Contra Costa Health Services EMS QI Data Summary

Annual Report: 2007

EMS QI Program (EQIP)Mission Statement

To ensure that quality emergency medical services are available for all people in Contra Costa County and that emergency medical care is consistent with best practices and evidence based medicine.

From Bricks to Road

Our EMS Performance Yellow Brick Road!

“Creating a Culture of Safety”

PatientsProvidersStakeholders

Who is involved?

EMS Agency Base-Trauma Center Emergency Dispatch BLS/ALS First

Responders Ground Ambulance Air Transport Receiving Facilities

First Responders

ALS Transport

Dispatch

Emergency Department

Patient

Contra Costa County Emergency Medical Services

Quality Improvement Program(EQIP)

EQIP Partnership

Contra Costa EMS QI Program Partnership

Question: How are we doing?

Answer:

What we do right!

Strong Commitment to Making Things Better

Great Environment to Solve Problems!

What did QI do in 2007?

A productive year of accomplishments!

Core EQIP Indicator Reports “Our EMS System Vital Signs” Utstein Report/Cardiac

Arrest Pediatric Report Documentation Trauma and Trauma Triage Patient Safety Reporting Airway Management Infrequent Skills (new) Medication Report

Chest Pain/STEMI Pain Evaluation & Treatment Shortness of Breath Destination Report AMA/Patient Refusal General Activity (Dispatch) Customer Satisfaction

QI Data Collection & Reporting

2007 22 QI studies

2003-200610 QI studies

2008Zoll Integration

First Responder View

Full View

of EMS

System Performance

Challenges Ahead•Data Warehouse

•Dispatch Integration

•ECG Transmission

•CARES Mapping

•CEMSIS Integration

•Report Automation

•Managing the Data Overload

•Long Term: ePCR push into Facility MEDRec

EMS Event (Patient Safety) Reporting2007 Summary Highlights

60% of reports come from our own EMS provider agencies

Analysis: Cooperation and Accountability!

60% of our EMS events communication related

Strategy: Focus is on root causes not symptoms!

Event Type # %

Communication 24 60%

Medication 7 17.5%

Destination 13 32.5%

Patient Care 36 90%

Billing 1 2.5%

Documentation-ePCR

14 35%

Response Time 12 30%

High Risk Communication

Patient Handoffs (CCCEMS 2006 Annual Report)

> 102,000 handoffs Up 20% from 2005

2008 Goal Improve handoff

communication

Paramedic EMS Patient Safety Practices

88-94% know use of weight charts/tapes improve safety but 14.5% did not always use.

3.4% reported a safety event in the last 3 years while 30 % did not.

11.5% no cross-checking during med handoffs.

29% stated Anonymous reporting would increase patient safety reporting.

CCCEMS data: Sept-Dec 2007 119 surveys (27% return rate)

EMS Patient Satisfaction

4685 responses 4.5% return rate 4 question survey

Confidence in skills Communication Service Comfort & pain control)

Positive responses 92% Neutral 3.5% Negative 4.5%

AMR Jan-Sept 2007

Ingestion Treatment AuditCharcoal Use and ALOC

Retrospective sample 2007 Results (41 cases)

87% Cases had charcoal given or attempted

86% no improvement or change 40% had GCS <15 or

deteriorated after charcoal

Evaluation: Charcoal Risk > Benefit

QI outcome: Elimination of charcoal in treatment guidelines to improve patient safety

DocumentationDelivery and Completion

Zoll 36-86% compliance

MEDS Improved 17% since Jan 2007 Fax delivery 99.7% effective

QI Expectation : Draft/complete ePCR with patient delivery.

Many challenges….slower progress

2007 Field Competency: Skills

How do we maintain competency?

Skill # attempts Success per Attempts

Historical

Data

Benchmarks

IV 28626 82% - -

Intubation 371 65% 70-83% 80-90%

Combitube 143 83% 70-89% -

External Jugular 111 66% - -

IO 24 100% - -

Thoracostomy 17 100% - -

Ranked in order of frequency

AMR Data from Jan-Dec 2007, Historical studies multi agency 2003-2006

Field Medication Utilization: Furosemide or Lasix

Monthly Furosemide Uses and Pulmonary Edema Impressions 2005-2007

0

10

20

30

40

50

60

70

80

90

100

Jan-0

5

Feb-0

5

Mar-

05

Apr-

05

May-

05

Jun-0

5

Jul-05

Aug-0

5

Sep-0

5

Oct

-05

Nov-

05

Dec-

05

Jan-0

6

Feb-0

6

Mar-

06

Apr-

06

May-

06

Jun-0

6

Jul-06

Aug-0

6

Sep-0

6

Oct

-06

Nov-

06

Dec-

06

Jan-0

7

Feb-0

7

Mar-

07

Apr-

07

May-

07

Jun-0

7

Jul-07

Aug-0

7

Use

s

Furosemide Uses Pulmonary Edema Impressions

Percentage Furosemide Use in Pulmonary Edema

0%

10%

20%

30%

40%

50%

60%

Jan-0

5

Feb-0

5

Mar-

05

Apr-

05

May-

05

Jun-0

5

Jul-05

Aug-0

5

Sep-0

5

Oct

-05

Nov-

05

Dec-

05

Jan-0

6

Feb-0

6

Mar-

06

Apr-

06

May-

06

Jun-0

6

Jul-06

Aug-0

6

Sep-0

6

Oct

-06

Nov-

06

Dec-

06

Jan-0

7

Feb-0

7

Mar-

07

Apr-

07

May-

07

Jun-0

7

Jul-07

Aug-0

7

Monthly Furosemide UsesPulmonary Edema vs. Other Paramedic Impressions

0

5

10

15

20

25

30

35

40

Jan-0

5

Feb

-05

Ma

r-05

Apr-

05

Ma

y-05

Jun-0

5

Jul-05

Aug-0

5

Sep-0

5

Oct

-05

No

v-0

5

De

c-0

5

Jan-0

6

Feb

-06

Ma

r-06

Apr-

06

Ma

y-06

Jun-0

6

Jul-06

Aug-0

6

Sep-0

6

Oct

-06

No

v-0

6

De

c-0

6

Jan-0

7

Feb

-07

Ma

r-07

Apr-

07

Ma

y-07

Jun-0

7

Jul-07

Aug-0

7

Pulmonary Edema Uses Uses - Other Impressions

Monthly Furosemide Uses 2004-2007

0

5

10

15

20

25

30

35

40

45

Pain Assessment and Management

Increased Usage of MorphineIn Blunt Trauma, Non-Trauma, and Abdominal Pain

0

20

40

60

80

100

120

140

Ja

n-0

4

Feb

-04

Mar-

04

Apr-

04

May-0

4

Ju

n-0

4

Ju

l-04

Aug

-04

Sep-0

4

Oct-04

No

v-0

4

Dec-0

4

Ja

n-0

5

Feb

-05

Mar-

05

Apr-

05

May-0

5

Ju

n-0

5

Ju

l-05

Aug

-05

Sep-0

5

Oct-05

No

v-0

5

Dec-0

5

Ja

n-0

6

Feb

-06

Mar-

06

Apr-

06

May-0

6

Ju

n-0

6

Ju

l-06

Aug

-06

Blunt Injury Non-traumatic body pain Abdominal Pain

Top 4 Paramedic Impressions Receiving Morphine

0

10

20

30

40

50

60

70

80

90

100

Jan-0

5

Feb-0

5

Mar-

05

Apr-

05

May-

05

Jun-0

5

Jul-05

Aug-0

5

Sep-0

5

Oct

-05

Nov-

05

Dec-

05

Jan-0

6

Feb-0

6

Mar-

06

Apr-

06

May-

06

Jun-0

6

Jul-06

Aug-0

6

Sep-0

6

Oct

-06

Nov-

06

Dec-

06

Jan-0

7

Feb-0

7

Mar-

07

Apr-

07

May-

07

Jun-0

7

Jul-07

Aug-0

7

Blunt Injury Non-traumatic body pain Abdominal Pain Chest Pain - suspected cardiac origin

Trauma Advanced AirwayEndotracheal Intubation Success - Trauma Airways

33.3%

50.0%

59.3%

49.5%

0%

10%

20%

30%

40%

50%

60%

70%

Perfusing Rhythm Pre-Arrest Arrest Overall

Clinical Setting

N = 36 N = 59N = 10 N = 105

Mortality - Trauma Patients with Perfusing RhythmsBy Final Paramedic Airway Technique

90.9%94.4%

50.0%

69.4%

100.0%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

EndotrachealIntubation

Combitube All AdvancedAirways

Failed AdvancedAirway

Overall

N = 11 N = 7 N = 18 N = 16 N = 34

Clinical Setting - Trauma - Advanced Airways

Traumatic Arrest56%

Non-Arrest - Perfusing Rhythm

34%

Pre-Arrest (CPR within 3

minutes)10%

Initial Advanced Airway InterventionTrauma Patients (N = 105)

Oral ET Intubation90.5%

Combitube9.5%

12 Lead Field UtilizationSce ne T ime - C he st Pain Suspe cte d C ardiac

H ow has 12 le ad affe cte d sce ne time s

15.916.6

14.9

5.0

7.0

9.0

11.0

13.0

15.0

17.0

19.0

2007 - A ll CP P atients 2007 - 12-Lead Done 2005 - A ll CP P atients

ECG Done - Che st Pain - Suspe cte d Cardiac O rigin

ECG Not Done49% T otal w ith ECG

done51%

Param e dic Im pre ssion - ECG Done

Other16%

A LOC4%

Respiratory non-spec if ic

4%

Cardiac non-spec if ic5%

Near Syncope Sy ncope

8%

Ches t Pain - Suspec t Cardiac Origin

40%

Ches t Pain - Non-spec if ic

12%

Weak/Sic k Dizz y /Nausea

11%

ECG Re adings Docume nte d - All 12-Le ad Patie nts

Results Documented

65%

Not Documented

35%

Chest Pain

C he st Pain - Asse ssme nt and T re atme nt

91%

76%85%

7%

50%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

P ain S caleDocum ented

Oxygenadm inis tration

A S A NTG M orphine

Parame dic Impre ssions - Patie nts G iv e n Aspirin - Q 1 2007

C hes t pain - non-spec ific

14%

C ardiac - non spec ific

4%

O ther10%

C hes t pain - suspec t cardiac

72%

Field Airway ManagementIntubation Succe ss Rate s

77%

79%

82%

43%

63%

88%

40%

33%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

A ll Intubations (106/137)

A ll A rres ts (96/121)

Cardiac or Respiratory A rres t (93/114)

Traum atic A rres t (3/7)

A ll Non-A rres t (10/16)

Respiratory Non-A rres t (7/8)

A LOC Non-A rres t (2/5)

Traum a Non-A rres t (1/3)

C u mu lative Su ccess - ET In tu bation

40%

59%

71%77%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

1 A ttem pt 2 A ttem pts 3 A ttem pts > 3 A ttem pts

Airw ay Management - ET or C ombitube Attempted

Intubation Initially77%

Com bitube After ET Failure

15%

No Advanced Airway

7%

Com bitube Initially (No ET)

1%

Parame dic Impre ssion - Intubation - Non-Arre st

A LOC31%

Traum a19%

Respiratory50%

AMR First Quarter 2007

EMS for Children Performance Indicators

EMS-C Indicator Total

N

CCCEMS

compliance

EMSA QI

Benchmark

Weight Documented 806 89% 90%

ALOC & Glucose Monitoring 14 71% 80%

ALOC & Hypoglycemia treated 0 - 80%

First Epinephrine dose correct by weight 5 67% 97%

Valium/Versed dosing correct by weight 5 80% 80%

Vascular Access and IO and trauma 287 69% 80%

Pain assessment and pain scale documented

36 5% 80%

AMR Jun-Aug 2006 (EMSC CQI Validation Study 2007)

Kids Needing EMSPrimary Impression <3y 3-7y 8-13y 14-18y Total

N %1. Blunt Injury 57 92 143 293 585 30.8%

2. Behavioral Disturbance

0 3 55 208 266 14.0%

3. Post-Seizure Seizure Status Epilepticus

95 37 31 32 195 10.2%

Total pediatric patients seen by 911

289 273 380 959 1901 55%

55 % children seen by 911 due to 3 conditions

105 pediatric patients/month (<18 yrs)

52 pediatric patients/month (<14) AMR Dec 2005-May 2007

Pediatric Field Skills Success

Procedure <3 yr 3-14 yr 15-18 yr 0-18 yr

60%

185

78%

743

88% 1971

75%

2899

13%

8

27%

17

26% 23

22%

48

86%

8

75%

7

0% 0

80%

15• 129 pedi-procedure attempts per month

• 0.7 pedi-procedure attempts per medic per monthAMR Dec 2005-Dec 2007

Goals 2008

• Improve QI information exchange

• Patient Safety• Handoff communication• QI Tool Implementation

• EMS Events• QI Activity Reports

• Standardization

• Full compliance with Title 22 QI

• Improve Field Care• STEMI• Pediatrics• Pain• Skills Success

On our way …..

Questions?