1. 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.

2. Background EMS adult CQI statewide inadequate Virtually no pediatric CQI Michigan’s electronic EMS information system, MERMAID was becoming established Many local EMS systems had adopted model pediatric prehospital protocols.

3. 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

4. Example of Case-Based Retrospective EMS Quality Improvement Process

5. Medical Director Discovers Badness

6. Problem Paramedic Contacted

7. Search for Additional Problems

8. Very Thorough Search

9. Confrontation of Paramedic

10. Get Those Bad Medics Off the Street

11. Public Flogging

12. Ultimate Penalty Permanent Revocation

13. 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

14. Methodology Created a CQI Model –NHTSA Leadership Guide to Quality Improvement –NEDARC Quality Improvement References –Used MERMaID – Electronic Medical Record

15. MERMaID

16. Methodology (con’t) 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

17. Clinical Indicators Created by multi-disciplinary panel Pediatric Indicators –Trauma –Respiratory distress –Seizure –Pain management Adult-Stroke

18. Results 30 Agencies Recruited –21 submitted data –HIPPA “phobia” –Smallest agencies lost Diverse Population –2 MSA’s Kalamazoo and Saginaw –Many rural agencies

19. Project Population Pre-CQI Interv. Pre-CQI Control Post-CQI Interv. Post-CQI Control TOTAL Total Patients 24,75625,67937,64040,298128,373 Ped Patients (<16 YO) 2,1292,1993,2373,45711,022 % Peds 8.6%8.5%8.6%8.5%8.6%

20. Findings No significant differences between –Pre- and post-CQI –Intervention and control group All groups did well (>85%) with documenting –Meds / Allergies –Peds GCS –Vital Signs

21. 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 >1 bronchodilator treatments EMS did very well in providing bronchodialtor treatment!

22. Seizure 5 to 10% of all pediatric patients has seizure related condition 72-93% IV access attempted (GCS<15) 81-95% Blood glucose checked (GCS<15) –3-4% of Seizure related patients hypoglycemic 0-50% of hypoglycemics treated 6-13% received anti-convulsant

23. 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 >97% spinal immobilization (when indicated) >92% IV access attempted (when indicated) 37-52% “Load and Go” (<10 min. @ scene) Rapid trauma management remains a challenge!

24. Pain Management 15 to 20% of all pediatric patients had potentially painful condition –Pain scores documented 32-40% of time Pain score >4 –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!

25. 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!

26. 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

27. What is the Next Step? MI 1 st STEPPS –Michigan’s 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

28. Thanks www.emscqi.org fales@msu.edu