Quality Improvement Part 2: Concurrent Review

   This is the second of a three-part series of articles that reviews the three components of a QI program and shows how each was successfully administered at Bucks County Rescue Squad and Central Bucks Ambulance--two midsized EMS agencies in southeastern Pennsylvania. Last month, we reviewed retrospective review. This month, we look at concurrent review.

   Any truly efficient quality improvement program needs to be active and engaged before, during and after the call.

   While retrospective quality review is an important part of the quality improvement process, it should not be the whole process. Theoretically, you could write a PCR for a totally fictitious call without ever leaving your seat. As long as you didn't document anything too bizarre, probably no one would ever question it. To really understand what's going on in your agency, you have to go beyond reading PCRs after the fact.

   Imagine an EMS crew getting the dreaded "10 minutes before the end of shift call" from a patient who just needs to be picked up off the floor and put back in her chair. The patient denies any complaints, there are no bones sticking through the skin, but department policy states vital signs must be taken on every patient, so what's the problem with just guesstimating them? It'll save a couple of minutes. If you don't look, you won't find anything that could bog you down with time-consuming treatments, so why not?

   To the expert EMS provider's eye, the patient looks like a pulse rate of...oh, say 80, a blood pressure of 120/70 and a respiratory rate of 12, so sign here and away we go. The patient gets exactly what she asked for, the agency is saved the expense of overtime, the providers get out of work on time and everybody's happy. Until the oncoming crew gets dispatched back to the same address an hour later for the same patient who fell again--this time resulting in a life-altering and possibly life-ending hip fracture.

   The new crew, a captive audience for the next 12 hours, has more than enough time to actually check vital signs, especially now that she is an obviously treatable patient. Lo and behold, they discover a pulse rate of 32. Hooking the patient up to a cardiac monitor reveals something unusual: There are P waves before most QRS complexes, but every once in a while, the P wave seems to be missing, along with the rest of the cardiac cycle, resulting in an extended period of asystole, typically followed by a ventricular escape beat. Eventually, but belatedly, a P wave does return. This ultimately ends up being diagnosed as sinus arrest or sick sinus syndrome, most likely resulting in a temporary decrease in level of consciousness and probably causing the several falls the patient has suffered lately. The same decreased perfusion that caused the falls could also affect the patient's sensorium, so she may not have been aware if she had blacked out briefly or suddenly became weak or dizzy. Had the first crew done its job and simply taken a standard set of vital signs, even though it meant getting home a little late, the patient may have been spared her current serious injury.

THE VALUE OF CONCURRENT QI

   Concurrent QI is where the quality coordinator, medical director or other EMS officers get out on the street to see what's going on. One mistaken concept is that there's little reason to do this, since the providers won't do anything wrong if they know they're being watched. Despite the fact that people often do a better job if they know they're being watched, not every deficiency in EMS is malicious. There are many problems or opportunities for improvement in EMS that could be due to lack of objective third-party evaluation and modification. Many real-world issues could not be imagined by supervisors or medical directors sitting in the sanctuary of their offices. The only way to see what's going on in the streets is to get out and observe it first-hand.

   David Jaslow, MD, MPH, FAAEM, medical director for Bucks County Rescue Squad, occasionally responds to calls to assist and evaluate patient care by EMS providers. On these responses, he observed that paramedics were not always taking a cardiac monitor into patients' homes and argued that the cardiac monitor is the only piece of equipment we carry that can save a patient's life, by virtue of its defibrillator component. Leaving the monitor in the ambulance, he says, is akin to a firefighter leaving the hose line on the engine or the police officer leaving his gun in the patrol car.

   Lending credence to Dr. Jaslow's point is that in addition to the two-lead cardiac monitor and defibrillator, the newer generation of monitors are now, for all intents and purposes, complete patient assessment packages that possess the capability to take and record blood pressure, pulse oximetry, 12-lead EKG and capnography. This is pretty much all of the data we need, other than the general impression while actually feeling a pulse and noting skin color and temperature during a rapid patient assessment. This was an issue no one would ever have identified while sitting in a room reading PCRs.

   There are several ways to do concurrent quality auditing, depending upon your position within the system, your availability and the flexibility of the system. If you hold an officer's position with supervisor status, you may have the ability to respond to scenes in a supervisor's vehicle. Officers in most systems do this, but it's frequently restricted to fire calls, hazmat, mass casualty incidents or other long-duration events and, as with the retrospective review, only high-intensity, high-profile calls are audited.

   While MCIs and long-duration incidents clearly do require more on-site management than single-patient calls, the point is that supervision, management and quality auditing should not be strictly limited to those types of calls. In the grand scheme of things, MCIs and long-duration incidents represent only a small percentage of EMS calls, but frequently end up getting 100% of supervisors' attention. Regardless of the business you're in, any operation that is mostly unsupervised is highly likely to have widespread and ongoing problems, especially if it has been a longstanding practice, as is the case in many EMS systems.

   Emergent supervisory response is not necessary for quality auditing of single-patient calls. Whether you "happen to be in the neighborhood" or just "wanted to get out of the office," you can stop by to see how things are going. It's a well-known fact that two-person EMS units, typical of most systems nowadays, are not sufficient for all types of calls. Depending upon your system, your crews may occasionally need to call an engine company or second unit to assist on cardiac arrests, bariatric patients or other difficult calls. Other times, crews may opt to do the best they can on their own. If your increased involvement is billed as a kinder, gentler supervision, there's a good chance your offer of assistance on scene will be welcomed with open arms. You can assist and audit patient care at the same time.

   Some systems mandate the quality coordinator ride one shift per year with each provider. This is more intrusive and obvious than showing up to offer help and observing providers in their natural habitat. As a supervisor or quality coordinator, if you ride a shift with a provider, chances are you won't witness totally normal behavior. But, as previously mentioned, many problems discovered during concurrent quality audits are not intentional--they're simply the result of poor or inefficient practices that have been perpetuated over the years. Concurrent quality evaluations can provide an opportunity to see where there is a need for improvement of efficiency or safety that may only be apparent to a neutral observer viewing the big picture.

   Next month we will review the third component of a QI program--prospective or pre-call quality improvement.

   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, PA. Contact him at jhayes763@yahoo.com.