Michigan Prehospital Pediatric Continuous Quality Improvement Project

1. Michigan Prehospital Pediatric Continuous Quality Improvement Project William D. Fales, MD, FACEP Michigan State University Kalamazoo Center for Medical Studies Supported in part by MC 00126 01 from the Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau.

2. Traditional EMS Quality Improvement • Typically Retrospective • Often Case-Focused • Review “fall-out” cases • Negatively focused • Resolutions often associated with punishment • Not real popular with EMS personnel

3. Example of Case-Based Retrospective EMS Quality Improvement Process

4. Medical Director Discovers Badness

5. Problem Paramedic Contacted

6. Search for Additional Problems

7. Very Thorough Search

8. Confrontation of Paramedic

9. Get Those Bad Medics Off the Street

10. Public Flogging

11. Ultimate Penalty Permanent Revocation

12. Michigan Prehospital Pediatric Continuous Quality Improvement Project • Goal: Create a pediatric-focused CQI Model and determine its impact on protocol compliance. • Assumption: Protocol Compliance = Quality

13. Methodology • Created a CQI Model • NHTSA Leadership Guide to Quality Improvement • NEDARC Quality Improvement References • Used MERMaID – Electronic Medical Record

14. MERMaID

15. Methodology (con’t) • Selected 30 agencies • Randomized into Intervention and Control Groups • Peds vs. Adult Stroke • CQI Workshops • CQI Software • Baseline Performance Data Acquired • Monthly Aggregate Feedback to Agencies / Personnel

16. Clinical Indicators • Created by multi-disciplinary panel • Pediatric Indicators • Trauma • Respiratory distress • Seizure • Pain management • Adult-Stroke

17. Results • 30 Agencies Recruited • 21 submitted data • HIPPA “phobia” • Smallest agencies lost • Diverse Population • 2 MSA’s • Kalamazoo and Saginaw • Many rural agencies

18. Project Population

19. Findings • No significant differences between • Pre- and post-CQI • Intervention and control group • All groups did well (>85%) with documenting • Meds / Allergies • Peds GCS • Vital Signs

20. Trauma • 16 to 19% used a Trauma protocol • Subset of all trauma patients • w/ Altered LOC = 6-11% of those with trauma • w/ Load and Go = 7-12% of those with trauma • >97% spinal immobilization (when indicated) • >92% IV access attempted (when indicated) • 37-52% “Load and Go” (<10 min. @ scene) • Rapid trauma management remains a challenge!

21. Pain Management • 15 to 20% of all pediatric patients had potentially painful condition • Pain scores documented 32-40% of time • Pain score >4 • 12-17% of those with likely pain • 3-4% of all ped patients • Of these 18-36% received analgesia • Prehospital pain management remains an important challenge!

22. Limitations • Small numbers within all subgroups • Use of protocol compliance as an indicator of quality • CQI interventions varied by agency • Most primarily provided aggregate feedback • Limitations that could not be controlled • e.g., medical control denied pain medication request • These are extremely low frequency events!

23. Conclusions • We were unable to demonstrate improved protocol compliance using a contemporary CQI model. • Positive areas of pediatric care • Collection of baseline patient data • Checking blood glucose and attempting IVs • Spinal immobilization in trauma • Bronchodilator use in respiratory distress • Areas in need of further efforts • Pain management • Rapid trauma management

24. What is the Next Step? • MI 1st STEPPS • Michigan’s First Simulation Training and Evaluation of Paramedics in Pediatrics • 2005 EMS-C Targeted Issues Grant • Evaluate impact of brief training every 4 months • Compare simulation-based and non-simulation based instruction

25. Thanks www.emscqi.org fales@msu.edu