Putting Research Into Practice

By the time he came to Pittsburgh, pioneering EMS physician Ronald D. Stewart, MD, had a pretty clear idea of what these new out-of-hospital emergency care systems entailed. 

As a young physician in the frigid sticks of northern Nova Scotia, where there was no ambulance service, he’d made house calls at all hours and referred patients epic distances to definitive care. Then he’d jumped seeming light years to Los Angeles, completing USC’s residency program in emergency medicine and becoming the first medical director for L.A. County’s new paramedic training program. LAC/USC Medical Center, Stewart recalled in a 1982 EMS Magazine article, saw as many patients in a day as his Canadian outpost had in a year.¹ 

So by 1978, when he moved to the University of Pittsburgh and became that city’s public safety medical director, Stewart knew both the urban and rural extremes of the spectrum. And they had some common needs, one of which was a solid base of science, research and education underlying these new interventions being brought to the field. 

So Stewart established the Center for Emergency Medicine of Western Pennsylvania (CEM). The CEM is a unique nonprofit that works across several fronts to improve the quality and delivery of emergency care. Says its vice president, Dan Swayze, DrPH, MBA, MEMS, “We are one of the few institutions in the world, if not the only one, dedicated to research, education and critical-care transport, working to improve the care that’s delivered both in hospital emergency departments and in the field.”

Along the way the CEM has had a sizable impact on EMS in the U.S., shaping everything from the DOT’s National Standard Curricula and top advocacy groups like NAEMSP, NAEMSE and SCAF to current ideas on community paramedicine and mobile healthcare and our growing body of knowledge in critical aspects of safety and other vital areas of study.

UPMC Partnership

Stewart launched the CEM with support from the University of Pittsburgh’s School of Medicine. The idea was to join and optimize city and school resources to improve the care delivered to patients. Five years later the Center expanded to become a consortium of hospitals. That membership has evolved over the years but now includes the University of Pittsburgh Medical Center’s Presbyterian Shadyside, Children’s Hospital and Mercy Hospital facilities. 

CEM has four primary arms: 

• Its Office of Education offers paramedic and EMT training, CPR/AED instruction, and a full assortment of letter-class supplements (ACLS, AMLS, EVOC, etc.). The CEM has been involved in EMS education for more than three decades and played parts in developing both the 1994 NSC and the University of Pittsburgh’s Bachelor’s of Science in EMS degree program. Its faculty have taught globally, and in fact the Center has trained nearly all paramedics for the country of Iceland.

• Its prolific Center for Research on Emergency Medical Services (CREMS) works with Pitt’s Department of Emergency Medicine and other university resources to investigate pressing questions among various cohorts of EMS organizations. 

• STAT MedEvac is a highly regarded air medical and critical care transportation service with 17 bases in four states. 

• Emed Health works to employ EMTs and paramedics in community and public health initiatives, and has helped innovate the kinds of concepts now taking hold in CP/MIH programs. It’s successfully used prehospital providers in prevention, screening and disease management initiatives to reduce costs and improve quality. 

Research

Almost all the research the CEM’s involved with is led by faculty at Pitt’s Department of Emergency Medicine. That provides “a rich source of intellectual and research capital,” notes CEM research director Daniel Patterson, PhD, NREMT-P, an assistant professor in the department. Most projects are initiated by those investigators, with the CEM working in collaboration. 

The breadth of Pitt’s EM research activities is described at www.emergencymedicine.pitt.edu/research, but of particular note to EMS types is its Emergency Medical Services Agency Research Network, or EMSARN. Founded in 2010, EMSARN is a collection of agencies joined for purposes of investigating safety issues and developing tools, information and resources all agencies can use toward better performance. The CEM, Department of Emergency Medicine and other entities fund its work. 

It’s a five-year effort with new cohorts recruited each year. (EMSARN is always seeking participants; find out more at www.emsarn.org.) Projects have included work on employee turnover, sleep and fatigue, conflict and teamwork, and safety culture. 

“Participating agencies benefit by receiving free detailed reports on their safety culture, worker sleep quality and fatigue, and turnover, compared to other agencies in an aggregate and anonymous format,” says Patterson. “These are useful for benchmarking, evaluating the impact of interventions, and informing decision-makers. From a science perspective, it helps us improve the evidence behind measurement of safety issues in EMS.” 

Some of what EMSARN is doing and finding is quite interesting: 

• Turnover—You might feel the EMS worker turnover rate is pretty bad. 

Per federal statistics, the U.S. average annual turnover rate in 2007, excluding farm jobs, reached almost 40%.² That number was inflated by transient industries like leisure and hospitality, but for health and social assistant positions was still almost 29%.In some nursing homes it’s been pegged as high as 190%.³ 

Starting in 2008, Pitt researchers set out to gauge the rate in EMS. They tracked 40 agencies over six months, chronicling terminations, new hires, open positions and associated costs. They found an overall mean annual turnover rate of just 10.7%. That was slightly lower among all-paid services (10.2%), slightly higher among volunteers (12.4%).⁴ 

The number among EMSARN-participating agencies crept up a little after that, reaching 13.8% in 2010.⁵ But that still suggests, if the surveyed organizations are representative, that the EMS turnover rate, far from being exceptionally high, is actually much lower than the national average. 

• Sleep and fatigue—This project examines sleep quality and fatigue in the EMS workforce. It found in 2012 that poor sleep quality and fatigue are common in EMS workers, and there’s evidence of association between sleep quality, fatigue and safety outcomes.⁶ 

Currently investigators are testing an app, SleepTrack (www.sleeptrack.org), that will let participants document their sleep, fatigue, and self-reported injuries before, during and after shift work. It employs “real-time momentary assessment via smartphone and text-message technology,” explains Patterson. “Based on our previous research, we feel investigations using real-time assessment will provide a more accurate picture of sleep, fatigue and injury in the EMS setting.” 

• Teamwork and conflict—This project produced the only known tool for measuring perceptions of teamwork between EMS partners, known as EMT-TEAMWORK.⁷ It’s now published and available for any organization to use. The next step involves deploying an innovative software scheduling tool to help facilitate measurement of team interaction/familiarity and teamwork perceptions. 

Much other research continues through Pitt EM as well, including projects looking at plasma administration in air-medical transport, tranexamic acid for trauma patients, lactate testing for prediction of resource need in trauma patients, clinical predictors of sepsis, and work with the Resuscitation Outcomes Consortium. 

Emed Health

Created in 2003, Emed Health was an early test model for using EMTs and paramedics in community and public health initiatives. Its goals are to reduce healthcare costs, improve satisfaction and the quality of patients’ lives, and create jobs, career paths and revenue streams for EMS agencies. 
EMS agencies in western Pennsylvania have long had interest in this kind of work, Swayze says, but were always hamstrung by costs and limited resources. 

“While the desire might be there, we’ve found becoming active in these new areas of healthcare and community health is really difficult for many of the small services in our area,” he says. “The managers struggle every day to keep their billing operating, keep their schedules operating, keep their trucks staffed, all these things. They’ve never had time, even though they’ve had the interest, to do the program development and really go out and to pitch this idea of using EMS in nontraditional roles to payers. Emed has really evolved over the past 10 years into trying to figure out where EMS has the natural capacity to do some of this work, and working with our internal health plan to try to figure out what things are of interest to them and how we can use EMS to complement existing efforts in those areas.” 

That health plan is UPMC’s, and it’s contracted for half a decade now with Emed to go visit and work with its high-risk members. With competitor Highmark, it’s also jointly funding the ambitious CONNECT community paramedic initiative in the Pittsburgh area. 

The UPMC/Emed partnership has produced some successes. An asthma program, for instance, sent medics to the homes of low-income patients who visited the hospital frequently for their disease. The medics worked to identify and mitigate household triggers, including working with landlords, and get patients connected with primary care physicians. As a result, they were able to reduce the number of subsequent ED visits, and their patients who were admitted had shorter stays. 

Under a care-transition program for CHF and COPD patients, medics visited within a couple of days of the patients’ return home to ensure they understood their discharge instructions, had follow-up appointments with their primary docs, had all necessary medications not in conflict, and generally had a treatment plan moving forward. Of 13 patients in the pilot, none needed readmission within 60 days. (The general CHF readmission rate is around 24% over 30 days.⁸) “When you look at the cost of CHF versus the cost of the intervention,” Swayze notes, “the savings was multiple for what they paid us to provide those services.” 

The CONNECT (Congress of Neighboring Communities) project, which involves the city of Pittsburgh and three dozen surrounding municipalities, launched in September and has had more than 100 patients referred thus far. Its inclusion criteria is vulnerability, as determined by the referring hospital. When community medics follow up with those vulnerable patients, they look beyond medical issues to social and environmental conditions as well, and help arrange interventions for whatever problems they find. That could mean transportation assistance or some other kind of economic or social-service help. They serve essentially as navigators, bridging patients to friends and family, government agencies, faith-based and other charities, or anyone else who might fill a need that could otherwise pose a cost to the medical system. 

Recently program providers turned to a church group in another county to get a ramp built for a 500-lb. patient who could no longer manage the steps in front of her house. That kind of thing may not be as thrilling as a cardiac save, but as Emed recognized some time ago, it’s likely part of the future of EMS. 

“I think the hospitals and insurance companies are going to look for that assistance from us,” says Swayze. “A lot of small EMS providers provide these services in rural communities, and the challenge will be creating sustainable models that work for them. But the opportunities are ripe for larger systems too, and it’s going to require a whole different approach to mutual aid and interagency cooperation. The hospitals and health plans are the natural payers, but they often have patient catchment areas much larger than any one EMS agency’s service area. So you have to figure out whether you’re going to cross borders to provide services to other communities, or whether you’re going to collaborate with other agencies to make sure you can catch everybody the hospitals and health plans needs you to work with.” 

Conclusion

There’s a lot more of interest to the Center for Emergency Medicine, including a communications center that's physician-staffed 24 hours a day and a role providing in-flight medical emergency consultation to major commercial airlines. With thousands such consults a year, this has resulted in new insight about the kinds of emergencies that happen in the air (see sidebar).⁹ It’s also poised to remain at the forefront of an anticipated continued growth in the directions of CP/MIH. 

“I think EMS agencies in general need to start learning about what different roles they can play,” says Swayze. “There’s going to be lots of cost cutting occurring over the next couple of years, and more opportunities to help extend the reach of the hospitals out into the communities these ambulance services cover. So even though community paramedicine and mobile integrated healthcare have kind of been the topic du jour and there’s a lot of interest, I don’t think we’ve seen anything yet. I think the real bulk of the demand for those services is going to come toward the later part of this year.” 

That may not be precisely the way Stewart saw it in 1982, when he described his role in Nova Scotia as “doctor, counselor, dentist, physician-to-sick-mariners, village vet, county coroner and church organist.”¹ But it’s a heck of a lot more than the technicians we’ve been in the past. 

References

1. Stewart R. EMS Revisited: Down the Rabbit Hole and Through the Looking Glass. EMS World, www.emsworld.com/article/10319905. 

2. Bureau of Labor Statistics. Job Openings and Labor Turnover Survey, www.bls.gov/jlt/#data. 

3. Bostick JE, Rantz MJ, Flesner MK, Riggs CJ. Systematic review of studies of staffing and quality in nursing homes. J Am Med Dir Assoc, 2006; 7(6): 366–76. 

4. Patterson PD, Jones CB, Hubble MW, et al. The longitudinal study of turnover and the cost of turnover in emergency medical services. Prehosp Emerg Care, 2010 Apr-Jun; 14(2): 209–21. 

5. www.emergencymedicine.pitt.edu/research/emsarn/emsarn-turnover-project. 

6. Patterson PD, Weaver MD, Frank RC, et al. Association between poor sleep, fatigue, and safety outcomes in emergency medical services providers. Prehosp Emerg Care, 2012 Jan–Mar; 16(1): 86–97. 

7. Patterson PD, Weaver MD, Weaver SJ, et al. Measuring teamwork and conflict among emergency medical technician personnel. Prehosp Emerg Care, 2012 Jan–Mar; 16(1): 98–108. 

8. Krumholz HM, Merrill AR, Schone EM, et al. Patterns of hospital performance in acute myocardial infarction and heart failure 30-day mortality and readmission. Circ Cardiovasc Qual Outcomes, 2009; 2: 407–13. 

9. Peterson DC, Martin-Gill C, Guyette FX, et al. Outcomes of medical emergencies on commerical airline flights. N Engl J Med, 2013; 368: 2,075–83. 

10. Friesen J. Q&A With Paramédico Author Benjamin Gilmour. EMS World, https://www.emsworld.com/article/11134263.