EMS Reason for Encounter (RFE) Greg Mears, MD FACEP Principal Investigator North Carolina EMS Medical Director University of North Carolina-Chapel Hill

RFE?  What is it?  When did this idea happen?  Where did the idea come from?  Why do we need it?  How do we get it?

What is it?  Coding system for EMS  Uniform description of the reason for an EMS encounter  Not diagnostic (not mapped to ICD-9)  Based on EMS curriculum skill set  Based on NHTSA dataset  Reproducible  A calculation, not a code

Reason for Encounter  Two year project  Funded by NHTSA

Where did the idea come from?  Problems  Quality Management  Patient Care  EMS System  EMS Technician  EMS Outcomes  EMS Research  Surveillance  Reimbursement

Example of Problem  Respiratory Distress could be:  Asthma  COPD  Pneumonia  Trauma-Chest wall contusion or pneumothx  Foreign Body  Congestive Heart Failure

Why do we need it?  Same issues  Quality Management  Outcomes  Research  Surveillance  Reimbursement  Also  System Design  Information Systems  Merging several systems data together  National EMS Database  Descriptive Information  Linkage or pass through to other healthcare information systems  EMS Policy and Funding

Final RFE  Definition  Purpose  Method  Datapoints  Evaluation

RFE Definition  An EMS reason for encounter is an objective description of the patient’s problem which forms the basis of EMS care, based on the compilation and/or calculation of existing EMS patient care report documentation.

Purpose  The RFE serves to subdivide EMS patients into defined groups which are reproducible, independent, and usable for EMS quality management.

Method  Dual Evaluation by pilot data to develop a final RFE  Cluster analysis based on all datapoints within either the NHTSA or PreMIS datasets. Did not reveal a valid method for RFE  Treed description based on Injury Complaint Location System Acuity Accepted method by the Task Force

Parameters  Must include all technician levels?  Must be derived from the NHTSA dataset? The datapoints will become a component of the NHTSA dataset version 2.0  Must conform to the EMS curriculum? The EMS curriculum addresses each of the datapoints at all personnel levels. The organ system data point was felt to only be valid for EMT-Paramedic level personnel  Must not require coding? Coding is not required, only completion of the datapoints as part of normal documentation

Analysis  Evaluate the models by validating the RFE with:  Provider coding of RFE  Hospital diagnosis Mapping RFE to Hospital Diagnosis failed. Decision: RFE must stand alone but be reproducible in the EMS community  Analysis for accuracy and reproducibility  Review of 500 NC PreMIS records which document RFE components  Multiple RFE’s per patient To complicated for the initial project. A single RFE per patient was determined to be the goal.

RFE Data Points  Injury Present  Primary Complaint Anatomic Location  Primary Symptom  Primary Complaint Organ System

Injury Present  Yes  No  Unknown Indication whether or not there was an injury.

Primary Complaint Anatomic Location  Abdomen  Back  Chest  Extremity-Lower  Extremity-Upper  General/Global  Genitalia  Head  Neck The anatomic location of the chief (primary) complaint as identified by EMS personnel

Primary Symptom  Bleeding  Breathing Problem  Change in Responsiveness  Choking  Death  Device/Equipment Problem  Diarrhea  Drainage/Discharge  Fever  Malaise  Mass/Lesion  Mental/Psych  Nausea/Vomiting  None  Pain  Palpitations  Rash/Itching  Swelling  Transport Only  Weakness  Wound The primary symptom present in the patient or observed by EMS personnel

Primary Complaint Organ System  Cardiovascular  Central Nervous System  Endocrine/Metabolic  Gastro-intestinal  Global/General  Musculoskeletal  Obstetrics/Gynecology  Psychological  Pulmonary  Renal  Skin The organ system of the patient chief (primary) complaint which is injured or affected, based on the evaluation of an EMT- Paramedic.

Verification  Large scale reliability of all EMS RFEs.  All technician levels  Rural vs. Urban  Volunteer vs. Paid  Other states, geography No able to be completed within time frame and funding level

Evaluation  500 Records were evaluated by the PI for the following:  Completion of the Datapoints based on the review of the Ambulance Care Report  Documentation of the EMT personnel level completing the form  Identification of a Volunteer or Paid EMS Service  Population of the Service Area

Evaluation Results Injury Present Anatomic Location Primary Symptom EMT-B 95/96 (99%) 92/96 (96%) 88/96 (92%) EMT-D 100/104 (96%) 98/104 (94%) 95/104 (91%) EMT-I 99/100 (99%) 96/100 (96%) 92/100 (92%) EMT-P 198/200 (99%) 195/200 (98%) 190/200 (95%)

EMS Reason for Encounter (RFE)