and for both light and dark

skin tones.

For more information on TransLite LLC visit www.veinlite.com,

e-mail [email protected] or call 281/240-3111.

EMSWORLD.com | JANUARY 2016 9

Paramedics are out in the trucks by themselves.

They have to have the IV access in the field and dont

have backup of another nurse to access a vein. The

paramedics love it because it makes their jobs easier. Nizar Mullani
http://emsworld.com/mailto:[email protected]://www.veinlite.com/http://veinlite.com/http://www.veinlite.com/

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MOULAGEOF THE MONTH

NEW

PODCASTSWORD ON THE STREET:

REPORT FROM ECCUHost Rob Lawrence

reports from this years

ECCU conference

held in San Diego,

December 8-11, 2015,

just weeks after the release of

the new Resuscitation Guidelines.

What will the science tell us about

ways to improve survival? How

will the new guidelines impact

instruction and practice? What are

the best practices in training and

community programs? Listen to

the resuscitation professionals

instructors, practitioners, survivors

and researchersdiscuss the

latest in cardiac care.

See EMSWorld.com/podcast.

BUILDING BIG DATAWith the acquisition of Rural/Metro Corp.,

AMRand the larger world of EMSis

poised to learn a lot more about the

effectiveness of a lot of the things we all

do. The companys already-substantial

focus on data will encompass millions

of additional points with the subsuming

of Rural/Metros various operations and

patient loads. That will tell all of us even

more even faster about the impacts of interventions across the spectrum

from 9-1-1 responses to transfers to community paramedicine and

mobile integrated healthcare.

Read more at EMSWorld.com/12146730.

QUICK TIMEWhats next for you in EMS? Catching up on your PCRs is certainly in the

mix, but what about a year from now or 10 years from now? Maybe youll

want to try something different. In this months Life Support column, Mike

Rubin discusses career options.


FEATURES

facebook.com/emsworldfans twitter.com/emsworldnews www.linkedin.com/groups?gid=1853412

V isit EMSWorld.com/webcastst oregister for upcoming presentations:

FEB 10, 2 PM ET:

RECOGNIZING AND

REACTING TO THE LOST

ADVANCED AIRWAYAll advanced airways are at

risk of dislodgement and failing

to recognize a dislodgement

can lead to serious morbidityranging from anoxic brain injury

to death. This webinar offers

best practices to prevent airway

dislodgement and immediately

recognize the lost airway,

and offers five strategies for

rapid and effective emergency

airway intervention. Presented

by Kevin Collopy, BA, FP-C,

CCEMT-P, NREMT-P, WEMT, and

sponsored by Physio-Control.

WEBCASTS

Bobbie Merica continues her guide to

simulating injuries and illnesses

through effective use of moulage.

This month: Industrial response, steam

burn, second degree.

See EMSWorld.com/12146211.

THE MEDBOT EDUCATORHow many of you know what a mobile virtual

presence device is? Of those who said yes, you

probably first heard of them from an episode

of the TV show The Big Bang Theory. Well, get

ready to put your geek on, because we are

about to look at how these devices might be

used for prehospital education and even more.


http://emsworld.com/http://emsworld.com/12146983http://emsworld.com/12146211http://emsworld.com/webcastshttp://www.linkedin.com/groups?gid=1853412http://twitter.com/emsworldnewshttp://www.facebook.com/emsworldfanshttp://emsworld.com/12146735http://emsworld.com/12146730http://emsworld.com/podcast

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55,300 new medics by 2022

The Emergency Medical Services field is expected to growmore than 23% over the next decade, adding over 55,000paramedic and EMT jobs. Are you ready?

Hire the right people based on science:

Infor Talent Science measures 39 key behavioral

attributes of your best employees and creates a profile

for screening applicants. Profiles can be incorporated

into your existing civil service processes to help

select, develop, and retain your medics and EMTs.

infor.com/publicsector

Talent Science

Supportdiversity

Enhanceperformance

Increaseretention

Improvesuccessionplanning

Infor Public Sector delivers a comprehensive suite of integrated, specific solutions that drive financial management, human

capital management, asset and work management, regulatory compliance, and healthcare information exchange. Infor

solutions increase operational efficiency, citizen satisfaction, government accountability, and process transparency and aretransforming how governments provide services to citizens.

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The US Bureau of Labor Statistics expects theemergency medical services (EMS) field to grow bymore than 23% over the next 10 years, adding over55,000 paramedic and EMT jobs to the 235,000skilled paramedics and EMTs already faithfully servingacross the United States. The additional workforceneeds are to due to increasing call volumes, agingpopulations, and a generally heavier reliance ongovernmental services. This presents additionalchallenges to an EMS community already grapplingwith the impact of the Affordable Care Act, shiftstowards community-based care, value-based

payments, and an aging workforce, especially infire-based EMS organizations.

Consider the findings of the most recent reportfrom the National Highway Transportation SafetyAdministration Office of Emergency Medical Services:

t 3FUBJOJOH XPSLFST JT B DIBMMFOHF XJUI QPPS

management practices, low wages and benefits, lackof career ladders, and disability contributingto turnover.

t 3FUFOUJPO PG PMEFS PS NPSF FYQFSJFODFE XPSLFST

[conserves] talent and experience within the EMSworkforce and increases workforce supply.

t %FWFMPQJOH TUSBUFHJFT UP BDDPNNPEBUF PMEFS PS

more experienced workers and increasing successfulrecruitment and retention of older individuals wouldprove helpful for addressing the [workforce] issue.

Its a complex proposition to hire the right candidatesfor roles that require highly technical medical skillsand a willingness to put oneself in harms way for thebenefit of a stranger. To help meet this challenge, theEMS community could benefit from science-based

hiring practices.

Talent science, or science-based hiring practices, isa predictive and analytics-based approach tomanaging human resource processes, like candidateselection, medics development, and successionplanning. This approach both objectively andstatistically links specified performance metrics tobehavioral characteristics of medics within an agencyto help establish a model of best fit that is unique toeach agency.

Heres how talent science works. Custom profiles arebuilt using large samples of incumbent medics andEMTs that reflect the behavioral makeup of the best-

suited candidate for a specific organization. This isimportant because while nearly all medics and EMTsshare a common sense of civic duty to help those inneed, the behavioral characteristics of a successfulmedic in a large fire-based organization may bedifferent from the behavioral characteristics of a medicor EMT in private agency or a quasi-governmentalorganization.

Next, job candidates are evaluated and rankedbased on their responses to a comprehensiveonline assessment that is designed to measure 39behavioral characteristics. The assessment compares

each candidates behaviors to the custom profilecorresponding to the position of medic or EMT withina specific organization. A report is then generated,visually describing how and where the candidate alignsand differs from the unique requirements of the profileand the defined needs of the organization.

This approach has proven to significantly reduceturnover and improve organizational performancein an industry with similar challenges to the EMScommunitythe nursing profession. A recentcontrolled study of over 1,000 newly hired nursescomparing the use of science-based hiring practicesto traditional hiring practices demonstrated a turnoverreduction of 47% and produced an annual savings ofover $2.4 million. By employing a similar approachwithin EMS, agencies can become more effectiveat identifying the most qualified candidates from askills perspective and can isolate those individualswhose characteristics make them the best fit for theorganization at large.

The workforce crisis facing the EMS profession willnot solve itself through procrastination and inaction.When medics leave, the loss in knowledge capital issubstantial and the ability to serve the community isdiminished. The community deserves the best from

our agencies, and using science can help the EMScommunity deliver on those expectations.

opyright 2015 Infor. www.infor.com. All rights reserved.

Addressing the EMS workforcecrisis with scienceKurt A. Steward, Ph.D., Vice President, Infor Public Sector
http://infor.com/publicsectorhttp://www.infor.com/

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GUESTEDITORIAL By Dan Swayze, DrPH, MBA, MEMS

Today more

than 1,000 EMS

providers havebeen trained to

help save lives

differently than

in the past.

The Next Great TraditionIts time to support the more than 1,000 EMS providers

working as community paramedics and MIH practitioners

More than 200 years of tradition, uninterrupted by

progress. Ive heard that phrase often to describe

how some firefighters hold strong to their rituals

and practices. But truth be told, the same could be

said of EMS.

Since the days of Napoleon, ambulance services

have existed primarily to transport the ill and injured

from where they fell to a hospital where they could

be treated.

More than 200 years ago, tradition dictated that

local townsfolk would transport injured soldiers to

the closest hospital in their hay wagons, but only

once the battle moved away. At the hospital, sur-

geons would begin their lifesaving interventions on

those who survived that long. But one surgeon, Dr.

Dominique Jean Larrey, was different. He believed the

surgeons should be deployed into combat to retrieve

the injured even while war raged around them. He

argued that by beginning care sooner, he could save

many more lives. Despite a belief that was undoubt-

edly unpopular with his peers, Larrey persevered and

invented the ambulance, the modern system of tri-

age and many other surgical innovations.

While you may have heard of Larreys contribu-

tion to our beginnings, think about this: He could

not have done it alone. He had to find colleaguesbrave enough to risk breaking with tradition to join

him in his cause. Larreys followers undoubtedly

faced opposition but were courageous enough to

embrace the new role despite the personal risk they

encountered. As brilliant as Larrey was, he could not

have put his idea into motion without the help of oth-

ers willing to gamble on a new model to help save

more lives.

Today more than 1,000 EMS providers have been

trained to help save lives differently than in the

past: in new roles as community paramedics and

mobile integrated healthcare practitioners. Thats

a small portion of all EMS personnel, but enough to

convince the editors of EMS Worldthat it is time to

support these brave new providers by dedicating a

series of articles over the coming year to this new

type of patient care. While articles on the finance

and administration of these programs remain criti-

cally important discussions, EMS Worldrecognizes

that those serving in this new role also need articles

focused on the aspects of patient care they will

encounter that are different than those faced in their

traditional roles.

We start the new series this month on page 56

discussing substance abuse. Instead of describing

the traditional approach to treating an overdose, the

article focuses on the terminology and treatment

paths available to those who suffer from either

addiction or pseudoaddiction caused by their chronic

pain. While the topic may not be popular among

those holding strong to our EMS traditions, those

practicing in this new role will encounter patients

needing these treatments regularly.

I applaud EMS WorldEditorial Director Nancy Perry

and Senior Editor John Erich for dedicating time and

space to help these new providers. Thanks to their

efforts and the bravery of the 1,000-plus provid-

ers willing to break from their traditional roles, we

are looking at the start of the next great tradition

of EMS.

ABOUT THE AUTHOR

Dan Swayze, DrPH, MBA, MEMS, is the vice president andCOO of the Center for Emergency Medicine of WesternPennsylvania and is widely considered one of the pioneersof the emerging field of community paramedicine. Dan has

been involved in EMS for more than 30 years.


Heather Bogdon andDavid Dupra from theCONNECT CommunityParamedic Program inPittsburgh, PA, are partof the rapidly growingnumber of communityparamedics in the

United States.

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Fla. Paramedic Elected to National Board PositionSunstar Paramedics Community Outreach Coordinator, Charlene

Cobb, has been elected to the Board of Directors for the NationalAssociation of Emergency Medical Technicians (NAEMT). She

will serve a s an at-large director.

During her two-year term, Cobb plans to work on creating

industry solutions for an easier transition for military medic vet-

erans who want to move into an EMS career. She also plans to develop strategies

to improve workplace safety and working with government representatives and

industry officials to pass the Field EMS Modernization and Innovation Act.

Cobb has been an active member of NAEMT since 2005. I am extremely hon-

ored to have been elected by my fellow NAEMT members, said Cobb. Over the

last 30 years, I have watched this field evolve and am excited to take a larger role

in making a difference for EMTs around the country.

For more on NAEMT, visit naemt.org.

Virginia Office of EMS Awards Agency of Excellence DesignationAt a recent event, the City of

Manassas Fire and Rescue System

was among the first agencies to be

awarded with the Agency of Excel-lence designation from the Virginia

Office of EMS.

This was the first year of a pilot

program that seeks to recognize

agencies that strive to operate

above the standards and require-

ments of Virginia EMS regulations.

Agencies were evaluated in

eight program areas: leadership/

management; emergency medical

dispatch; clinical care measures;

operational medical direction; life

safety; community support andinvolvement; recruitment and retention; and performance and risk.

Im glad we could be part of this pilot program, said Manassas Fire and Rescue

Chief Brett Bowman. The men and women of the City of Manassas Fire and

Rescue team are exceptional, and I am proud that they have been recognized for

their serv ice to the community.

The designation as an Agency of Excellence lasts for three years, at which time

an agency must reapply for the certification. For more information, visit www.

vdh.state.va.us/OEMS.

EMS Supervisor Lt. Matt Fox (pictured), alongwith Battalion Chief Todd Lupton, helpedsteer the City of Manassas Fire and RescueSystem through the pilot program.

Every two secondssomeone in the

U.S. needs blood.

More than 41,000blood donations

are needed

every day.

The averagered blood celltransfusion is

approximately3 pints.

The blood typemost often

requested by

hospitals is Type O.

The number ofblood donationscollected in the

U.S. in a year is15.7 million.

There are 9.2million blood

donors in the U.S.

each year.

JANUARY IS NATIONAL BLOO D DONOR MONTH

Cool/Not Cool

Happy Breathe-day!Jane Powers sure knows how to throw a party!

Three years after surviv ing a cardiac arrest, Pow-

ers has turned her ow n birthday celebrations into

annual CPR training events complete with EMS

instructors.

Powers, a longtime employee of the Arizona Dia-

mondbacks baseball team, collapsed in a tunnel

under the Diamondbacks stadium after a 2012

game, and was pulseless when found by umpire

Jim Joyce. Joyce used the CPR hed learned as a

young man to help resuscitate Powers, who now

offers hands-only CPR familiarization to dozens

of volunteers each year. You never know when

you could be in that situation (to use CPR), says

Powers. You want to be as prepared as Jim Joyce

was for me. Cool!

A Barbaric RitualJason Waldeck, a former volunteer firefighter

in Ellis County, TX, says he put up with months

of hazing after joining the Waxahachie station.

According to Waldeck, though, none of that comes

close to the sadistic treatment he endured last

January at the hands of fellow firefighters.

Waldeck says he was pinned down and sexually

assaulted by five colleagues while the girlfriend of

one videotaped the incident.

Eight people, including the departments chief

and assistant chief, have been indicted on charges

associated with the assault.

I cant get it out of my mind, says Waldeck. Ive

had thoughts of suicide.

It would be deplorable to classify the alleged

incident merely as hazing gone awry, or to link the

accused to a work-hard-play-hard characterization

of emergency services. This isnt about firefight-

ing or volunteering; its about savage, sociopathic

behavior perpetrated by the strong against the

weak. Uncool!

NEWS NETWORK

http://www.vdh.state.va.us/OEMShttp://www.vdh.state.va.us/OEMShttp://emsworld.com/http://naemt.org/

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Gainful employment information available at ColumbiaSouthern.edu/Disclosure.

ColumbiaSouthern.edu/EMSworld |877.258.7153

FLEXIBLE.

AFFORDABLE.

ONLINE.

Learn more about our online degrees, workshops, and CEUs.

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CASES WITH A TWIST By David Page, MS, NRP, & Will Krost, MBA, NRP


Remember,

slow is smooth

and smooth is fast.

Repetitive RisksFor this EMS crew, unloading the stretcher proved

dangerous to both patient and provider

This inaugural column is dedicated to our peers

who risk their lives to serve others daily. In this

column we will explore cases in which things

didnt quite go as planned. Sometimes this

means we were surprised by a clinical presentation,

while others involve near-misses or adverse events.

While we love EMS, the work we perform is often

conducted in unpredictable and harsh environments

with limited information and resources and high

stress. EMS personnel are 2 times more likely to

be killed on duty, and five times more likely to suf-

fer a transportation-related injury, than the average

worker.1We hope this column will help promote an

open, honest and timely process to communicate

potential mishaps and promote a culture of safety

in EMS operations.

This Months Case

After an emergent transport to the hospital, the crew

was unloading the stretcher loaded with a roughly

200-pound critical patient in congestive heart fail-

ure. Crew member #1 was at the foot of the stretcher,

operating the manual control, while crew member #2

was on the patients right side, watching and ready

to catch the wheels.

As expected, with ER staff watching as they met

the ambulance in the garage, the crew was moving

quickly to get the critical patient inside. Crew mem-

ber #1 began to give a quick report while starting to

pull back on the stretcher. The hospital has a slightly

uneven garage floor (to allow for drainage in the

center), and the vehicle and stretcher were slightly

tipped to the patients left side.

As the crew pulled the stretcher out, the safety

bar missed the safety hook. The stretcher came

out of the back of the ambulance rapidly, with its

wheels still retracted. Crew member #1 at the foot

of the stretcher tried to hold the weight. Unfortu-

nately the stretcher tipped toward the left, and the

patient reached out to the left side as crew member

#2 (on the patients right side) pulled up, trying to

help prevent the stretcher from hitting the ground.

Momentum shifted to the left side.

To complicate matters, this stretcher was

equipped with a canvas basket behind the head.

When the stretcher began tipping out of balance, a

Straps, oxygen bottlesand special baskets can

catch on the safety latch,creating further danger.

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worn and loose strap caught the safety hook, mak-

ing it harder for both crew members to maintain the

stretcher upright.

At this point the stretcher twisted and inverted,

almost completely falling to the ground. The patientstruck their head, face and upper left shoulder on

the jagged ambulance bumper first, then the floor.

Assisted by the ER staff, the patient was rolled and

placed on a long spine board with cervical precau-

tions and then quickly moved into the critical care

room.

Crew member #2, leaning while trying to lift,

immediately felt severe back pain and fell forward,

striking their head on the overturned stretcher and

sustaining an inch-long laceration to the forehead.

The patient died of heart failure shortly after

admission. On review the traumatic injuries, while

serious and possibly having delayed care, were not

found to be directly responsible for the patients

death. Crew member #2 sustained a herniated L5-S1

low-back injury that required a laminectomy and

extensive rehab, and continues on light duty with

the goal of returning to work in the field.

Root Cause AnalysisWhen analyzing adverse events, safety experts

talk about gaps or holes in safety practices lin-

ing up to cause a perfect storm that results in

injury. (See the Swiss cheese model explained

here: https://psnet.ahrq.gov/primers/primer/21/

systems-approach.)

In this case the crew, with a combined 14 years of

experience, acted like so many other crews would.

With a critical patients best interest in mind, they

moved quickly performing a routine taskunload-

ing the stretcher, a procedure they have completed

thousands of times without mishap. They were nei-

ther disregarding safety nor acting recklessly. In the

blink of an eye, they became distracted with reports

to the ER staff and relied on a safety hook that had

never failed them.

It is common for us to be complacent and disre-

gard risks during repetitive tasks that have never

caused us harm. Like our use of stretchers on every

call, pilots will take off and land an airplane on every

flight. And like aviation, where most crashes occur

on take-off and landing, we also know most injuries

to providers and patients will occur during stretcher

loads and unloads. Have you ever thought, I dont

need to wear my seat belt, Im just driving down the

block to the store? When it hasnt happened to us,

we can think It doesnt happen to me. Our compla-cency leads us to slip, then trip.

Nonpreventable Factors

The single hook, combined with a stretcher safety

bar that is curved, combined with a garage that

is tilted, combined with straps from equipment

baskets, combined with an unload procedure that

requires holding weight until wheels descend and

lock, is a system design disaster waiting to happen.

Preventable Factors

Crew distraction, lack of communication during a

critical task, moving too quickly and disregarding

risks are all elements that could have been mitigated

in this case.

Lessons

This event is as tragic as it is common. Clearly we

need systems that have improved safety design.

Help may be on the way from stretcher manufac-

turers offering no-lift systems. In the meantime,

what can you do to prevent this from happening on

your next call?

We are big fans of crew resource management

(see sidebar). In keeping with aviations red rule

when potential risks exist, it is essential that we stop

(or at least slow down enough to think about the

procedure), perform a cross-check with a partner,

follow a clear checklist, use clear verbalization of

keywords, and repeat back confirmation (closedloop communication). Maintaining a sterile cockpit

CRM TipsTHIS COLUMN WILL FEATURE A MONTHLY TIP ON CREW RESOURCE

Management (CRM) principles and techniques that apply to the cases we

present.

CRM techniques have led to improved communication, teamwork and

safety in the military, commercial aviation and now EMS/fire agencies.

In this inaugural column, patients and providers were injured in a stretch-

er mishap. In aviation most crashes occur on take-off and landing. If we

apply this principle to EMS, lets imagine a systematic process to improve

stretcher loading (take-off) and unloading (landing):

Sterile cockpitDuring take-offs and landings, crews are silent unless

there is a concern for safety. In our EMS case, we do not want to create

distractions until cr itical stretcher procedures are completed. These might

include wheels being up and the stretcher being latched.

Key wordsThe critical step in stretcher unloading is to ensure the

wheels are down and locked.

ChecklistsFor procedures we know might injure a patient or ourselves,

we have to take additional steps to reduce risks. One of these is to pause,

review key steps in a checklist, and read back these steps for a second

person to confirm we have not missed anything. For procedures that carry

excess risk like aviations red rulechecklists force crews to stop, read

back and ensure we have critical elements covered.
https://psnet.ahrq.gov/primers/primer/21/systems-approachhttps://psnet.ahrq.gov/primers/primer/21/systems-approachhttp://emsworld.com/

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could also prevent unnecessary distraction. In this

case identifying an environmental hazard (tilted

garage floor) and waiting for a third person to help

is also possible.

Improving safety parameters, such as removingloose straps, placing two safety hooks and ensur-

ing the stretcher bar is updated to be flat, will help

mitigate some risks.

Standardizing the process of loading and unload-

ing would be the single greatest mitigator of risk in

this case. Streamlined and vetted processes have

been proven to mitigate almost all errors.

From simple procedures such as ensuring a door is

locked before an airplane takes off to complex crash

landings into a river, cross-checks with a standard-

ized checklist have saved many lives. Remember,

slow is smooth, and smooth is fast.

Why Do We Need This Column?

Recent studies report between 98,000 and 210,000

deaths each year are due to preventable medical

errors.24We know that errors in areas like medica-

tion administration, airway management, assess-

ment errors and patient falls are not just happening

in hospitals. These same errors occur in ambulances,

but providers are afraid to report them for fear of

being dismissed, and agencies are afraid to report

them from fear of being sued. Unfortunately, without

reporting or tracking these errors, we cannot under-

stand the depth of the problem or create systems

to improve our safety.

In 2013, responding to a request from the Nation-

al EMS Advisory Council (NEMSAC), the National

Highway Traffic Safety Administration (NHTSA)

collaborated with the American College of Emer-

gency Physicians (ACEP) to publish the Strategy for

a National EMS Culture of Safety (www.emsculture-

ofsafety.org). This landmark do cument outlines the

need, framework and steps for EMS to implement

major operational changes that will lead to improved

safety.

To become more reliable we must implement just

culture. Learning from our mistakes so we do not

repeat them is a key component of this process. We

must make it safe to report errors without fear of

reprisals and analyze the root cause of the adverse

event. Like aviation, we need to focus on systems of

safety, not blaming individuals.

The Center for Leadership and Research (CLIR),

in collaboration with the National Association of

EMTs (NAEMT), has set up an international report-

ing website and database to track these errors atwww.emseventreport.com. The brainchild of para-

medic Gary Wingrove, this tool allows EMS providers

to anonymously report near-miss or actual adverse

events without fear of punishment.

In this column we intend to report on cases where

things simply didnt go as planned. We will hidedetails to protect the privacy of those who share

these events, but we want to help create a national

culture of safety that is not afraid to shed light on

near-miss or adverse events. We are committed to

facilitating honest and prompt reporting so that oth-

ers will learn from them and avoid them. Send com-

ments and feedback to [email protected].

REFERENCES

1. Braithwaite S, et al. Strategy for a National EMS Culture of Safet y; p 6,www.emscultureofsafety.org.

2. James JT. A new, evidence-based estimate of patient harms associated

with hospital care.J Patient Safet y, 2013 Sep; 9(3): 1228.3. Institute of Medicine. To Err is Human, https://iom.nationalacademies.org.

4. Department of Health and Human Services Of fice of InspectorGeneral.Adverse Ev ents in Hospital s: National Incid ence Among Med icalBeneficiaries, http://oig.hhs.gov/oei/reports/oei-06-09-00090.pdf.

BIBLIOGRAPHY

Hobgood C, XIe J, Winder B, Hooker J. Error Identification, Disclosure, andReporting: Practice Patterns of T hree Emergency Medicine Provider Types.Acad Emer g Med, 2004; 11: 1969.

Hubble MW, Paschal KR, Sanders TA. Medication calculation skills ofpracticing paramedics. Prehosp Emerg Care,2000; 4: 25360.

Kothari R, Barsan W, Brott T, Broderick J, Ashbrock S. Frequency andaccuracy of prehospital diagnosis of acute stroke. Stroke, 1995; 26: 93741.

Rittenberger JC, Beck PW, Paris PM. Errors of omission in the treatment of

prehospital chest pain patients. Prehosp Emerg Care,2005; 9 : 27.Vilke GM, Tornabene SV, Stepanski B, et al. Paramedic self-reportedmedication errors. Prehosp Emerg Care,2006; 10: 45762.

ABOUT THE AUTHORSDavid Page, MS, NRP,is director of the Prehospital CareResearch Forum at UCLA. He is a senior lecturer and PhDcandidate at Monash University. He has over 30 years ofexperience in EMS and continues to be active as a fieldparamedic for Allina Health EMS in the Minneapolis/St. Paularea.

Will Krost, MBA , NRP,is a fourth-year medical student and afaculty member at the George Washington University Schoolof Medicine and Health Sciences in the Departments of ClinicalResearch and Leadership and Health Sciences. He has over 23years of experience in EMS operations, critical care transportand hospital administration.

Please help us identify

errors and near-miss

events that affect the

safety of EMS providers

and patients. Report

events anonymously at

www.emseventreport.

com.

E.V.E.N.T. is an anony-

mous tool designed

to improve the safety,

quality and consistent

delivery of EMS. The

data collected will

be used to develop

policies, procedures

and training programs.

A similar system used

by airline pilots has ledto important system

improvements based

upon pilot-reported

near-miss situations

and errors.

REPORTEVENTS

CASES WITH A TWIST

Video ChallengeCAN YOU COME UP WITH A VIDEO THAT

demonstrates sterile cockpit, key words anduse of a checklist for safe loading and unload-

ing of the stretcher? If you do, please send the

link to [email protected]. Our partners

at North Ambulance and Jones and Bartlett

Learning filmed this stretcher cross-check

seen here: EMSReference.com/checklists.

Editors note:Cases

are obfuscated and

amalgamated to

protect patient privacy

and provider anonymity.

While staying as true as

possible to the actual

event, creative license

is used to better explain

the lesson(s) in the

case.
http://www.emseventreport.com/http://www.emseventreport.com/https://iom.nationalacademies.org/https://iom.nationalacademies.org/http://www.emscultureofsafety.org/http://www.emscultureofsafety.org/http://emsreference.com/checklistsmailto:[email protected]://oig.hhs.gov/oei/reports/oei-06-09-00090.pdfhttp://www.emscultureofsafety.org/mailto:[email protected]://www.emseventreport.com/http://emsworld.com/

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LUDWIG ON LEADERSHIP By Gary Ludwig, MS, EMT-P


When you

accept a

leadership

position,

it is not

jus t a tit le.

How Will You Be Remembered?It is your responsibility to leave your EMS

organization better than you found it

Management is doing things right, leadership is doing

the right things. Peter Drucker

When you come to the end of your career in

whatever leadership role you retire from,

how will you be remembered? Will the

number of people who show up at your

retirement party not even fill a telephone booth,

or will it be a large hall overflowing with those who

want to wish you well and thank you for everything

you did to contribute to the organization?

I have worked with some chief fire officers in my

career for whom the only people who showed up at

the retirement party were the retirees family and

those working in the building so they could get the

free food. It is very sad that your subordinates could

think so little of you and that you made no contri-

butions to better the organization; in fact, you may

have made it worse. For these individuals, that will

be their legacy and how they will be remembered

for years to come.

Clean the Campsite

The Boy Scouts have a saying: Leave the campsite

better than you found it. This means making sure

you clean up any mess you created. All your trash

should be picked up and all camp fires put out,

restoring the campsite to its natural state. Even if

you arrived and found cans and wrappers left by

someone else, it is your responsibility to clean it up.

This saying can also apply to leaders of EMS orga-

nizations. Whatever leadership role you find yourself

in, whether it is a supervisor, a middle-level man-

agement position or the head of the EMS organiza-

tion, one of your responsibilities is to move the EMS

organization forward and leave it better than you

found it. How do you do this? You become a leader

instead of a manager.

Leadership vs. ManagementWhat is the difference between leadership and

management? It is very simple: You lead employ-

ees and manage things. We manage budgets, fleets,

payroll, inventories and computer systems, but we

lead people.

Leaders who fail and whose staff cannot wait

until they retire lack vision of where the organization

should be and, since they have no vision, they cannot

share that vision with their subordinates.

Leaders who leave an organization better than

they found it learn to create a vision of where the

organization should be and then find that one ingre-

dient that motivates people to share in that vision.

Just because you create a vision of where the

organization should be does not mean your employ-

ees will rubberstamp your vision. You have to be

able to share your vision and find a way of getting

employees to buy into your vision.

Most leaders find a way to get employees to share

their vision by empowering them in the process. As

President Dwight Eisenhower said, Leadership is the

art of getting someone else to do something you

want done because he wants to do it. Eisenhower

certainly understood this concept. Who else could

command millions of troops in battle to conquer

Europe while he had never been in battle himself?

You may not care what your employees think

about you when you retire. You may just wish to walk

out the door on your last day, never to be seen again.

If that is the case, then you were not a leader and you

were probably not even a manager.

In a leadership position you have a responsibility

to lead your organization and your employees and

make your EMS organization successful. If you do not

accept this responsibility, you should have stepped

down from your position way before your retirement.

When you accept a leadership position, it is not just

a title. It is a responsibility that you should fully accept

and strive for the success of your EMS organization.

ABOU T T HE AU T H ORGary Ludwig, MS, EMT-P, is chief of the Champaign (IL)Fire Department. He is a well-known author and lecturerwho has successfully managed large, award-winningmetropolitan fire-based EMS systems in St. Louis andMemphis. He has a total of 37 years of fire, rescue and EMSexperience and has been a paramedic for over 35 years.

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EMS Compass is setting the profession on

a path toward performance measurementand improvement

When staff in the National Highway Traf-

fic Safety Administration (NHTSA)

Office of EMS decided to support EMS

Compass, it made perfect sense. For

decades, NHTSA has funded projects

that have helped make the nations EMS systems what

they are today. Twenty years ago, theAgenda for the

Future presented a vision of a data-driven EMS sys-

tem; more recently, the National EMS InformationSystem (NEMSIS) established data standards and the

Prehospital Evidence-Based Guidelines (EBG) project

established treatment guidelines based on research

findings. Each has bui lt on those that came before

it, and EMS Compass is no different.

Its the logical next stepapplying those stan-

dard data elements and medical research to create

performance measures that will help EMS agencies

meaningfully use their data to improve patient care.

In December 2014 the National Association ofState EMS Officials (NASEMSO), through a coop-

By Michael Gerber, MPH, NRP

How to Measure andImprove EMS Systems


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erative agreement with NHTSA, publicly launched

EMS Compass. Since then, the initiative has tackled

difficult issues, from how to decide which measures

to use to how to be inclusive of the entire EMS com-

munity. But the focus of EMS Compass has been cre-

ating a replicable process for identifying, designing

and testing performance measuresa process that

can be used well into the future by organizations

hoping to develop measures that support improving

prehospital medical care.

In order to take the next step as a profession, EMS

must embrace a culture of improvementone where

we measure the things that truly matter to patients

and we work to improve the processes that result inthe best possible patient care, says Bob Bass, MD,

How EMS Leaders Use Data to Improve EMS SystemsIf we have measures that are truly patient-centeredI believe

well make much better decisions and make much more significant

improvement, said Mike Taigman, General Manager of AMR in Ventura

County, CA, during one of a series of 10 webinars held in June 2015 by EMS

Compass as part of the initiatives effort to engage and receive input

from the EMS community. Each webinar tackled one of the 9 domains of

measures EMS Compass is addressing.

Taigman admitted that measuring patient outcomes is a struggle in

EMS and medicine generally. But that doesnt mean EMS shouldnt strive

to have performance measures that are as patient-centered as possible.

During the session on population and public health, Taigman described

the process measures that he believes EMS can use when true patient

outcome measures are difficult to assess. A process measure, EMS

Compass Project Manager Nick Nudell explained, is one that evaluates

a step in the process that is linked to outcomes but is not the outcome

itself.

Taigmans examples included measuring the time from the first 9-1-1

call to certain evidence-based procedures for time-sensitive conditions,

such as:

First chest compression for cardiac arrest;

Restoration of blood flow for STEMI;

First CT scan interpretation for stroke;

Infusion of two liters of fluid for sepsis.

There are six domains of measures that correlate to the priorities in

the U.S. Department of Health and Human Services National Quality

Strategy. Population and public health is one; the other five are patient

and family engagement, patient safety, care coordination, efficient use of

healthcare resources, and clinical process and effectiveness. In keeping

with the project charter to address all aspects of an EMS system, the

initiative added three other domains: workforce, fleet and data.

In the EMS workforce webinar, Daniel Patterson, PhD, a senior scientist

with the Carolinas Healthcare System in Charlotte, NC, discussed ways

to measure fatigue and the safety culture within an organizationall of

which have been linked to safety outcomes by research, he said.

While in the past some of these measures have used questionnaires

that can be time-consuming to administer to staff, Patterson and other

researchers have been working to refine those surveys to make them

shorter but still valid. Other ways of measuring these factors, such as

using text messaging to assess fatigue, are currently being investigated.

Mike Ragone, director of system design for AMR, spoke about the

difference between measuring on scene times and at patient times

during the session on efficient use of healthcare resources. On scene

time versus at patient side, as we all know, can be a huge difference,

Ragone said, citing the example of responding to a casino where it maytake 15 minutes to reach the patient after arriving. If we do not separate

them, we wont be able to draw conclusions about the clinical relevance

of response times, he added.

Ragone discussed some of the different ways systems are trying to

measure accurate at-patient times, from communicating via the radio in

order to let dispatchers mark the time to using handheld devices, such

as smart phones, that allow the practitioners in the field to accurately

record the time.

Although EMS Compass aims to create performance measures around

the data standards established by NEMSIS, it was clear that this effort to

use data to assess system performance may also drive changes to how

data is collected, as EMS systems determine which elements are most

critical to analyze.

The use of analytics and data to save lives is at theheart of operations at The Richmond AmbulanceAuthority in Richmond, VA. Two of RAAs leaders werefeatured in the EMS Compass webinar series, COO RobLawrence on the use of performance management inEMS and Fleet Manager Dan Fellows who discussedmetric-led fleet management.

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former director of the Maryland Institute

for EMS Systems, who is serving as the EMS

Compass steering committee chair.

On January 13 the EMS Compass steering

committee meets in person for the third

time to discuss the progress of the mea-

sure development process. The committee,composed of several experts in performance

measurement and improvement from both

inside and outside the EMS community, is

also expected to be reviewing and prioritiz-

ing the first sets of performance measures.

Building Measures

But the bulk of the work for EMS Compass

has occurred between those meetings, when

dozens of volunteer members of the initia-

tives working groups have spent countless

hours designing, refining and testing themeasures.

When the EMS Compass Measurement

Design Group first gathered in Washing-

ton nearly a year ago, its members knew

they had a challenge before them. Since

then, they have helped create a measure-

ment design process that is transparent

and evidence-based, with opportunities

for members of the public to participate.

In addition, they have sifted through

hundreds of potential measures submitted

by the EMS community and present in the

literature, choosing the ones that EMS agen-cies can use to help them in their pursuit of

providing high-quality care to patients and

making a difference in their communities.

Choosing the vital few measures and

making sure we specify clear operational

definitions to know the data to include,

what to exclude and how to calculate the

measures are essential to ensuring EMS

agencies can use the measures to sup-

port improvement, says David Will iams,

PhD, executive director at the Institute

for Healthcare Improvement and chair ofthe EMS Compass Measurement Design

Group. Measurement is vital to knowing

how an agency is reliably delivering results

and whether efforts to improve processes

are moving their dots on their charts, and

EMS Compass will help provide a good place

for agencies to start to look at meaningful

process and outcome measures that can

enable them to focus on improvement and

reliability.

From the start, EMS Compass has

focused on using NEMSIS data points in

its measures when possible. Because NEM-SIS creates a standard for collecting EMS

patient data, the vast majority of U.S. EMS

agencies are gathering the same in forma-

tion on each patient. NEMSIS-compliant

electronic patient care reports (ePCRs)

also ensure that the data are stored in the

same way, so they can be sent to state and

national databases and used for research

and analysis.

But for EMS Compass, the NEMSIS stan-

dard also means that clinical performance

measures can be designed so that any agencyusing NEMSIS-compliant PCRs can use the

measures in the same way. They can even be

built into software that automatically pulls

the information from individual ePCRs and

calculates how an agency is performing on

a specific measure.

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To support EMS Compasss efforts to

design measures that can be automated

when using NEMSIS data, the project has

enlisted a group of volunteers from sev-

eral leading EMS technology and software

companies. Chaired by FirstWatch Product

Strategist Debbie Gilligan, the EMS Com-pass Technology Developers Group has

focused on matching the proposed perfor-

mance measures to NEMSIS data points,

and testing them to make sure EMS agen-

cies could implement the measures with the

EMS clinical data they already have.

The possibilities created by having elec-

tronic records, a uniform data standard, and

performance measures using that data are

pretty exciting, Gilligan says. Its been fun

to get in a room with people from all these

innovative companies who are in many wayscompetitors, but who all have one goal in

mindfinding ways to make it easier for

people to get more out of their data.

Building consensus around performance

measures is not easy, as many other areas

of healthcare have discovered. During the

EMS Compass process, the committee

members and project leaders have navi-

gated some complicated questions, from

what level of evidence review was needed

to which sources of data could be consid-

ered. Early on, it became clear that many

members of the initiative recognized some

key measuresclinical outcomeswould

rely on EMS agencies being able to access

data from outside sources, such as hospitals.Information should flow seamlessly

from prehospital care to hospital care and

back, Bass says. To me I see that as a really

important part of what were doingto say

heres the science, here are the measures,

heres the way it needs to be done.

At the same time, he acknowledged, most

EMS agencies continue to struggle to get

access to outcome information from hos-

pitals. Recognizing that, many of the mea-

sures were designed to serve as surrogate

measures that use data currently collected

by providers when they complete patientcare reports only until they are able to link

with hospital data to collect the complete

measures.

Maybe you have to do that initially just

so you get some baseline on the EMS pro-

cesses and start measuring, Bass says. But

we have to be willing to say that the right

way to measure performance often includes

patient outcomes, such as survival to dis-

charge for cardiac arrest. And maybe having

a measure that says that will help improve

the state of data-sharing between hospitalsand EMS systems.

Establishing a Foundation

Based on Evidence

Equally important to using available data

is creating measures that are based on the


Building consensus around

performance measures is not

easy, as many other areas of

healthcare have discovered.

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latest evidence and best practices in pre-

hospital care. The ultimate purpose of per-

formance measures is to improve patient

care and EMS practiceand therefore the

patient experience and outcomes. Perfor-

mance measures often drive programmatic

changes, so it was essential to the EMS

Compass leaders to only measure processes

that have a demonstrated positive impact.

For example, while measuring IV successrates has long been a standard for many

EMS performance management programs,

there has never been a proven association

between IV success rates and patient out-

comes. While it is clearly important that

paramedics can competently perform skills

they are expected to perform, EMS Com-

pass leaders chose to focus on measures

linked to patient outcomes, such as the abil-

ity to accurately identify stroke patients, or

administration of aspirin for heart attack

victims. Members of the initiative looked

to sources such as American Heart Asso-ciation guidelines and articles published

in the peer-reviewed medical literature to

ensure the EMS Compass measures would

be assessing evidence-based practices.

A key opportunity in improvement is

to use measurement to support EMS sys-

tems to reliably deliver evidence-based

care, Williams says. Not measuring the

care processes that matter will not improve

outcomes.

Focus on Local ImprovementEMS Compass leaders say the initiative is

focused solely on creating measures that

support systems to improve care, and the

project has no ability or authority to require

agencies to use or report the measures. But

with changes to healthcare funding occur-

ring across the industry, many members of

the EMS community and EMS Compass

team have acknowledged that in the future,

healthcare payers, local governments and

other entities may look for additional mea-

sures to use to assess EMS payments or hold

systems accountablein a sense, this isalready happening in cities across the coun-

try that have response time requirements

tied to contract payments for EMS services.

If insurance companies and the U.S. Centers

for Medicare and Medicaid Services (CMS)

later link payments to performance, some

EMS leaders argue, itd be better for them to

use measures developed by the EMS com-

munity and based on solid medical research.

Our goal is to create evidence-based

measures that support the improvement of

the quality of care at the local level, period,says Dia Gainor, executive director of NAS-

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and building consensus around measures

was a priority for the initiative, regardless of

potential other uses of the measures. From

the start, EMS Compass has involved dozens

of EMTs, paramedics, educators, adminis-

trators, medical directors and other experts

on its various committees. The steeringcommittee also included several experts

from outside EMS, including Kedar Mate,

MD, a physician and improvement expert

with the Institute for Healthcare Improve-

ment (IHI); Patria de Lancer Julnes, PhD,

a performance measurement expert and

researcher at Penn State Harrisburg; Todd

Olmsted, PhD, a health economist at the

University of Texas; and Martha Hayward,

a patient advocate with IHI.

A Community EffortBeyond the impressive roster direct ly asso-

ciated with the project are the dozens of

individuals and agencies who submitted

measures during the public call for mea-

sures. In order to be as open and inclusive

as possible, EMS Compass began its mea-

surement design process by asking members

of the public to submit ideas for measures.

The response exceeded even the expecta-

tions of the initiatives leaders when they

received more than 400 submissions.

From the beginning, Ive been receiving

so many e-mails, seeing great turnout atmeetings, hearing from so many different

members of the EMS community, says Nick

Nudell, the EMS Compass project manager.

Its exciting to see so many people engaged

and interested in contributing.Since then, EMS Compass has hosted

several webinars and conference sessions

to share information and receive feedback,

and the proposed measures are all avail-

able for public comment on the initiatives

website, emscompass.org, prior to review by

the steering committee. EMS Compass has

also encouraged agencies to test the specific

measures to ensure that agencies are able to

access the data and calculate the measures

as intended.

Even with a process that is so focused on

inclusiveness and evidence and testing, it isclear that EMS performance measures cre-

ated today cannot be thought of as perma-

nent. As research reveals new findings and

different data becomes available, the EMS

community must be willing to adapt and

re-evaluate performance measures. What

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specific measures, is a process for devel-

oping and revisiting measures. The mem-

bers of the EMS Compass team hope that

the process theyve createdbased largely

on the model used by the National Qual-ity Forum and the larger healthcare com-

munitywill be used in the future by the

EMS profession to develop new measures,

to reassess old measures and ensure that

EMS agencies continue to have the tools

they need to support improvement.

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It is clear that EMS performance

measures created today cannot be

thought of as permanent.

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The real legacy of EMS Compass, and

our main measure for knowing it is a suc-

cess, will be a culture of performance

improvement across EMS, from volunteers

in the smallest rural agencies to chiefs in the

busiest urban departments, Gainor says.

Everyone in EMS shares the same goalproviding the best care to our patientsand

EMS Compass will help us do just that.

In fact, creating a sustainable process f

619215-jan-2016

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