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	Southern Tier Regional Emergency Medical Services Council

I. Guidelines for Prehospital Provider Services

Service specific quality improvement activity should be conducted by the most capable person(s) available within each service. The development of the QI process begins with the identification of the service's Reviewer.

The Service Reviewer has available resources such as:

1. Existing protocols and standards
2. The EMS QI Coordinator at your primary receiving hospital
3. Your service and/or system Medical Director
4. Prehospital Care Reports (PCRs)
5. Service specific data available from the State PCR System
6. Field supervision by experienced personnel
7. Education curricula
8. OSHA Regulations, Worker's Compensation, etc.
9. Cobra
10. Article 30
11. 405.19 regulations
12. Part 800
13. Part 80
14. Title 10, Part 708

A basic tool for any prehospital QI program is PCR review. This is called retrospective review and is the easiest to implement.

To begin, the QI Reviewer should select specific indicators that will be reviewed on a regular basis. These indicators will cause certain PCRs to "fall out".

The basic list of indicators that trigger review will be established by the Regional QI Committee in cooperation with STREMAC. Some examples of review indicators are:

1. *All pediatric transports age 6 and under
2. Medical control/service request
3. *Cardiac arrest
4. *Multiple trauma
5. Shock of any origin
6. Unconscious/unknown cause
7. Heart rate less than 60 or greater than 120
8. BP greater that 160/90 or less than 90 systolic
9. Respirations greater than 28 or less than 12
10. Service/provider/patient/family/hospital complaint
11. Protocol deviation
12. *GCS <13
13. Any other issue of concern

*These are the minimum identifiers as established by Regional QI and STREMAC. The frequency of review is determined by the Area QI Committee, with approval of the Regional QI Committee, and can be based on frequency of runs, types of runs, number of personnel, etc. However, formal interaction between the base hospital and the service should occur on at least a quarterly basis.

Once the PCRs are identified to be reviewed from your list of indicators, the QI Reviewer will be assessing such things as:

1. Appropriateness of care: the degree to which the correct care is provided given the current state of the art. Are written protocols current? Was there any deviation from written protocol?
2. Continuity of care: the degree to which the care needed by patients is coordinated among providers and across organizations and time. Was medical control contacted appropriately?
3. Timeliness of care: the degree to which care is provided to patients when it is needed. Was on-scene time less than 20 minutes?

As the service QI Reviewers begin to ask questions about the system and identify areas of concern, they can turn to the many resources described above. In particular, the primary receiving hospital can provide data, education and expertise in problem solving.

QI is an ongoing activity, including regular periodic review. The process described above will help each service document its care, provide constructive feedback, identify deficiencies and improve performance through appropriate inservice programs. From a medical-legal perspective, such a program will reduce risk by reinforcing the delivery of appropriate care. More importantly, from the patient perspective, your efforts will contribute to the overall goal of EMS: reducing death and disability.

In addition to regular review of the service list of indicators, periodic review of such things as all patients with chest pain, all pedestrian injuries or diabetic problems might be selected for a focused study (see form #4 for a tool). Follow the steps listed below for the review process, use approved review forms and proceed from there.

The basic steps for review are:

1. Selecting a subject for study, which includes an operational definition of the condition or procedure under study and a definition of patients to be included.
2. Developing criteria and standards, defining acceptable levels of quality.
3. Collecting data.
4. Comparing data to criteria and standards in order to identify areas of excellence and deficiencies.
5. Determining causes of deficiencies and taking corrective action, including:
1. determining who or what is expected to change
2. determining who is responsible for implementing action
3. determining what action is appropriate, and
4. determining when it is expected to occur.
6. F. Evaluating the study.
   Focused studies are done as a need arises, not on a regular basis. For example, perhaps there is a concern over cardiac patients not being given O2 as per protocol You might pull all PCRs on cardiac patients for a 3 month period. Look to see if O2 was administered in all cases. If not, what percentage did not receive O2. If your acceptable level of practice as determined beforehand is 100% and compliance in your study is only 80%, then you must inservice your personnel, send out a memo, post notices, contact service medical director, etc. Then, after a preestablished period of time, you must complete a similar review to see if compliance has improved. Quality Improvement is a way of looking at improving care, not finding problems for punitive action. Proposals for any focused study should be approved by the Area and Regional QI Committees to identify opportunities for Region-wide focused studies and to avoid duplication.