#5:  Create Benchmarks Designed to Prove our Worth.

This column has invested numerous bytes encouraging EMS to actively pursue the creation of empirical data that demonstrates that what we do actually makes a difference.  This needs to start locally in your service area.  Do STEMI patients who call 9-1-1 and receive ALS care in the pre-hospital setting have a better outcome in your community?  Does shaving 2 minutes off your fractile response times result in improved cardiac arrest survival outcome?  Does having two paramedics on a call improve patient outcomes in your area? 

Notice any themes here?  The two keys are ‘your’ and ‘outcome’. 

The term ‘outcome’ is one that is somewhat foreign in EMS.  We need to evaluate EMS services based on outcomes.  Philanthropic organizations used to fund programs based on ‘outputs’ such as how many school children received free breakfast, or how many uninsured persons received medical care in free clinics.  Today, these organizations realize that ‘outputs’ don’t really matter.  What matters is how many of the children who received free breakfast showed improvement in standardized testing scores, or how many of the uninsured patients required hospitalization for preventable illnesses before and after the clinic program was established. 

Focusing on your local area creates a manageable population upon to evaluate.  You know your area the best and can evaluate the outcomes of your efforts on a local basis.  Once enough local EMS areas have outcome data, the data can be combined and more globally evaluated.

#4: Abandon Tradition.

One phrase that should be eliminated from our vocabulary is “That’s the way we’ve always done it.”  This is a new year, a new environment and a new world.  Doing things the way we’ve always done it will not work anymore.  How we respond to calls, how we train our paramedics or even the type of services we provide all need to be objectively evaluated and changed in response to community needs.  If we continue to ‘wait’ for the call, send everyone as fast as they can and teach paramedics life-saving human skills on plastic dolls, our service model will be replaced with one that is more effective, safer and more highly skilled.  The people we serve are becoming smarter and more demanding.  Elected and appointed officials are asking questions like “Will consolidating services make the system more effective and efficient?”  “What’s the most cost effective way to reduce the time from the time someone calls 9-1-1 to the time an EMS professional is at the scene?”  Or my favorite, “If it’s just a cut finger, why were there 6 responders in my kitchen?”  The status quo will not be tolerated much longer. 

#3: Eliminate Mediocrity.

‘Good enough’ IS NOT “good enough”.  If there are aspects of your service delivery that are arguably mediocre, either improve them, or eliminate them.  The most obvious is ALS care.  We have a real problem in EMS that is finally gaining national attention – skills proficiency.  EMTs and paramedics are technicians – professionals who are supposed to be proficient at a particular skill.  Computer technicians fix computers, automobile technicians fix automobiles, paramedics fix people.  If the Geek Squad^® could only reformat your hard drive correctly 63% of the time, would you keep using them?  If you have to bring your car back to your mechanic 25% of the time a repair was done, would you change mechanics?  Why then do we accept performance by paramedics at the 60% proficiency rate??   It is amazing to me that EMS leaders will vehemently oppose adding a practical skills component to a paramedic exam and increasing the passing score for a written exam from 70% to 80%.  “Sorry ma’am that I gave the wrong drug, but I got that question wrong on the exam” is not an acceptable statement to a widow.  Neither is “Man, that trachea didn’t look anything like the one on the mannequin last year!”

#2: Remember Our Mission.

We have become so focused on the ‘activity’ of EMS that we’ve lost sight of the ‘mission’ of EMS.  We should move away from the “how can we get there faster?” concept to the “how can we reduce the number of EMS responses and save more lives?” mind set.  The concept of prevention is nothing new to EMS, especially fire-based EMS.  Fire departments use educational programs and inspections to prevent fires.  Why can’t we do this with EMS?  There is typically a relatively predicable call pattern in our local response areas, such as dangerous intersections, 9-1-1 system abusing assisted living facilities, or “old man Matt’s” house for the twice-weekly D50 bolus.  Use these patterns to create a safer, more responsive system to meet the needs of these high frequency responses.  Petition to have a traffic light put in the intersection or change the timing of an existing light, educate the ALF on the appropriate use of 9-1-1 and for goodness sake, go see Matt on regular basis and check his glucose level BEFORE he has a diabetic incident.

One of the seriously overlooked parts of our mission is the “First, do no harm” concept.  Hippocrates developed the medical oath based on this primary concept.  It not only applies to the actual patient we have, but with the potential patients we MAY have.  Just today in EMSN News (http://www.emsnetwork.org/) there are 5 articles within the past 24 hours about emergency vehicle crashes, all of which resulted in injury to either the emergency personnel or the people involved in the crash.  Is this consistent with the ‘do no further harm’ concept?  Probably not.  Take a hard and objective look at your system.  How many of the responses actually result in a patient transport?  How many of those transports require ALS care?  How many require a “HOT” transport to the hospital.  The answers may surprise you.  I’ll reveal our stats…  For the most recent 12 months in Volusia County, Florida, 57.5% of the EMS responses resulted a patient transport, 35.2% of those received ALS care, and only 9.7% were transported lights and siren.  Although a true medical emergency requiring a “HOT” transport only occurred 10% of the time, guess what % of the calls got a “HOT” First Response??  91.5% in some agencies.  See anything wrong with this scenario?

There are those that will say, “But you just never know if that cut finger in the kitchen might lead to hemorrhagic or worse yet, toxic shock, besides, it’s what we’ve always done and the public expects that!”  (See Resolutions #3, 4 and 5).

#1:  Keep the Patient as our #1 Priority

Let’s make some bumper stickers for EMS vehicles…  “It’s the Patient, Stupid!”  Or, “The Patient is Job 1!”  Too many decisions in EMS are based on the needs of companies, agencies, governments, unions or payers.  The 2006 legislative program for the Florida Fire Chief’s Association actually states on page 9: “501.8.2 – Oppose legislation or rule requiring the collection of data that is not aggregate in nature and/or allows itself to be subject to quality assurance investigation by the state or any other investigating body.”  Oppose quality assurance??  Do you suppose that is a patient focused statement, or a statement with some other agenda?  We all need to become advocates for the PATIENT, not our own agendas or empires.  This is already taking place in some arenas as EMS leaders become more and more aware that others are beginning to externally evaluate the level of service they provide.  Some EMS leaders are turning the corner to patient focused issues.  Those who used to ask, “How come you won’t let us transport patients?” are now beginning to ask “How can we improve our intubation success rate?” or “How can we increase the patient contact time for our paramedics?”  If we continuously ask ‘what’s best for the patient?’ the rest will sort itself out in the long run.

By subscribing to these or other similar ‘Resolutions’, who knows, maybe we’ll start a ‘Revolution’…  (Fade in the song from the Beatles…).

Happy New Year!