Quality Improvement and Safety Abstracts for the 2024 National Association of EMS Physicians Annual Meeting

Presented here are the six abstracts from the quality improvement and safety poster session, held at the National Association of EMS Physicians (NAEMSP) Annual Meeting in Austin, Texas in January 2024. The session accepts sub-missions on successful quality improvement and safety projects. All submissions were reviewed and scored in a blinded fashion by a selection committee made up of representatives of the NAEMSP Quality and Safety Committee. The order of listing is random. Abstracts have been minimally edited for journal style.


Introduction:
Research has identified risks among some patient groups who decline ambulance transport.To mitigate these risks, front-line paramedics in our EMS agency have an option to refer patients for community paramedic follow-up.Quality assurance activity signaled the referral was underused.With the arrival of COVID-19 and its associated increase in nontransports, we aimed to improve the existing referral process and reduce the potential heightened risk to vulnerable, nontransported patients.Objective: Our service conducted a quality improvement project aiming to increase the number of referrals to community paramedics through the existing at-risk referral (ARR) process.Methods: After evaluating the key drivers affecting the ARR process, our team applied successive knowledge-building tests of change that informed modifications to the referral process.Adopted changes included: (1) stipulation that COVID-19 patients who decline transport receive an ARR; (2) new protocol guidance for ARR criteria; (3) a documentation rule supporting policy direction; and (4) virtual and in-person education to address the knowledge gaps identified through Plan-Do-Study-Act (PDSA) cycles.Education delivered to front-line crews emphasized ARR and nontransport decision-making concepts, and the nuance of emerging COVID-19 disease knowledge in this context.The primary measure was the total monthly number of ARRs, analyzed with a PDSA annotated run chart.The project period ran from January 2019 to March 2022.Results: There were 14,322 ARRs submitted over the 39 months of the project period.From January 2019 until March 2020, a run-chart analysis reveals a stable process with a median of 42 ARRs per month.A trend of increasing ARRs outside of previous stable limits began in April 2020 and reached a high of 302 (July 2020).This trend stabilized into a shift in November 2020 for the remainder of the project period, with a median of 770 ARRs per month.Conclusion: A local quality improvement project increased the number of referrals to community paramedics among potentially vulnerable 9-1-1 callers who declined transport during COVID-19.Future analysis aims to evaluate the effects of the referrals and balancing measures of the change on patient and system outcomes.Results: Over a 24-month period a series of learning and implementation PDSA cycles were performed that resulted in improvement from a median of 15% non-RLS response to the current median of 32%, more than doubling the number of responses managed without the use of RLS.

Conclusion:
The current EMD card changes are being managed by responder knowledge, and further improvements will require programming changes in the computer-aided design (CAD) to support crews with system tools.The learning PDSAs identified that the lay-public community groups were frequently more ready to embrace reducing RLS use than the field responders.Further education of responders around the risks and benefits of RLS use will be required, and the community acceptance of RLS reduction should be a component of that education.Sustained performance improvement was achieved through many interventions and not just one "root cause" solution.Background: Mechanical thrombectomy has become standard treatment for patients with acute ischemic stroke caused by large vessel occlusion (LVO).Currently mechanical thrombectomy is only offered at comprehensive stroke centers (CSC).Prehospital triage of patients with suspected LVO is considered the "holy grail" of stroke innovation.Vision, aphasia, neglect (VAN) is a large vessel occlusion screening tool developed to assess functional neurovascular anatomy.Prior studies have demonstrated that VAN is easily taught, adopted, and accurately identifies patients with LVO.Problem: A multitude of stroke assessment tools exist.Some have been developed for LVO screening but with limitations.In our system, many patients with LVO were being transported to primary stroke centers rather than the CSC in our system.This led to limitations in care or delays due to the need for transfer to the CSC.Interventions: We aimed to increase utilization of helicopter EMS (HEMS) for transport of suspected LVO occlusion strokes directly from the scene to a CSC.Updated 2022-23 statewide standing orders included implementation of the VAN stroke assessment and time criteria for direct transport to a CSC.Initial statewide training for ALS clinicians involved didactic education and hands-on skills.Follow-up education was tailored to encourage the utilization of air assets by ground paramedics in the two counties furthest away from the comprehensive stroke center.Results: Use of HEMS for transport of stroke patients increase by three times with initial rollout of new standing orders.With focused follow-up education, the transport rate further increased.Conclusions: Focused education on use of VAN for identification of possible LVO stroke was associated with increased utilization of HEMS for direct transportation of patients from the prehospital scene to a CSC.Future: Direct case-by-case follow-up working with the state stroke system to assess accuracy of transport decisions.Introduction: Ambulance diversion and delays in ambulance patient offload times (APOT) are increasing challenges across acute-care delivery systems.A municipal EMS system initiated a multi-disciplinary and multi-organizational continuous quality improvement (CQI) program to reduce APOT and ambulance diversion in a sustained manner.

The Carrots and
Objective: System-wide objectives were to reduce the 90th percentile APOT to less than 30 min city-wide, and reduce total ambulance diversion hours by 20%.Additional, hospital-specific targets aimed to lower diversion usage and APOT by 5% month-on-month.Interventions: In January 2022, a CQI initiative targeting reduction in diversion and APOT was begun.First, a multi-disciplinary committee was convened with representation from the local EMS agency, ambulance providers, and hospital systems.The committee conducted a value stream mapping exercise and identified root cause contributors and possible countermeasures to test within both EMS system policy and health care system operations.Target improvement and operational metrics were added to EMS system policy by Fall of 2022.Initial improvement efforts focused on diversion reduction, while a second phase focused on APOT.Results: There was a reduction of average total daily diversion hours (across all hospitals) from a baseline of 32.5 hospital-hours in January 2022 to 24.9 hospital-hours in June 2023.The largest hospital to reduce diversion hours was the trauma center (from 15.6 to 9 h daily).Diversion suspension (due to four hospitals initiating diversion at one time) was reduced from a peak of 49% to 23% of diversion hours.Use of "trauma override" status to keep the trauma center on diversion was reduced from a peak of 9.4 h per day to 4.5 h per day.System-wide APOT did not change from the onset of the CQI program, with a 90th percentile APOT of 40 min noted in January 2022 and June 2023.However, system APOT was reduced from a peak 52 min after the second (APOT-focused) phase of the initiative began, with individual hospitals trending toward improvement.Conclusions: Multi-stakeholder engagement in EMS system improvement efforts, with clearly defined targets, can lead to improvements in efficiency in transfers of care from the prehospital to hospital setting.
Mercer a,b , Andrew Holcomb a,b , Ryan Seymour a,b , Elaina Gunn a,b , Kayleigh Hillcoat a,b , Christopher B. Colwell a,b , and John F. Brown a,b

Compliance for Prehospital EMS Clinicians through Automation of Quality Assurance Program
Our outcome measure was noncompliance rate, and we also monitored balancing measures of ketorolac administrations and pain management rates.Results: Data gathering and project conceptualization began in January 2023.During review, we identified 13 clinicians with high rates of noncompliance (�20%) and common reasons for noncompliance (age 41.4% and clinician impressions 30.3% of noncompliance, respectively).After several PDSAs with no improvement (board post, intermittent coaching, and a brief online reminder during quarterly training), an in-depth email detailing the project was shared with the company.Additionally, all field clinicians were subscribed to an automated alert that emailed individuals if they had noncompliant administrations.Since April, our noncompliance rate has improved to an average of 5.7%, down from 2022s rate of 12.1%.
Conclusion:Leveraging the Model for Improvement and automated alerts has resulted in improved ketorolac compliance.Using charting software to perform background monitoring and to automatically alert clinicians with guideline deviations, we have seen improved performance, more timely feedback, and increased capacity of the quality department.Future plans include mirroring the automated system for other medications.3.

National EMS Quality Improvement Partnership: Reducing Lights-and-Siren Use in EMS
, and discussion were performed on SimpleQI, a cloud-based quality improvement platform.Four 4-H learning sessions and one-on-one QI support between sessions was provided.Resources were shared including examples of dispatch guidelines, clinical protocols, curricula for teaching EMS clinicians about the use of L&S, and a press release for community engagement.
participate in a 15-month QI project to reduce L&S use during EMS responses and transports.Using the Institute for Healthcare Improvement Breakthrough Series Collaborative format, the aim was to increase the percentage of 9-1-1 responses without L&S to 70% or greater and for transports to 95% or greater.PDSA cycles, data tracking, analysis, resource sharing