Pre-hospital PI assesses transport appropriateness and quality of care

Emergency medical services (EMS) systems date back to the 19th century, when Napoleon's chief surgeon devised ways to rapidly stabilize and transport wounded soldiers to field hospitals. On the most basic level, pre-hospital care hasn't changed much since then. It still involves using the best method to get patients to the right place as quickly as possible. Whether that happens successfully or not is the core of pre-hospital performance improvement (PI).

Mayo Clinic trauma surgeon Scott P. Zietlow, M.D., says, "When I look at PI in the pre-hospital setting, I look at three main categories. One is the appropriateness of transport. For example, there is a substantial difference in the capabilities of rotor-wing and fixed-wing aircraft and the care that can be provided in them. Some helicopters are profoundly cramped. Even placing a breathing tube or chest tube can be difficult. Those are important considerations from a trauma perspective."

Other considerations are quality of care en route, including the skill, training and experience of providers, the type of equipment available, and whether the patient was transported to the right place in the right amount of time.

"The last big area to look at is opportunities for improvement," Dr. Zietlow says. "How did it go? What could have been done better? Were protocols and guidelines followed? And if not, why not?" Answering those questions requires commitment, engagement and a PI process that really works.

Making it work

Flight nurse Kathleen S. Berns, R.N., C.N.S., says, "We have a flight team meeting every month where we review every trauma transport, and we use audit filters that bring things forward for review. If there is a problem, it's usually a systems problem. We look for a pattern that repeats over time. Then we address it with education, new guidelines, simulation training or e-learning. We're a profoundly experienced team, and we all know when things go well and when they don't, and sometimes even when we're doing our best, we don't end up with an optimal outcome."

She adds that peer review is also an integral part of the process. "We foster a very healthy environment where everyone is allowed to review openly. Some of what we do is borrowed from morbidity and mortality conferences. Our reviews are never punitive; we start by recognizing that everyone is trying to do their best and is profoundly interested in getting the best outcomes. We have a great program, with strong team involvement and support. You have to have that kind of culture or you can't do meaningful or accurate PI."

As for protocols and guidelines, ED practices are often adopted and adapted for use in the field. "What we do really is an extension of the ED in terms of the care provided," Berns explains. "We also do a lot of research and investigate what other people are doing. And we review our guidelines on a regular basis throughout the year, so they're as fresh and current and evidence-based as possible."

Challenges and rewards

In 2006, the Institute of Medicine (IOM) issued several recommendations for improving pre-hospital care. Chief among them was the development of national guidelines for treating and transporting patients based on the best available evidence. The IOM took this step because there were wide variations in pre-hospital trauma care and little evidence regarding outcomes.

Today, widespread differences in pre-hospital intervention still exist and performance improvement is highly variable.

Dr. Zietlow says, "So much depends on the community. Some have active PI and some don't. We're lucky because we have a system that works very well for us and other areas in the country do a very good job. But in some places, guidelines and protocols can be hit or miss. As more statewide trauma systems are implemented, that will become better. But right now, it's a challenge."

Even a designated trauma center in a good statewide system can have problems. One of the main difficulties at Mayo, Berns says, is the inability to integrate pre-hospital records with the hospital's electronic records. "It's really challenging to have two registries," she explains. "We can still do pre-hospital PI, but we have to be sure nothing falls through the cracks."

She adds, "Within Mayo, we have our own system in place. But there are other basic life support providers for southeastern Minnesota, and we don't own or run those systems. We might be face to face with those providers in the ED for seconds to minutes, and if we don't get all the information we need in that time, that's it, because they're on to the next job. We're trying to find a better system for that."

Finding better systems is an integral part of the PI process. By and large, Mayo Clinic's process is successful, although Dr. Zietlow notes it took time, hard work and an investment in resources to get there.

"If a center were to start a PI program tomorrow, they wouldn't be where we are now because of our experience and the trust that develops over time and the people we have. Many programs can't afford to invest in personnel. And many can't afford to review guidelines every year."

Berns adds, "We're quite unique in what we do. Our trauma department has a trauma video review; everything that happens in the trauma bay is recorded. So we really do PI every day. We have a lot of people looking at us, and occasionally they're not shy about telling us what we're doing wrong. We all know that what we do is high visibility, high intensity, high risk and high reward."

Pre-hospital PI has to have that same kind of ongoing intensity, Dr. Zietlow notes. "PI is an iterative process. You want things to go upward in a spiral, not in a circle. It's never really done."