coughenour rural challenges in ems

8/11/2019 COUGHENOUR Rural Challenges in EMS

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Rural Challenges in EMS

Outcomes andPerformance

Improvement

Jeffrey Coughenour MD FACSAssistant Professor of Surgery and

Emergency MedicineMedical Director, Mitchell Trauma Center


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Disclosures

Industry supported research

Reflectance Medical, Inc. and ZOLL Medical

Content expert, not legal expert


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Objectives

Define tenets of a successful patient safetyand performance improvement (PIPS)program

Prohibitions

Legal protection


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Health Care Risk

Complex technology

Constantly changing medications and best-practice

Individual competence

System constraints

Patient variation, co-morbid conditions


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Optimal Outcomes

Mitigate risk

Performance improvement and patientsafety (PIPS) process and outcome

Depends on your perspective


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PIPS Defined

A continuous, multidisciplinary effort tomeasure, evaluate, and improve the process

of care and its outcome

Major objectives

Reduce inappropriate variations in care

Improve patient safety


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PIPS

Supported by reliable method of datacollection, valid and objective

Multidisciplinary review defines correctivestrategy

Effect of change documented as cyclerepeats


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Intubationsuccess rates

Intubation success ratesby provider, location

Targeted education,equipment

Didactic and practicalskills, scenarios


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Participants

Multidisciplinary Committee

Input from several disciplines

System issues

Peer Review Committee

Experienced providers, objective review

Individual, case-specific issues


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Systems Hospital

Trauma surgeons

Specialty serviceliaisons

OR services

Intensivists/ICUleadership

Rehabilitationservices

EMS

Hospitaladministration

Nursing leadership

Prevention

Education

Trauma registry

Respiratory therapy Transfusion services


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Systems EMS

Medical director

Service administrator

Board representation

Service representative(EMT, EMT-P)

Hospitalrepresentation (TCDdisciplines)

Mutual aid services Fire

Law enforcement

Air service


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Peer Review EMS

Medical director

Service administrator

Board representation

Service employees(EMT, EMT-P)

Administrator and/orrepresentation fromadjacent services

Hospital TCDrepresentation*


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Leadership

Medical direction

Champion, defines data dictionary, categoriesof review, leads multidisciplinary discussion to

formulate corrective action

Program manager

Logistics


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Accountability

Empower the program to address issuesthat involve multiple disciplines

Approval, governing body

Adequate administrative support

Define lines of authority and responsibility

Committee

Membership


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Opportunity for Improvement

Eliminate language that places blame

Not punitive

Constructive and all-inclusive


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Issue Identification

Event

Error, mistake, incident, accident or deviation,regardless of patient harm

Patient safety

Avoidance of injury or AE resulting fromprocesses of health care delivery

The Joint Commission, 2008


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Issue Identification

Concurrent process best

Data dictionary

Medical record Referrals, feedback

External audit filters


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Validation

Systematic approach

Real issues that require multidisciplinaryinput and potential for system change

Necessary for completion of the cycle


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Documentation

Issue identification

Case summary

Corrective actions Documentation of resolution, re-

evaluation, loop closure


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TJC Taxonomy

Impact

Outcome or effect of the issue, harm, etc.

Type

Implied or visible processes that were flawedor failed

Domain

Characteristics of the setting where the issueoccurred, individuals involved


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TJC Taxonomy

Cause

Factors that led to the issue/incident

Prevention and Mitigation

Corrective action plan


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Case 1

54, MVC, transfer from NTC in evening 8hours after injury

Initially hypotensive, now stable after 6Lcrystalloid, 4 PRBCs

Pulmonary contusions, rib fxs, open tib/fib,brain injury GCS 13

Suspicion of lower thoracic spine fracture


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Case 1

Ortho requests spine clearance prior to OR

NS recommends MRI for thoracic spine

Develops cyanosis despite good rhythm onMRI monitor

Removed from MRI, asystolic

CPR instituted, resuscitated, severe anoxicinjury


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Case 1

Support withdrawn 5 days later

Further review indicted significant basedeficit with near collapse of vena cava onarrival


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Case 1

Impact

Medical: Death

Non-medical: Potential legal consequences

Type

Communication: Questionable advice

Patient management: Questionable delegation,

correct study but untimely


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Case 1

Domain

Setting: Diagnostic procedures

Staff: Resident, nursing

Cause

Organization: Culture

Human: Provider knowledge

Prevention and Mitigation ?


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Case 2

Adult female, missed BCVI causedalteration in screening guidelines


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Case 3

Difficult airway in the ED, severalopportunities for improvement


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Case 4

Difficult field intubation, fatal injuries

No immediate action necessary

Referral to ground EMS for education?


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Case 5

Inefficient evaluation leads to change inpractice


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Prohibition

Lack of buy-in from medical staff and/oradministrative leadership

Punitive, not constructive

Amount of effort

Fear


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Protection

Chapter 537, Torts and Actions forDamages

Section 537.035 Defines health care

professional Physician/surgeon, dentist, podiatrist,

optometrist, pharmacist, chiropractor,

psychologist, nurse, social worker, professionalcounselor, mental health professional


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Protection

permitted or required to disclose any informationacquired in connection with or in the course of suchproceeding, or to disclose any opinion, recommendation,or evaluation of the committee or board, or any member

thereof; provided, however, that information otherwisediscoverable or admissible from original sources is not tobe construed as immune from discovery or use in anyproceeding merely because it was presented during

proceedings before a peer review committee nor is amember, employee, or agent of such committee


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Protection

19 CSR 30-40.375 Uniform Data Collection

19 CSR 30-40.430 TC Designation Standard 4(B) 3. A regular multidisciplinary trauma conference

that includes representation of all members of thetrauma team, with minutes of the conferences toinclude attendance and findings.


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PSO Protection

Patient Safety and Quality ImprovementAct, 2005

Patient Safety Evaluation System requiredpart of the ACA

Patient safety work product may still bediscoverable if required reporting

Kentucky Supreme Court; Tibbs, et al. v. Bunnell(2012-SC-000603-MR)

Fancher v. Shields (Jefferson Circuit Court Div. 2 10-CI-4219)


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Summary Points

Measure, evaluate, improve the process ofcare and outcomes

Valid, objective data collection

Honest inspection, multidisciplinary input

CAP focused and obtainable


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Summary Points

Document to your needs and comfort level

Peer review protection difficult topic

Not easy but immeasurable benefit toyour program and patients

Why are you here?


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coughenour rural challenges in ems

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