Local and National Efforts Improve Rural EMS Safety
by Candi Helseth
Getting ready to leave the office late one Friday evening, Rowan County Emergency Medical Service (EMS) Paramedic Bradley Dean became alarmed when he read about a medication error that another EMS service had reported on the web-based EMS Voluntary Event Notification Tool (EVENT).
Dean, who also oversees safety training for Rowan County EMS in North Carolina, headed directly to the ambulance bay. There he found the same potential for error: two medications with very different purposes packaged very similarly by different manufacturers. They were placed in close proximity in the small ambulance fridge. Dean immediately ordered re-marking and repositioning the meds, preventing a similar incident from happening in Rowan County.
Preventing harm is EVENT's main purpose. The web-based system, implemented in 2010, encourages anonymous reporting of EMS errors throughout the United States and Canada. In March, EVENT expanded its outreach with the addition of “near misses” (potential EMS practitioner problems recognized before they actually occurred) and EMS practitioner line of duty death incidents (LODD). The National Association of Emergency Medical Technicians (NAEMT) and the Center for Leadership, Innovation and Research for EMS (CLIR-EMS) jointly developed the program.
“EVENT is a non-punitive, confidential system that helps to identify changes needed in EMS systems and processes, and does so without placing blame on individual practitioners,” said Gary Wingrove, CLIR-EMS president and director of Gold Cross/Mayo Clinic Medical Transport of Minnesota and Western Wisconsin.
“The goal is to improve these EMS systems by identifying situations where a patient was potentially harmed, could possibly be harmed or where a ‘close call’ has occurred. This anonymous information is shared among providers and the data is used in training, educating and preventing similar events from occurring in the future.”
No national model for safety practices, or any formal means of research and data collection to facilitate improvements, previously existed in the EMS industry, Wingrove said, adding that hospitals use event reporting systems as a key component contributing to quality improvement (QI) efforts. Wingrove and Matt Womble, formerly a Rural Hospital and EMS Specialist at the NC Office of Rural Health and Community Care (ORHCC) and now VP for Program Development at the NC Foundation for Advanced Health Programs, review EVENT reports in the United States and notify area EMS governing bodies where the event occurred. Patient safety incidents are also posted to a Google Group to improve awareness among EMS practitioners nationwide. Aggregate data that is shared online highlights EMS trends and practice analyses. EVENT reports also establish a way to determine if equipment failures are attributable to faulty development that needs to be addressed or if a failure was simply an isolated incident.
“The purpose here is to gather information and learn from it,” Womble said. “With any kind of stress and in fast-paced environments like trauma situations, we know the chance for human error increases. We haven’t had a universal way to report errors or near misses. We don’t have a lot of data in EMS about the factors that contribute to errors. By using frontline information we get from EVENT, we identify where we can improve EMS services and how to do so in the fastest way possible.”
Implementing better safety protocols and practices
Gold Cross ambulance service in Minnesota and Western Wisconsin has implemented safety initiatives including a driver monitoring system that measures ambulance acceleration, braking and provider handling.
EMS safety and quality improvement begins at local levels. Safety and protocols vary greatly from state to state, and even regionally within a state, Wingrove said.
A 2008 study, Contributing Factors and Issues Associated With Rural Ambulance Crashes, found that at least 6,500 ambulance crashes occur annually in the United States. Accidents in rural areas tend to be more severe in terms of injury or death, mostly due to the greater distances and travel times to reach hospitals and more limited availability of additional EMS staff when an accident occurs. Another study co-authored by Daniel Patterson, a researcher and primary investigator with the Emergency Medical Services Agency Research Network (EMSARN), found that more than one-half of EMS providers suffer from poor sleep quality and mental and physical fatigue while at work.
Rowan County EMS, which responds to about 13,000 calls each year, developed and implemented a triage protocol to address safety issues related to transporting general medicine patients. Dean said family requests for patient transports to large, distant hospitals were taking ambulances out of their area for extended periods when the severity of the patient’s condition didn’t warrant it. North Carolina has statewide triage and destination protocols aimed at improving outcomes for cardiac, stroke, trauma and burn patients.
“The state is looking at implementing our protocol statewide too,” Dean said. “Our plan reduces long distance transports, which also reduces staff fatigue and decreases risk of ambulance accidents.”
Gold Cross ambulance service assesses and addresses possible ambulance operation issues using a driver monitoring system, which can measure safety factors such as ambulance acceleration, braking and provider handling. Gold Cross has also adapted its air ambulance Risk Assessment Tool (RAT) for ground EMS operations. Paramedics complete a risk assessment prior to long distance transfers to assess the safety risk of each transport. The tool assesses and scores factors such as the vehicle operator’s experience, road conditions, weather, crew fatigue, etc. The final score determines how the transport will proceed and what factors need to change for transport to occur safely.
“I think our innovation shows in the way we achieve our safety program, specifically these tools,” Wingrove commented. “Some other EMS agencies have started adopting our methods.”
In operation for 50 years, Gold Cross has been integrated with Mayo Clinic Medical Transport since 1994. The ground ambulance serves 12 percent of the state’s population in urban and rural areas, responding to more than 50,000 calls each year. As a result, Wingrove said, its increased volume translates into improved financial resources for advanced safety technologies.
Employee training is critical to improving safety, said Gold Cross Safety and Emergency Planning Coordinator Mike Sveen. In addition to its EMS staff, Gold Cross trains rural firefighters, law enforcement and other first responders. Dual response, where firefighters and ambulance are simultaneously dispatched to a call, is common in rural service areas. In certain situations—such as defiant patients under the influence of drugs or alcohol or where accident scenes may involve hazardous chemicals - local law enforcement also responds.
“We really work on training people on scene recognition to make sure the scene is safe before they enter,” Sveen said. “We have resources for them in our ambulances like standard operating guidelines on hazardous materials and ways to identify those chemicals.”
Rowan County EMS educates and empowers staff, Dean said. “We’ve had a couple cases where patients using cocaine were having adverse reactions. Our staff knows what they need to do to be most effective with a violent patient and how they should also keep themselves safe, like thinking through how they have a way to escape if the situation gets too bad. And they have the authority to make decisions without having to call in and ask.”
Pressing for better national patient safety measures and data
The variation in state safety programs results in a fragmented system nationwide, Wingrove said. He is working with Womble and Dean to develop a national EMS Patient Safety Organization slated to begin by the end of this year. PSOs are under the umbrella of the Agency for Healthcare Research and Quality (AHRQ).
“The concept is that having a PSO will drive QI and systems improvement based on data collection and reporting,” Womble explained. “A PSO sets higher standards for agencies. We had a case here where a stair chair broke and the patient was dropped. Fortunately, the patient was OK but we could see the design was faulty. We wanted the company to recall it and redesign it but it took a long time to get to that point. A PSO will essentially give us more teeth to get a product changed, for instance, because we have a greater group of people pressing for these safety changes.”
Womble said North Carolina was one of the first states to implement an EMS data system. The University of North Carolina (UNC) School of Medicine oversees an EMS Performance Improvement Center responsible for collecting and assimilating data from EMS agencies’ patient care reports statewide. These are entered into the North Carolina Office of EMS (NC OEMS) Prehospital Medical Information System (PreMIS) developed to improve quality and performance of EMS systems across the state.
Because state data collection and abilities differ so much, the National EMS Information System (NEMSIS), was developed to help local and state agencies collect more standardized elements and eventually submit the data to a national EMS database.
But despite the efforts underway, Patterson says the EMS industry is a long way from achieving a national safety culture. EMSARN’s definition of safety culture is that “it encompasses the behaviors, actions, inaction, policies, procedures, language, traditions, and practices that front-line and administrative personnel engage in every day in EMS agencies.” Currently, EMSARN is conducting research to develop and test measures of safety for the EMS setting, provide benchmarking safety data for EMS nationwide, and give individual EMS agencies a free resource for evaluating and monitoring safety conditions.
“Individual worker perceptions of their EMS agency's safety culture have a direct impact on the interactions between EMS clinicians and their patients,” Patterson asserted. “Those interactions then determine, in part, the safety outcomes for both patients and providers. To improve safety in EMS, we need a total rethinking of how we care for patients and how we deliver that care.”
Services Integration Strengthens Rural EMS
by Candi Helseth
Marilyn Luce (EMT-P), left, Kevin McGinnis (EMT-P), and Nicole Prescott (EMT-I) demonstrate the preparedness of the Winthrop (Maine) Ambulance Service.
Eight years after a national landmark study called for integration of rural Emergency Medical Services (EMS) with other prehospital and hospital providers, the EMS industry struggles with an identity crisis and a fragmented system that makes full integration a formidable challenge.
Consensus exists that integrating EMS systems will improve availability and access to advanced EMS care in rural and frontier communities, according to Nels Sanddal, a longtime EMS researcher and Manager of Trauma Systems with the American College of Surgeons (ACS). However, EMS's role in three different arenas—health care, public health and public safety—contribute to the "identity crisis" that makes it difficult to formulate a plan to best integrate all prehospital resources. The fact that EMS agencies are governed differently from state to state and owned and operated in many different ways makes it even more difficult to regionalize all the resources.
The 2004 HRSA study, Rural and Frontier EMS Agenda for the Future, reported, " Integration does not mean that a local EMS system has to become a part of a larger organization and lose its independence. But in today’s environment, EMS must collaborate closely with local health care systems, public health, and public safety. EMS agencies may also want to form closer connections with other ‘sectors’ in the community. Regionally, EMS needs to think about its role in the continuum of health care delivery.”
Where these recommendations are being put into practice, results are confirming that the emergency response system gets stronger. This is being demonstrated by programs in Oregon, Minnesota and Maine, which are integrating rural EMS with other services, and improving patient care, EMS response times and provider skills.
Simulations conducted like this one in Clatsop County, Ore., help local EMS, fire and law enforcement learn how to better integrate services to provide trauma care.
Smarter trauma care in Oregon using dummies (and humans)
In northwest Oregon, several agencies with special interests in trauma have united to improve trauma care at 15 rural northwest Oregon sites. The sites were selected for full-system activation response trauma scenarios with multiple patients.
“The real-life scenarios include community volunteers acting as patients along with simulation manikins controlled by nearby operators,” explained Robert Duehmig, Oregon Office of Rural Health (ORH) Director of Communications. “The exercises provide a safe learning environment where providers practice skills they don’t utilize on a regular basis because there isn’t a large volume of trauma calls in these rural areas.”
Robert Burk, an EMT with Medix Ambulance in Clatsop County, was among rural EMS, fire and law enforcement department responders involved in a recent scenario where two vans, fully loaded with students and adults, “collided” near the high school. Hands-on practice included extricating patients pinned in vehicles, treating and triaging patients, and determining transport destinations appropriate to the severity of their conditions. Medix provided ground transport to Columbia Memorial Hospital, a Critical Access Hospital in Astoria, and Life Flight transported critically injured patients to a Portland Level 4 trauma center.
Prior to the simulation, Life Flight staff provided a daylong educational session for rural practitioners. Following the scenario, participants met to identify ways to improve the emergency medical response and system of care based on what they learned. Analyses of Pre- and Post-tests demonstrate that rural practitioners’ confidence in providing trauma care has improved, Duehmig said.
“I’ve learned better ways to perform critical care skills that we don’t do routinely,” Burk said. “It was good for all of us to learn how to assess trauma patients, how to all work together, and where it’s best to route patients. The more training we can do, the more we learn what we can do better.”
Duehmig said all simulations include a pediatric emphasis because initial planning indicated that providers had minimal experience caring for injured and critically ill children. To date, five simulations have taken place and four more have been scheduled. Partners in the project are ORH, the Oregon Department of Transportation, Oregon EMS for Children, Oregon Health Authority, and Life Flight Network. ORH funded the project through a HRSA Flex grant.
Improving trauma care outcomes is also the purpose of an online course ACS has developed. More than 35 states, along with India and China, have enrolled providers in the Rural Trauma Team Development Course (RTTDC).
“This course strongly encourages integration of prehospital care providers with hospital teams,” Sanddal said. “The key to the content is that it promotes utilization of all available health care resources to resuscitate and stabilize critical trauma patients. It also provides key concepts for developing regional system relationships.”
Moving beyond trauma care in Minnesota
Minnesota’s Comprehensive Advanced Life Support (CALS) educational program reaches beyond trauma care “to integrate rural prehospital and hospital-based emergency care providers into a highly functional team that can effectively care for a wide variety of time sensitive emergencies, including trauma, stroke, heart attacks, shock, sepsis and airway management,” according to Dr. Darrell Carter, a family medicine physician in Granite Falls, Minn. Carter, who developed the concept, worked with a team of EMS practitioners, and emergency medicine and family medicine providers to build the CALS model.
One of CALS' more unusual features is that it takes EMS practitioners into the hospital ER to continue helping with patient care by assisting staff at the hospital in an organized team effort. As a result, Carter said, communication improves among all caretakers, facilitating better patient transitions and quality of care. Traditionally, the EMS role has ended with transport of the patient to the hospital ER.
“CALS helps providers manage the great majority of emergencies which present to the door of a rural emergency room,” Carter said. “We don’t have surgeons or specialists that care for specific patients. In a Critical Access Hospital, the same staff cares for the trauma patients and the stroke patients.”
More than 5,000 Minnesota providers have received CALS training through funding approved by the Minnesota State Legislature. Wisconsin has developed its own statewide CALS courses under the umbrella of the Minnesota-based program. Minnesota trainers have also taught CALS courses in Nebraska, Michigan, Oklahoma, Texas, Missouri, California and Canada. CALS training is provided for medical personnel who staff all the U.S. Embassies, and a pilot program is underway to adapt the U.S. version for Kenya and other developing countries where missionary physicians want to implement it.
Paramedics and EMTs providing integrated care in Maine
Three-year pilot projects under the umbrella of Maine Emergency Medical Services are integrating paramedics and emergency medical technicians (EMTs) into rural public health and medical facilities. Pilot program developer Kevin McGinnis said the projects leverage EMS resources, including EMS mobility and 24/7 availability, to address local health care and public health needs while serving as a practical way to hone little-used EMS skills.
“These projects will augment existing health care programs and enhance EMS practitioners’ skills in areas where low emergency call volumes result in insufficient practice of clinical skills,” McGinnis said. “I see a ripe future for true integration as this proceeds.”
Under project guidelines, licensed paramedics who have taken a college-level community paramedicine course can assist primary care providers. Enabled or enhanced pilot projects are more narrowly scoped to allow EMTs and paramedics to work under a physician’s supervision on specific community projects. Rural communities define the projects. For those projects to be approved, “they must demonstrate integration with community health teams,” McGinnis said.
Maine has long integrated fire and EMS services in rural communities, McGinnis said. EMT-certified firefighters respond to all EMS calls and can provide care such as resuscitation, defibrillation, bleeding control and patient stabilization. Because rural ambulance services may be located in towns 15 to 20 minutes away, the firefighters are often first to arrive at an EMS call.
More progress needed with rural EMS integration
While progress has been made towards integrating rural EMS, the industry still has a long way to go to achieve recommendations made in the 2006 Institute of Medicine report, The Future of Emergency Care. The report proposed that future EMS efforts focus on emergency health care delivery in a manner that is regionalized, coordinated and accountable, and that those efforts involve EMS working with multiple systems in all arenas, as well as at local, state and federal levels to "enable continuous communication and enhance the benefits of overall system integration, including better and safer patient care."
Failure to integrate EMS into local systems of care and into regional and national networks is likely to result in ongoing deterioration that further limits availability and access to advanced EMS care in rural and frontier areas, Sanddal asserted. But integration is only one component in the future viability of rural EMS. “We also need to figure out a way to pay for EMS and support it long term,” Sanddal added. “Who is going to take on the planning responsibility for this critical part of our health care system?”
Unfortunately, there doesn’t appear to be an answer to that question. What rural patients can expect in terms of prehospital care still depends greatly on where they live.