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Roundtable: Fire-based EMS leaders share the benefits of a QA/QI program

A commitment to EMS excellence establishes a lasting reputation of respect, reliability and integrity

By Joe Locke, AAS; Kelly Wright, MS

Data continues to emerge as an invaluable resource. As the EMS industry begins to navigate data complexities, utilizing data for progress with an ethical focus is imperative. The value of data is limitless; working with technological advancements for positive change can be applied across many disciplines, from prehospital training and quality management programs, to in-hospital patient outcome analysis.

The expectation of EMS is to transform chaos into well-coordinated, life-saving care. To fulfill that expectation, we should continuously improve the quality of our emergency medical service delivery.

In this article, a panel of leaders from fire-based EMS agencies with a formal quality management (QM) program who have significantly reduced errors, increased provider competence and increased EMS billing revenue, share their methods with others who want to implement similar data-driven QM practices.

Emphasizing EMS

Since the early 1990s, the Monroe Fire Department has globally taken pride in delivering high-quality, leading-edge EMS care.

The department piloted a study utilizing prehospital pulse oximetry when no one else in the state of Ohio had that technology. This opened the door to innovation and the department soon implemented disposable colorimetric capnography for endotracheal tube placement, balanced crystalloid solutions for volume resuscitation, 12-lead EKG interpretation, video laryngoscopy, TXA therapy and – most recently – rapid sequence intubation.

While these are all procedural improvements, what makes them work is the mindset of the practitioners utilizing these tools. EMS has always been a source of pride at the Monroe Fire Department. Unfortunately, this pride is not pervasive in fire-based EMS. EMS accounts for between 70-85% of the average fire department’s run volume, and yet, many fire departments view EMS as a necessary evil that sucks time and resources away from staffing fire engines. The reality is that many fire departments only have paid staff because EMS is a part of their service line.

Monroe Fire has always embraced EMS as a critical part of its service, and emphasized the efficient and skilled performance of EMS duties. This manifested through a strong focus on EMS training, quarterly skills checks and a robust quality management program. We believed that if our paramedics would perform rapid sequence intubation, the quality and intensity of medical oversight needed to match the aggressiveness of the protocols. For example, before Monroe paramedics could perform rapid sequence intubation, they had to complete a 40-hour class, including a dynamic simulation component, and pass a written test with a minimum of 90%.

During the hiring process, it is made clear that EMS is a strong focus within the fire department, and the direct expectation is that nothing short of excellence will be tolerated. This approach was initially met with some individual personnel struggles. Still, in the presence of a well-established EMS culture, it was easier for the outliers to conform than to find themselves as the team’s weakest link.

EMS leadership at Monroe is deliberate, intentional and focused. We have created a system in which excellence is expected, identified and quantified. Simply put, if you find yourself on your back looking up, you want a Monroe paramedic staring down at you. They prepare constantly to be the best part of your worst day.

— Dan Rauh, MS, ACNP-BC, intensivist nurse practitioner, Critical Care Unit, Columbus Regional Hospital

Prioritizing quality EMS

As a young paramedic, I had the fortunate opportunity to run with two paramedics with a wealth of EMS knowledge. In addition to being paramedics, they were both registered nurses with many years of experience working in emergency departments. I cannot begin to list how much I learned from them.

As our department transitioned from a combination department of community members to a 100% career department, we unfortunately lost these invaluable EMS experts. While the benefits of converting to a career department were vast, everything had a downside.

Once I became fire chief, I wanted to find a way to install this EMS expert role back into the department. While all emergency responses are essential, I argue that EMS calls are the most important. It is what we do most often, and we are dealing with people’s lives, not property. Therefore, we instituted an EMS supervisor on each shift. This person’s job is to be an EMS expert like the one that I benefited from years ago.

A large portion of our improvement can be attributed to our comprehensive training program as well as the implementation of our QA/QI program which our EMS supervisors manage. These data driven programs ensure that our providers are superiorly trained and meet organizational expectations.

— Chief Steve Agenbroad, MPA, Clearcreek Fire, Springboro, Ohio

Data-based QM programs aid department management

When looking at all the programs and services a fire department provides to the community, it is hard to determine where to spend your time, resources and budget. As a fire chief, I demand that we be at the top of our game and train to the point where our actions are second nature. We have developed a high-quality training program and a robust QA/QI process that focuses on many areas to optimize success.

The QM program has collected an abundance of quality data that we have been able to analyze and make informed decisions regarding resource allocation and training needs, thereby increasing our efficiency. We have focused our attention on the areas we need to improve. This has allowed our training program to target department resources in these areas to build them to our standards. The Quality Improvement program works with the protocol and enhances department operational efficiency, coordination and effectiveness. We can develop performance metrics and benchmarks through these programs to hold our personnel accountable.

With shrinking or stagnant budgets, we need to optimize the allocation of our resources. A working QA/QI program has allowed us to direct this funding where it will supply the most benefit for department operations and, in turn, positive patient outcomes.

— Chief David Leverage, BS, Monroe (Ohio) Fire Department

The importance of EMS

From an emergency medicine perspective, EMS brings expertise to the prehospital setting, with the ability to stabilize or reverse many lethal conditions. These providers are trained to recognize and respond to all manner of emergencies, from minor presentations to significant life threats, such as strokes, heart attacks, traumas, sepsis, drug overdoses, arrhythmias, respiratory failures and cardiac arrest.

Literature has proven the benefits of rapid intervention time and again in cases of cardiac, neurologic, infectious and traumatic emergencies. When EMS recognizes these conditions, initiates appropriate treatment to stabilize the patient to the greatest extent possible, and makes a prearrival notification call to the hospital, it confirms continuity of care and rapid therapy, leading to better patient outcomes. Physicians in the hospital see improved outcomes with shorter door-to-needle times for thrombolytics in stroke and shorter door-to-balloon times in AMI, resulting in a greater likelihood of a patient eventually walking out of the hospital with an intact quality of life.

When serving as a medical director of an EMS agency, I assist with any needed training or oversight, protocol development or specific competencies. It has been my experience that a formal QA/QI program allows a medical director of an EMS agency greater assurance that quality is maintained among newly hired staff and seasoned members. This engenders trust and confidence that internal programs are constantly in place to maintain excellence in EMS at that department.

Our community EMS providers must have up-to-date training and clear and quality-driven protocols to demonstrate mastery of their skills. When quality assurance/quality improvement programs are in place, EMS providers are perpetually held accountable, allowing for continuous professional growth, which undoubtedly saves lives.

— Dr. Jill Aston, MD, FACEP, medical director, City of Monroe (Ohio) Fire Department

A commitment to excellence

A long-standing commitment to providing outstanding EMS care establishes a lasting reputation of respect, reliability, and integrity from our peers, community, and healthcare organizations.

Monroe Fire Department is fortunate that this commitment has been part of its culture since the early 1990s thanks in large part to Dan Rauh, who made excellence in EMS an expectation. This identity must be earned through high-quality training, creating high-quality providers. Having data to show a dedication to perpetual growth and improvement across various data points changes the view from an opinion to an objective illustration of excellence.

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About the authors

Joe Locke, AAS, is EMS coordinator, City of Monroe Fire department.
Kelly Wright, MS is a City of Monroe GIS specialist.