How your CQI program defines successful clinical practices

Now that your system has purchased, trained, developed processes, and implemented capnography; what process do you have in place to ensure this tool is being used as efficiently and effectively as possible?


By Chris Cebollero

Capnography has become part of the standard of care for many of the patients we encounter. Capnography gives the EMS provider a rapid and reliable assessment of their patient’s pulmonary, circulatory and metabolic functions. More importantly, it gives real-time feedback regarding CO2 exhalation.

Now that your system has purchased, trained, developed processes, and implemented capnography; what process do you have in place to ensure this tool is being used as efficiently and effectively as possible?

Quality improvement in EMS
Every EMS system needs a continuous quality improvement (CQI) program — which is a system of checks and balances — to allow EMS leaders the ability to determine how care is being delivered, if that care is making a difference, and if processes are being followed. The strength of the CQI program can guide an organization in many directions and allow you to measure system processes in the past, present or future.

For any CQI process to be successful and guide the change needed, every person involved in the organization needs to understand they are part the CQI process. Regardless of your position, CQI has a direct impact on the customers we serve. CQI allows for better collection of data, improves clinical practice and can guide protocol changes and equipment purchases. Remember, a rock-solid CQI program should always be educational and never punitive.

If your system does not have a CQI program, or if you are looking to upgrade your current program, a great starting resource is the National Highway Traffic Safety Administration (NHTSA) document called "A Leadership Guide to Quality Improvement in EMS."

Stages of a successful CQI program
These are the stages of a successful CQI program:

  1. Audits allow the system to take a look at the strengths and challenges within the system. Audits should be conducted on a scheduled basis with results reported to the whole agency.
  2. Develop goals to evaluate performance and work toward performance improvement.  Let’s say field providers are only using capnography 60 percent of the time. Setting a goal of 100 percent use initially may seem too great. Try setting smaller goals of success over time to eventually achieve the 100 percent utilization benchmark.
  3. Develop new standards of care based on progress toward the intended goal. Sometimes we put processes into place that are just not working. They looked good on paper, but in practical use fall short of the intended goal. Look at how the process is working and keep tweaking until success is achieved.
  4. Key Performance Indicators (KPIs) are used to develop structures, processes and outcomes. For these indicators to be of value you need a reliable and consistent way to define and measure results.
  5. Benchmarking allows EMS agencies to measure themselves against similar agencies or national standards. Benchmarking is a practice that should be used more widely and national performance measures are being developed by the EMS Compass initiative.
  6. Report feedback to providers as part of each audit. Feedback to providers can be positive or negative. Everyone deserves a pat on the back for great work, conversely, when the audit finds shortcomings a discussion or training needs to occur. 

CQI for capnography
Some of the areas that CQI can be best used to determine the effectiveness of capnography include data collection on:

  • Using on intubated and non-intubated patients
  • Confirming successful of intubation
  • Interpreting waveforms accurately
  • Monitoring the effectiveness of chest compressions
  • Monitoring the treatment and management of medical patients with conditions like asthma, drowning, or sepsis

Without feedback based on audits work performance and use of capnography may gradually erode. Your CQI program truly keeps the workforce inspired and motivated, and reduces risk and liability within the organization.

CQI as a guide for training
Any CQI program should be educational in nature. Unfortunately too many systems use CQI as a punitive tool and many providers take umbrage to this approach. A punitive approach leads to failure to report and poor documentation which lead to poor patient care.

Developing a CQI program that truly allows the field provider to learn and develop into a top-notch clinician is the ultimate goal. For example, if the system average for capnography use is 80 percent posting a report — publicly shaming — the providers below the benchmark is punitive. A better approach is to share organization success and performance and then conduct instruction, as needed, to the providers falling short of the benchmark. Instruction could be accomplished by a field supervisor meeting up with crewmembers, discussing challenges, strengthening knowledge and thus increasing performance.

CQI can protect clinicians
Recently, paramedics were accused of performing poor CPR and a missed intubation on patient that was not resuscitated. The organization’s electronic data collection and strong CQI program allowed the leaders to confirm the patient had strong chest compressions with minimal time off the chest, and after intubation the patient had normal ETCO2. These details debunked the accusation.

Does your system have a CQI program in place to improve and protect your field providers?  

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