Michigan Prehospital Pediatric Continuous Quality Improvement Project

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Michigan Prehospital Pediatric Continuous Quality
Improvement Project

• William D. Fales, MD, FACEP
• Michigan State University
• Kalamazoo Center for Medical Studies

Supported in part by MC 00126 01 from the
Department of Health and Human Services, Health
Resources and Services Administration, Maternal
and Child Health Bureau.
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Background

• EMS adult CQI statewide inadequate
• Virtually no pediatric CQI
• Michigans electronic EMS information system,
  MERMAID was becoming established
• Many local EMS systems had adopted model
  pediatric prehospital protocols.

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Traditional EMS Quality Improvement

• Typically Retrospective
• Often Case-Focused
• Review fall-out cases
• Negatively focused
• Resolutions often associated with punishment
• Not real popular with EMS personnel

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Example of Case-Based Retrospective EMS Quality
Improvement Process
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Medical Director Discovers Badness
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Problem Paramedic Contacted
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Search for Additional Problems
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Very Thorough Search
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Confrontation of Paramedic
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Get Those Bad Medics Off the Street
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Public Flogging
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Ultimate Penalty Permanent Revocation
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Michigan Prehospital Pediatric Continuous
Quality Improvement Project

• Goal Create a pediatric-focused CQI Model and
  determine its impact on protocol compliance.
• Assumption Protocol Compliance Quality

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Methodology

• Created a CQI Model
• NHTSA Leadership Guide to Quality Improvement
• NEDARC Quality Improvement References
• Used MERMaID Electronic Medical Record

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MERMaID
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Methodology (cont)

• Selected 30 agencies
• Randomized into Intervention and Control Groups
• Peds vs. Adult Stroke
• CQI Workshops
• CQI Software
• Baseline Performance Data Acquired
• Monthly Aggregate Feedback to Agencies / Personnel

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Clinical Indicators

• Created by multi-disciplinary panel
• Pediatric Indicators
• Trauma
• Respiratory distress
• Seizure
• Pain management
• Adult-Stroke

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Results

• 30 Agencies Recruited
• 21 submitted data
• HIPPA phobia
• Smallest agencies lost
• Diverse Population
• 2 MSAs
• Kalamazoo and Saginaw
• Many rural agencies

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Project Population
Pre-CQI Interv. Pre-CQI Control Post-CQI Interv. Post-CQI Control TOTAL
Total Patients 24,756 25,679 37,640 40,298 128,373
Ped Patients (lt16 YO) 2,129 2,199 3,237 3,457 11,022
Peds 8.6 8.5 8.6 8.5 8.6
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Findings

• No significant differences between
• Pre- and post-CQI
• Intervention and control group
• All groups did well (gt85) with documenting
• Meds / Allergies
• Peds GCS
• Vital Signs

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Respiratory Distress

• 6 to 11 of all pediatric patients
• O2 documented in 43 to 57 of these
• Likely a documentation issue
• Bronchodilator indicated 16-22 of resp dist.
• All received gt1 bronchodilator treatments
• EMS did very well in providing bronchodialtor
  treatment!

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Seizure

• 5 to 10 of all pediatric patients has seizure
  related condition
• 72-93 IV access attempted (GCSlt15)
• 81-95 Blood glucose checked (GCSlt15)
• 3-4 of Seizure related patients hypoglycemic
• 0-50 of hypoglycemics treated
• 6-13 received anti-convulsant

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Trauma

• 16 to 19 used a Trauma protocol
• Subset of all trauma patients
• w/ Altered LOC 6-11 of those with trauma
• w/ Load and Go 7-12 of those with trauma
• gt97 spinal immobilization (when indicated)
• gt92 IV access attempted (when indicated)
• 37-52 Load and Go (lt10 min. _at_ scene)
• Rapid trauma management remains a challenge!

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Pain Management

• 15 to 20 of all pediatric patients had
  potentially painful condition
• Pain scores documented 32-40 of time
• Pain score gt4
• 12-17 of those with likely pain
• 3-4 of all ped patients
• Of these 18-36 received analgesia
• Prehospital pain management remains an important
  challenge!

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Limitations

• Small numbers within all subgroups
• Use of protocol compliance as an indicator of
  quality
• CQI interventions varied by agency
• Most primarily provided aggregate feedback
• Limitations that could not be controlled
• e.g., medical control denied pain medication
  request
• These are extremely low frequency events!

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Conclusions

• We were unable to demonstrate improved protocol
  compliance using a contemporary CQI model.
• Positive areas of pediatric care
• Collection of baseline patient data
• Checking blood glucose and attempting IVs
• Spinal immobilization in trauma
• Bronchodilator use in respiratory distress
• Areas in need of further efforts
• Pain management
• Rapid trauma management

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What is the Next Step?

• MI 1st STEPPS
• Michigans First Simulation Training and
  Evaluation of Paramedics in Pediatrics
• 2005 EMS-C Targeted Issues Grant
• Evaluate impact of brief training every 4 months
• Compare simulation-based and non-simulation based
  instruction

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Thanks

• www.emscqi.org
• fales_at_msu.edu