How EMS is not patient-centered

Updated June 2015

“The best interest of the patient is the only interest to be considered.”

— William J. Mayo, M.D.

Nearly every EMS system I’ve visited over the years vows to put patients first, to do anything for patients or to be patient-centered. Like most of us, I took that as a given. Of course we do that, I thought; our job, after all, is to take care of patients.

Then I heard Don Berwick, M.D., give his keynote speech at the Institute for Healthcare Improvement’s National Forum in 2006. As IHI’s founder, Dr. Berwick’s annual speech is the kind of thing hospital CEOs and medical school deans line up for like they’re going to see the Grateful Dead.

His opening words were, “Every hospital in America claims to be patient-centered. I’m here to tell you that’s a lie.” He went on to describe the things he sees in hospitals every day, like being told that he could not go into the cath lab with a friend who was terrified of the procedure; having his wife woken up to take her sleeping pill; and subjecting patients to wearing those oh-so-flattering hospital gowns.

Sadly, we have equivalent things that are not patient-centered designed into our EMS systems by protocol, culture or convenience.

How EMS is not patient-centered

Here’s one example that hits close to home for me: A friend of mine was being transported to a cardiac receiving center for an urgent catheterization when she asked the paramedic transporting her how she was doing. The medic replied, “Pretty good, considering I’m still awake 36 hours into my 48-hour shift.” My friend, a safety engineer, was too frightened to ask if her partner driving the ambulance had also been awake that long.

Most normal (non-EMS) people think that working more than eight hours is exhausting, yet we see shift schedules that are 48 or even 96 hours in some EMS systems.

Need more examples? How about these kinds of statements, which are all too common in all too many EMS systems: “I’m sorry your husband can’t ride in back with you” or, “This is going to hurt while we splint you, but don’t worry—we will give you something for the pain once we get you into the ambulance.” Or how about the fact that we strap people to hard plastic boards to cover our own tails more often than to protect their necks, or that we take everyone to the emergency department even when the neighborhood clinic could see them faster for a third of the cost, or that the only time most people ride in a vehicle facing backward is in an ambulance?

Walk into any EMS system in the country and ask how they are doing with airway management. Chances are they’ll say something like, “We are 92% successful.” When you ask what that number means, people will tell you, “92% of the people we try to intubate get a tube” or, “60% of our intubations are successful on the first try, but 92% get it eventually” or, “We are going away from intubation, and 92% have a successful supraglottic airway placed.” The problem is that all these numbers and explanations are provider-centered, not patient-centered.

From the patient’s perspective, their airway goes well beyond the trachea all the way down to the alveolar ducts. Yes, people in cardiac arrest and those with apnea from a heroin overdose have airway problems, but so do people with asthma, pulmonary edema and pneumonia. Patients want and need to have an airway that’s open and free of gunk, and that easily exchanges air with the outside world and allows for well-oxygenated blood. While having an endotracheal tube or supraglottic airway placed may be part of meeting these needs, they are only part of the story. The full picture includes good assessment and may include sitting the patient up and delivering inhaled beta-agonists, CPAP, suction and the like. It’s certainly a lot easier to count intubations, but it’s time for us to measure results from a patient perspective.

There is no standard way to measure these results, but it probably involves some combination of EtCO2, SpO2, respiratory distress scale and others. Maybe including a checklist that looks at the bundle of assessments and interventions necessary to produce and maintain an open, clean airway with a free flow of air would be the most patient-centered measurement.

Questioning quality

Almost every fire department, ambulance service, dispatch center, emergency department, cardiac cath lab and trauma center has some kind of “quality” program. If you should get broadsided by a drunk driver on your Harley Road Glide, shatter your femur and get your bell rung because your helmet is the size of a beanie, how many separate “quality” programs will have something to do with your care? The list would likely include dispatch, fire first response, paramedic ambulance service, emergency department, trauma team, radiology, lab, orthopedics, neurology, ICU and rehabilitation.

From your perspective as the patient, every one of these parts has to do a great job as part of your care process or you’re not going to do as well as you could. Everything needs to work, and the process starts with having the tower that picks up the signal from the bystander’s cell phone route the 911 call to a primary PSAP, which needs to correctly identify the nature and jurisdiction of the crash to send the call to the proper secondary PSAP. Then the 911 call taker needs to capture the right location, assess the seriousness of your situation and tell the caller what to do for you until help arrives; then the dispatcher needs to alert the closest EMS resources. The process ends with you walking without pain or a limp. In between there will be splinting, transport, hopefully some opiates, X-rays, a CAT scan, labs, hospital food, someone helping you out of bed to stand for the first time and a whole lot more. From your perspective, the whole thing is one big system.

In patient-centered systems, you won’t hear people say, “Outcomes are beyond the control of EMS” or, “We knew the patient needed to be immobilized, but the first medic on scene is in charge and we weren’t first.” We are all responsible for contributing to outcomes and results. We must have communication practices that encourage people to speak about concerns and encourage others to hear those concerns and give them due consideration. Just like in an aircraft where crew resource management is practiced, a management system that makes optimal use of all available resources—equipment, procedures and people—to promote safety and operational efficiency is essential in EMS.

In patient-centered systems, the distinction between good clinical care and good customer service is out of place. Good customer service is a component of good clinical care and vice versa. In patient-centered systems, how a patient feels is not only used for diagnostic information; it’s used to assess the level of suffering and to identify opportunities to help people feel better and get better.
Let Dr. Berwick’s words guide us as we explore new ways to think about patient-centered quality management systems over the next few issues: “Others have struggled to find a proper definition of patient-centeredness. Three useful maxims that I have encountered are these: (1) The needs of the patient come first. (2) Nothing about me without me. (3) Every patient is the only patient.”

Mike Taigman is the general manager for AMR’s Ventura County and Gold Coast operations. He’s also part of the national leadership team for Caring for Maria, AMR’s national performance improvement collaborative.