Quality Corner--Part 10: The Two-Minute EMS Challenge

 As quality coordinator for Bucks County Rescue Squad—a medium-sized, third service EMS agency in southeastern Pennsylvania—about a year ago I made a major discovery in the realm of concurrent quality improvement when I decided to jump aboard the ambulance and take in a few calls with the duty crew. I told the crew I needed to get out of the office and was going to tag along, adding that I’d be their go-fer and offering my services for whatever they wanted. “Great,” one provider replied, his tone betraying more his sense of resignation than appreciation. I had predetermined that I would resist all temptation to do anything other than observe unless specifically asked.

A little more than an hour into the shift, the medic unit was dispatched for a patient with syncope. Shortly thereafter, we pulled up to the front of a single-family dwelling. The crew grabbed the cardiac monitor, O₂ and jump kit, and up the steps and in the front door they went. I trailed behind, posting myself at the doorway to take in the scene. The crew placed their equipment on either side of the 45-year-old female sitting on the sofa, who did not appear to be in any obvious distress. “I was cleaning the house and all of a sudden got very dizzy and weak and felt like I was going to pass out,” she offered.

Medic No. 1 felt for a radial pulse while No. 2 asked if she was having any chest pain or shortness of breath. The patient denied chest pains or any additional complaints other than still “feeling a little shaky.” Medic 2 then asked the patient if she had any past medical history, while Medic 1 took his turn palpating the opposite radial pulse. The patient replied that she had hypertension and high cholesterol, as she handed Medic 2 three prescription bottles of medicine. He wrote down her meds, and he and his partner continued taking turns asking a few additional questions. After several minutes, Medic 1 suggested they move to the ambulance.

The medics collected their unused equipment and escorted the patient outside. We all climbed into the ambulance, and the patient was directed to the litter. Nine minutes after initial patient contact, a full set of vital signs was finally taken. Her pulse rate was 96, BP 138/68, respiratory rate 18, SPO₂ 96%, and a normal sinus rhythm was displayed on the cardiac monitor. A 12-lead ECG was negative for ischemia or injury. In this case, no critical medical problem was found; however, the inefficiency of the crews’ initial patient assessment, duplication of effort and several minutes of wasted time were striking.

Over the next few weeks, I audited several more calls with our squad and observed some calls with surrounding agencies. Much to my surprise, the inefficiency and lack of any organized effort by EMS crews was more common than I could ever have imagined.

What a great opportunity to improve patient care by way of the first and single most important component of patient care—the initial patient assessment—and all while making the job quicker and easier for the providers. The fix was simple: pre-defined roles and teamwork.

Taking a New Approach

My wonderfully supportive and long-enduring EMT partner Mary Wallover agreed to yet another of my harebrained schemes. This one, however, she quickly recognized had potential. It was decided that for advanced life support calls, Mary would obtain a full set of vital signs and attach the cardiac monitor and pulse ox, while I took a history and performed an exam.

A decade ago, cardiac monitors displayed cardiac rhythms and included a defibrillator, and that was it. Today, most cardiac monitors used by EMS are for all intents and purposes complete patient assessment packages capable of obtaining heart rate, noninvasive blood pressure, pulse oximetry and cardiac rhythm. Some monitors even provide respiratory rate acquired through one of the ECG electrodes.

For my part, I would note the general impression, skin color, respiratory effort, feel for the quality and rate of the pulse, check capillary refill, inquire about the OPQRST (Onset, Provocation/Palliation, Quality, Radiation, Severity and Time of onset), and perform a focused exam based on the chief compliant, auscultate lung sounds for respiratory distress, palpate the abdomen for abdominal pain, etc.

This model of patient assessment can be applied despite the crew configuration, whether EMT and paramedic or dual medics, and whether each crew member has the same role on every call or their roles alternate. The key points to this team approach of patient assessment are predetermined roles and initiation of an organized, coordinated assessment.

So we hit the streets with our new efficiency program ready to go. After the very first call it was apparent that we were getting a lot more done, a lot quicker and with less effort. And since our assessment was no longer haphazard or fragmented, whereby a key piece of information could be missed, it was now comprehensive, so each vital sign or piece of information acquired, when put together, painted a more complete and accurate picture of the patient’s true condition. Within two minutes we knew everything we initially needed to know about the patient, mainly whether the patient was critical or potentially critical, required immediate intervention or, as in most cases, could wait for any interventions to be initiated until we were in the ambulance or en route to the hospital. This coordinated team approach to rapid patient assessment is what I’ve come to call the Two Minute EMS Challenge.

Introducing the New Standards

At our next medical command reauthorization, we rolled out our new standard of care mandating rapid, coordinated patient assessment to be initiated as soon as possible after making patient contact—a standard proven to be as timesaving and convenient for the providers as it is efficient and potentially lifesaving for patients.

Of course, the one reliable factor with any change in standards or procedures that you can bank on is resistance to that change. It’s human nature and is the reason managers, supervisors and EMS officers will always have job security. As quality coordinator, I have always encouraged error reporting as a non-punitive function. As many times in the past, the benefit of this policy again became apparent. Within two weeks of implementation, two different providers came forward to admit they deviated from the new standard, only to get bit by it in the end.

The first case was dispatched as a respiratory distress. The crew arrived to find a conscious and alert 61-year-old male who had been experiencing shortness of breath for about a week. He presented with what the provider described as mild shortness of breath. The crew acquired a radial pulse of 80, blood pressure of 148/90 and respiratory rate estimated to be about 20 per minute. The providers admitted to not applying the cardiac monitor or pulse ox, since they felt they had already identified the problem. They placed the patient on 4 liters of O₂ via nasal cannula and moved the patient to the ambulance. Once in the ambulance—nine minutes after initial patient contact—the pulse ox was applied and the SPO₂ was discovered to be 78%. Considering that 78% was after 4 liters of O₂ had already been administered, this patient was obviously severely hypoxic and was quickly, but belatedly, switched to high-flow O₂. The provider acknowledged a lesson learned.

The second case was dispatched as an emergency transportation. The crew arrived to find a 52-year-old male complaining of generalized weakness. This provider also admitted to not initially attaching the cardiac monitor to the patient, because the patient “did not appear to be in any distress.” The patient’s skin color was good, respiratory rate was 16 and BP was 132/68. The radial pulse was weak, but felt like about 112, so attaching the cardiac monitor was deferred until he was moved to the ambulance. Once in the ambulance, the rest of the assessment was performed—10 minutes after initial patient contact. Lo and behold, the patient was discovered to be in SVT at a rate of 200/min. The radial pulse taken by the provider, while an honest observation, was inaccurate due to the fact that at very fast rates, every heartbeat may not produce a palpable pulse.

These two cases, both coming within just two weeks of implementing our mandate for rapid, coordinated patient assessment, underscored perfectly the validity of that standard. But, more importantly, for the providers who deviated from the standard of care, it confirmed the importance of the initial patient assessment.

In this age of evidence-based medicine, where statistical proof is required to validate any recommendation, statistically proving that patients who receive a rapid comprehensive assessment are better off than those who receive a delayed or incomplete assessment seems difficult, if not impossible, for a non-academic like me. But I’m pretty sure, at this point, most people—EMS management, the rest of medicine and the public at large—all assume that efficient initial assessments are already being done. The importance of such an assessment would seem to speak for itself. I would also point to a corollary in trauma care: the golden hour. While some controversy exists, it is a generally accepted standard that the quicker you get trauma patients to an appropriate facility, the better they will fare. Similarly, the quicker you identify and begin treating critically ill patients, the better their outcome will likely be.

For the statistical wonks, I can report the findings of a rudimentary time comparison of before and after initiation of our mandate for rapid initial assessment. In September 2009, the average time to acquire a ‘full’ set of vitals signs was 7.7 minutes after patient contact; in September 2010, it was 3.2 minutes, or ‘full’ vital sign acquisition 4.5 minutes sooner.

Conclusion

While I cannot yet offer irrefutable proof that acquiring a full set of vitals signs 4.5 minutes sooner has saved any lives at our agency, it is safe to say that a small subset of non-obviously critical patients would have been identified quicker. And that begs the questions: How long can a patient compensate in a potentially lethal arrhythmia like ventricular tachycardia? How long can a hypoxic patient withstand hypoperfusion before succumbing? There’s obviously a tipping point to every life-threatening emergency, and emergency medicine has always operated on the premise that time does matter. But, beyond controversy and assumptions, initial patient assessment is Job #1 in EMS and the single most important thing EMS agencies pay their providers to do. It’s also the one area where we cannot afford to take short cuts, as the above two cases demonstrate.

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 located in northeastern Pennsylvania. He has 30 years' experience in EMS. Contact Joe at jhayes763@yahoo.com.