Quality Corner: Part 3--What Is Quality Care?

Every book written on the subject of quality invariably includes either a generic textbook definition or an author's unique personal description of the concept. So, here's mine: Quality patient care is simply providing the best patient care within your capability. And given that our profession is one of the few in which matters truly are life and death, we have no less moral obligation than physicians to constantly strive to improve that capability. The ultimate goal of high-quality patient care is for every patient, from the cardiac arrest to the lift assist, to receive the full benefit of your training, experience and skills within the scope of your practice.

There's obviously no magic attached to my definition of quality patient care. It's perfectly acceptable and might not even be a bad idea to come up with your own. Achieving success is much easier if you define what success is, or at least set some benchmarks or goals you'd like to achieve.

Early ALS: The Best Insurance

I've found in my experience as a quality improvement coordinator that early advanced life support monitoring and IV access are the best insurance against unanticipated problems for at-risk patients. At-risk patients are those patients who are not obviously critical upon your arrival, but who have the potential to degenerate based on significant past medical history, abnormal vital signs or, most commonly, a red flag in their HPI (history of present illness). These are the patients who, from time to time, will unexpectedly crash on you after you downgrade their care to a basic life support ride or after you drop them at the ER--or, even worse, the patients you allow to refuse treatment/transport without a good-faith effort to convince them of the need for a more thorough assessment by a physician, and who consequently end up right back in the system an hour or so later, typically for something that now is a full-blown medical emergency.

Every medic, including me, has boasted of our superhuman power to tell if a patient is sick by just a glance across the room. Many times you can--but not always. Anyone who has been in EMS for any length of time has had that patient who seemed to be perfectly fine, with normal vital signs and a good general appearance, whom they ended up transporting BLS, only to see them unexpectedly crash en route to the hospital. If this has happened to you, hopefully you asked yourself whether you might have missed something along the way. Maybe it wasn't a vital sign or anything tangible at the moment of your assessment. The only clue may have been nothing more than the original reason the patient called 9-1-1--they fainted briefly, suddenly felt weak or fatigued, or experienced a sudden episode of nausea and broke out in a sweat. Many times, by the time you arrive on scene, the original episode may have resolved, or the patient fully recovered. They could be back to feeling perfectly fine, with normal vital signs.

But pathology is a dynamic process. Onset can be acute or chronic; things can progress continuously, or symptoms may come and go. Sometimes one brief episode of symptoms may be the only warning you get of significant underlying problem. Therefore, anyone who is concerned enough to call 9-1-1 should be taken seriously and assessed objectively, even if their complaint or symptoms don't make perfect sense to you at the time. Physician Richard Rathgeber, DO, of Doylestown Hospital in Pennsylvania, summed up the importance of assessing the atypical patient complaint for me not long ago: "If a patient tells me Martians are landing, I start looking for spaceships."

Index of Suspicion

Being an EMS provider requires a certain degree of detective work. You can never assume anything on face value. How many times have you been dispatched for one reason and found the actual nature of the call to be something completely different? I more than once have been dispatched for a fall victim, only to arrive on scene of a cardiac arrest. Opposite ends of the medical spectrum, but cardiac arrests do tend to fall, so not a totally inaccurate dispatch.

The gold standard of EMS is to overtriage to ALS for medical patients for the same reason we overtriage trauma patients to trauma centers: so we don't miss anything. Obvious life threats are...well, obvious; many other life threats are not. The goal of progressive EMS, just as Johnny and Roy once explained to a patient, is to "bring the hospital to the patient," rather than making the patient wait and suffer more, untreated, during transport.

If you're a quality coordinator who has discovered or developed a successful quality care initiative or program, write it up and share your brilliance with the rest of EMS as a guest columnist at Quality Corner. Submissions should be about 900 words, and please also include a short biography and head shot. Remember, none of us are as smart as all of us.

Joe Hayes, NREMT-P, is deputy chief of the Bucks County Rescue Squad in Bristol, PA, and a staff medic at Central Bucks Ambulance in Doylestown. He is the quality improvement coordinator for both of these midsize third-service EMS agencies in northeastern Pennsylvania. He has 30 years' experience in EMS. Contact Joe at jhayes763@yahoo.com