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Best Practices for EMS
A best practice can be defined as a technique, method, process, activity, incentive or reward that's more effective at delivering a particular outcome than other techniques, methods, processes, etc. By using proper processes, checks and testing, the thinking goes, projects can be rolled out and completed with fewer problems and unforeseen complications.
Best practices do not commit people or companies to inflexible, unchanging traditions. Instead, the best practices approach is a philosophical model centering around continuous learning and improvement based on evaluating current processes and breaking down what's worked, how and why. By understanding this, these methods and systems can then be shared elsewhere without a need to replicate them exactly.
Unfortunately, in today's clinical, training/education or even operational realms, there are precious few tested best practices and little way to adequately share them with the EMS community at large. In this article, we highlight several initiatives and practices that are being successfully implemented by EMS organizations in the U.S.
Conclusion
EMS systems are in a constant state of flux, with issues and directives constantly evolving and re-evolving. These include training programs, federal and state laws and guidelines, day-to-day operational realities and more. One way EMS managers can ease this burden is by sharing best practices. While resources and personnel differ from system to system, best practices should serve as inspiration, providing a framework for improvement, but being as modifiable as required by local circumstances. The challenge, for EMS agencies brave enough to break old patterns to gain needed improvement, is to make these proven ideas even more relevant by implementing them in our own backyards.
Black Box Technology
One of the most dangerous tasks undertaken in EMS is driving an emergency vehicle. An operator has to concentrate on traffic flow, emergency radio transmissions, geography and updates on patients' conditions. Inherent distractions like these make risk reduction and management-that is, improving safety and performance while reducing accidents and operating costs-difficult at best.
Ambulance crashes are usually about the drivers. In 2001, researchers conducted a retrospective analysis of all fatal ambulance crashes reported to NHTSA's Fatality Analysis Reporting System (FARS) from 1987-97. During this 10-year period, 339 ambulance crashes caused 405 fatalities and 838 injuries. Sixteen percent of ambulance operators in the study results were cited, of whom 41% had poor driving records.1 As well, a review of fatal ambulance crashes occurring between 1991-2002 that appeared in the CDC's Morbidity and Mortality Weekly Report in 2003 found that driver-related factors, like driving too fast or in the wrong lane, seemed to have a greater impact than weather and road conditions.2 Poor driving histories by vehicle operators were also shown to be significant predictors for fatal crashes, both overall and among EMS workers specifically. Almost 50% of crash-involved ambulance drivers had some kind of collision or moving violation in the three years before their fatal event, and a special group had more than one offense listed in the FARS database.
So what's an EMS agency to do? Other than patient care, the major responsibility of EMS providers is transportation of the sick and injured. It would seem obvious that such transportation is expected to occur in a safe and prudent manner. So, just as a responsible EMS agency conducts routine quality improvement and assurance reviews of the patient care rendered by its personnel, why shouldn't those same administrators review driving habits? The answer from most EMS leadership would be that they can't monitor every driver every minute they have an ambulance out on the road.
Or can they? One of the best tools in this regard is implementing on-board computer systems, aka "black boxes," for ambulance fleets. These devices can monitor and record unsafe vehicle operation when drivers exceed set parameters for things like speed and g-forces caused by rapid accelerations, hard decelerations and high-speed turns. They can also monitor other important safety indicators, such as use of seat belts, use of a spotter while backing up and proper utilization of emergency lights and siren. Some can provide immediate in-vehicle audio feedback to drivers who start driving unsafely. Most of the common models are able, much like aircraft flight data recorders, to monitor driver behavior and store the information for retrospective analysis. This allows the identification and correction of bad habits before they result in crashes, injuries or deaths. The most widely used black box product is the Road Safety SafeForce System.
After a few months using black box technology, significant changes in workforce driving behavior are not only possible, but probable. In fall 2002, Metro EMS of Little Rock, AR, facing an average of one severe crash and several smaller incidents involving agency vehicles each year, began a project to reduce its accidents rates and wear and tear on its vehicles by using Road Safety. After a couple of months spent educating the staff about on-board computer systems and preparing them for the project, the black boxes were installed in March 2003. The units were implemented in three phases: 1) For four weeks they silently recorded driver behavior; 2) for the next two months, they emitted warning tones for incidents of unsafe driving; 3) finally, identifying key fobs were introduced to link the computer records to specific drivers. The results were amazing: By that June seat belt violations plummeted from a high of over 13,000 per month to almost nonexistent. Monthly episodes of speeding, which had hovered between a quarter and a half million, also dropped, with some minor spikes, to roughly 2,000 or less. Occurrences of "force overs," or hard cornering, dropped from 25,000 a month to less than 3,000.
During the evaluation period, which covered 18 months and 1.9 million service miles, there was only one minor ambulance crash. And the benefits were not just safety-related: Metro EMS experienced a 20% cost savings in vehicle maintenance within six months, with 10%-20% less brake and tire wear and reduced oil consumption. As a result of these savings, the on-board computer system paid for its own implementation in one year.4
Sunstar EMS, in Pinellas County, FL, saw similar results. According to director Chuck Kearns, after the system was installed into all Sunstar vehicles about five years ago, it had a measurable impact on safety almost immediately. The first year the number of accidents went from 19 to one. As was the case with Metro EMS, Sunstar also experienced cost savings in maintenance, especially in brake-system repairs and the need for replacement parts. Previously, front brake pads lasted 5,000 miles; now vehicles can go more than 20,000 miles before replacement. Multiply this over a sizable fleet, and the savings become significant.5
An unexpected side benefit for both organizations came in handling complaints. Metro EMS was able to refute an allegation that a vehicle had stopped at a McDonald's en route to the hospital by verifying in the system that its vehicle had made no unscheduled stops. Sunstar received a complaint that an ambulance was seen speeding. The administration asked the complaining resident for the time and location of the incident, and the unit number on the side of the vehicle in question. Once that information was obtained, the history of that truck was reviewed in the database, and it was found that the crew had not been speeding.
In the past, these administrations may have been put into a position of not knowing what really happened and having their crews cautioned or disciplined unfairly. This time it could be proven unequivocally that the complaints had no merit.
For more information regarding Road Safety products, visit www.roadsafety.com.
Gelatin IV Model
Any advanced EMT remembers the first time he started his first IV on a real person. Squeamishness aside, what's probably most memorable is how dissimilar the experience was from practicing on the disembodied, trackmark-pocked training arm in their class lab. Visit most paramedic programs today, and you'll probably find IV arm models made of ridged pieces of rubber over plastic and foam forms with plastic tubes running under the rubber to simulate veins. The tactile sensation is nothing like human flesh, and the holes in the "skin" made by any catheter larger than a 24-gauge remain open, allowing the "veins" to leak uncontrollably.
While more sophisticated simulation for general medical training is now possible through the use of full-size computerized manikins, these units are very expensive. Smaller training centers and EMS agencies doing skill retention by and large still rely on the thick-skinned, hole-riddled but relatively cheaper IV arms. The general sense is that these tools are a compromise: While they may not give an accurate sense of the skill, at least they are a relatively inexpensive way to work on the process before students are unleashed upon their patients.
A few years ago Dr. Susan Stroud was faced with an even more frightening prospect when she took over the medical student procedures lab at the University of Utah Medical School: When it came to training medical students on the placement of IVs, Stroud was told that the previous instructor had had the students practice on each other, without the benefit of any training models-they got only a slide show before being let loose among their classmates with tourniquets and catheters.
Dismayed at the school-sanctioned bloodletting, Stroud set about changing the practice. Researching the purchase of commercial training arms, she was stunned by their cost. After considering some of the more amorphous, flat-surfaced models with submerged veins, Stroud determined she could probably come up with something similar at a fraction of the price. And so the gelatin intravenous model (GIM) was born.6
The GIM offers some features commercial IV trainers do not. First, it is easily (and cheaply) built out of readily available materials: a baking pan, gelatin mix (the real stuff, not Jell-O) and some Penrose drains sealed with fake blood inside, and you have yourself a GIM. Second, unlike the rubber-armed versions, multiple IV sticks into the GIM do not cause the junkie look after just a few sticks-the holes reseal, preventing free-flowing loss of the filling in the submerged "vein." The final, and most important, benefit is that the tactile experience provided by the GIM is reportedly more like human flesh than some of the higher-end IV trainers: The "skin" gives under pressure, and the "veins" can roll.
A good idea rarely stays secret long, and Stroud's recipe has made its way beyond the University of Utah and into other medical programs. This led to the discovery of another great feature: It's modifiable. According to Stroud, one program adjusted the recipe to make it thicker, so it could use the GIM to train residents to put in central lines. The GIM is also being used to teach residents and ED techs how to place peripheral IVs and central lines using ultrasound.
At the IV clinic Stroud conducts every year, response from both students and trainers has been overwhelmingly positive. But despite such feedback, the question remains: Will it work for EMS? This simple yet effective training innovation so tickled the interest of emergency physician David Cone, of Yale University, that he and a colleague decided to study its use by paramedic students. A critical, demanding and sometimes-stubborn group, EMS providers typically do not suffer bad ideas gracefully. Given its lack of aesthetics (it looks like ballistic gel in a box) and the simple preparation ("What do you mean the medical director made this?"), the GIM looked like something likely to be panned. But while Cone's sample size was small (14 students), the results were surprising: Using a Likert scale of 1-5 (5 being best or strongly agreed) to rate the students' perceptions of ease of use, realism and effectiveness, especially when compared to traditional rubber arms, students gave the GIM high marks across the board, with mean scores above 4 in each category. As Cone and Vivek Parwani noted in their writeup of this study in the Oct.-Dec. 2006 issue of Prehospital Emergency Care, given the financial constraints faced by most EMS training programs, this model is definitely a viable alternative.7
For more information regarding the GIM, see the full set of instructions in Prehospital Emergency Care 10(4): 515-17, Oct.-Dec. 2006.
Online Scheduling/Staffing
One of the biggest headaches an agency administrator can face is scheduling their staff. When you have to consider vacation time, personal time, requests for shift changes, sick time and other unplanned events, putting together a workable schedule for a 24/7 service, then communicating it to the whole organization in a timely manner, can be a thankless, time-consuming job. Volunteer service manpower coordination can be even more of a challenge, since paid work can trump volunteers' commitments, leading to more last-minute needs for coverage.
Enter www.emsplanner.com, an online scheduling service for EMS agencies that enables administrators to easily manage shift schedules. The idea came to Brian Yun in March 2005, when he was the director of quality improvement for Tufts University EMS in Medford, MA. Encountering frustrations like those described above, Yun decided to look for a user-friendly online scheduling program. Unable to find one that was affordable and allowed individual members to sign themselves up, he contacted his friend Noah Spitzer-Williams, a Computer Science major, to see if he could build a prototype that fit Tufts EMS's needs. Spitzer-Williams did, and after a trial period of two months-which resulted in an overwhelming positive response from the Tufts EMS administration-the duo decided to create a more professional program and market it for other volunteer EMS organizations. EMS Planner resulted; it is currently used by a number of collegiate and municipal (private and town) EMS agencies in the northeast.
EMS Planner serves as a solution to inefficient methods of pen-and-paper and whiteboard scheduling, or having members e-mail their availability to someone who must integrate it all into a general schedule. It is easy to use and cost-effective. The system is completely Web-based, so there's no software to install and maintain on local computers. Members sign themselves up for shifts, then the administrator accesses the schedule to approve or reject those requests. The two levels of programs EMS Planner offers, basic and premium, have no limit on the number of users enrolled per agency.
Having its roots in the world of collegiate EMS, the system is kept affordable for even the smallest of services. The basic program costs $800 a year and offers online scheduling, a customizable calendar and features such as e-mail reminders and member statistics. The premium package, for $200 more a year, expands to include such features as a message board, text-message reminders and additional setup details. EMS organizations can sign up online and set up their schedules in less than an hour. Agencies can engage in a free 90-day trial before deciding to commit.
Agencies that have implemented EMS Planner report less frustration with the scheduling process. These services have a better handle on their scheduling needs and can communicate them readily. This sort of tool can only help increase member retention. When you consider the time and effort normally spent not only developing a schedule, but also sending out reminders to submit availability or requests to fill empty shifts, tracking employee/member hours or just communicating to everyone about various issues, this type of system pays for itself.8
For more information, visit www.emsplanner.com.
References
- Kahn CA, Pirrallo RG, Kuhn EM. Characteristics of fatal ambulance crashes in the United States: An 11-year retrospective analysis. Preh Emerg Care 5(3): 261-9, Jul-Sep 2001.
- Centers for Disease Control and Prevention. Ambulance crash-related injuries among emergency medical services workers-United States, 1991-2002. MMWR52(8): 154-56, Feb 28, 2003.
- Proudfoot SL. Ambulance crashes: Fatality factors for EMS workers. Emerg Med Serv 31(6): 71-4, Jun 2005.
- Levick NR, Swanson J. An optimal solution for enhancing ambulance safety: Implementing a driver performance feedback and monitoring device in ground emergency medical service vehicles. Annu Proc Assoc Adv Automot Med49: 35-50, 2005.
- Kearns C. Personal correspondence, Nov. 20, 2006.
- Stroud S. Personal correspondence, Nov. 13, 2006.
- Parwani V, Cone DC. A novel inexpensive IV catheterization training model for paramedic students. Preh Emerg Care 10(4): 515-17, Oct-Dec 2006.
- Yun B. Personal correspondence, May 3, 2006.
Katherine O'Connor, BS, EMT-P, is an EMS systems specialist for the Westchester County Department of Emergency Services in Valhalla, NY, and the program coordinator for the Westchester Regional EMS Council. Katherine has 16 years of EMS experience as both a BLS and ALS provider and educator. She can be reached at oconnor.ke@gmail.com.
Raphael M. Barishansky, MPH, is the deputy director of the New York City Department of Health and Mental Hygiene's Bureau of Emergency Management. Ray has over 16 years of experience in EMS as a provider, manager, author and lecturer. He is also a member of EMS Magazine's editorial advisory board. He can be reached at rbarishansky@gmail.com.
If your agency is engaged in a "best practice" you would like to see highlighted in EMS Magazine, e-mail nancy.perry@cygnusb2b.com.
