Experts Note How to Drive Improvement in EMS Care Quality and Safety

By Dorothy Brooks

Important new research reveals there is considerable variation in the quality and safety of care provided by emergency medical services (EMS) agencies across the country, and that much of this variation can be tied to whether the EMS care was provided in an urban or rural area.

To establish these findings, investigators used the data from the National EMS Information System (NEMSIS) on all the EMS 911 responses that occurred in the United States in 2019.¹ Then, they assessed the performance of these responses on 10 of 11 key quality measures established by National EMS Quality Alliance (NEMSQA) in 2019, a relatively new nonprofit group established to develop evidence-based quality and safety metrics pertaining to care provided by prehospital providers.²

Michael Redlener, MD, FAEMS, medical director for the Mount Sinai West Emergency Department in the Mount Sinai Health System, medical director for the Mount Sinai EMS Service in New York City, and the lead author of this research, tells EDM that the idea behind this study was, for the first time, to merge the work of NEMSIS and NEMSQA, a group for which he currently is serving as president of the board of directors.

“The question that drives this study — and has driven my work over the course of the last 10 years — is really about how do we know in EMS that we’re doing a good job in taking care of patients,” Redlener says. “There’s been a lot of work in the industry toward getting to acceptable clinical quality measures, and ones that are evidence-based that we’re able to measure.”

The 10 quality metrics used in the study pertain to treatment of hypoglycemia or low blood sugar, stroke, seizures, pain, trauma, medication safety, and transport safety. An 11th quality indicator established by NEMSQA was not included in the study because it required documentation of a child’s weight — data unavailable from the NEMSIS database.³

Among some of the more notable findings, the researchers reported that in cases involving suspected stroke patients, roughly one-third did not receive a documented stroke assessment, potentially indicating a missed opportunity to accelerate care for a time-sensitive condition.

Another finding pertained to pediatric cases involving children who were wheezing or experiencing asthma attacks. In 39% of these cases, no treatment to ease breathing was provided and documented during the EMS response. This, too, is a problem given that earlier treatment can lead to sooner relief from distress in these young patients.

Also, in cases involving trauma patients, pain improved in only 16% of cases following treatment by EMS, revealing another missed opportunity to provide patients with earlier relief.

Overall, the researchers reported the performance for at least half of the EMS agencies evaluated fell below 35% for five out of the 10 quality/safety measures. However, they also noted that there were some agencies that achieved “perfect or near-perfect” performance, and they suggested that these top performers should be further investigated for the purpose of identifying best practices that can be disseminated.

When the researchers analyzed the data by agency size and location, they found significant variation between the care provided by EMS in rural areas compared to urban areas. For instance, they reported that EMS responders in mostly rural areas were less likely to treat low blood sugar, to improve pain for trauma patients, or to take patients meeting the CDC criteria for trauma to a designated trauma center. The rural EMS agencies also were more likely to use lights and sirens unnecessarily during transport than their urban EMS counterparts, even though studies have shown that when lights and sirens are used, there is a higher likelihood for accidents, injuries, and deaths.^4,5

Redlener emphasizes that the shortcomings highlighted in the study are not just about how good an EMS service is, but also what resources are available. “If I live in an area where there is just a basic EMS service and they can’t give albuterol [for asthma], then the issue isn’t whether they are a good EMS provider; it has to do with system design,” he says. “There’s a tremendous amount of variability across the country with respect to resources and whether EMS [agencies] have the equipment they need to do the work to take care of patients. So it’s all about, in my mind, making sure that the resources are there for EMS to do their job.”

In a similar vein, Redlener points out there are some areas that have well-developed systems where a stroke assessment provides key data that EMS providers look at, and that essentially drive where patients go. “They may go to stroke centers or even interventional stroke centers,” he says.

But Redlener notes that in other places where the system is not so well-developed, the stroke assessment is not the focus of attention of the EMS services or the medical directors. “Part of what we hope to achieve with this study is to really highlight the clinical aspects of what we’re doing in EMS and make sure we put a spotlight on it,” he says. “With that spotlight, we hope that [EMS care] can be improved.”

Redlener acknowledges that the traditional way EMS is funded, whereby compensation is only provided when patients are transported to the hospital, can be a barrier to quality improvement efforts focused on the clinical care that prehospital providers are delivering. However, he observes that such payment methodologies are being reassessed at both the state and federal levels, and he notes there is definitely new thinking in this area.

For example, he points to the Centers for Medicare & Medicaid Services’ (CMS) Emergency Triage, Treat, and Transport (ET3) Model as one project that was focused on rewarding prehospital providers for their clinical care — not just transportation to the hospital. The payment model also provided participating EMS providers with the flexibility to treat lower-acuity patients at the scene or to transport them to lower-acuity settings, such as urgent care centers, when emergency level was not required.

“What that does is it incentivizes EMS services to not transport as much, and to not bring as much burden to the EDs … and also to get recognized for the work they do in the field,” he explains.

While CMS ended the ET3 program in December 2023 because of lower-than-expected participation, the agency noted that the lessons learned from this work can aid in the development of future initiatives.⁶

In the meantime, Redlener would like to see more work around clinical quality and safety from the EMS providers themselves. “Incentivizing good clinical care is what we want to do, and I’d rather have the EMS industry develop quality measures that make sense as opposed to having quality measures that are forced upon the industry without including the stakeholders,” he says.

Further, he notes the study results provide a good starting point from which EMS groups can begin to assess where they stand on the specific quality measures, and where they should focus their improvement efforts. “This is all about giving tools to EMS agencies to improve their care,” shares Redlener. “As part of the National EMS Quality Alliance, I’ve had a role in thinking about how to enable agencies to take advantage of these measures and these tools so that they can … look at the clinical care that they are providing.”

Redlener stresses that emergency medicine physicians are extremely important partners when it comes to focusing on the clinical aspects of EMS care. “There is a lot of system-based work that can happen, whether it [focuses] on strokes, heart attacks, or the care of cardiac arrest patients,” he says. “Building relationships with EMS agencies and empowering them to do the best clinical care they can is really key to the success of clinical care in EMS.”

As an example, Redlener notes that at Mount Sinai, he participates in monthly quality meetings with EMS providers where key clinical indicators — many of which are the NEMSQA quality and safety measures — are reviewed. “I think it is really important to have a structure where you have the stakeholders in EMS care come together … to really look at the clinical aspects of care,” he says. “Instead of spending time on specific chart views and critiquing individual providers, take a step back and look at the system and the clinical measures that you can derive from the data that we put into the system every day.”

Redlener adds that the satisfaction that prehospital providers gain from an EMS career comes from taking care of patients. “This is important because we need to align what we care about as a system so that it aligns with the reasons why people go into this work,” he says. “When you choose a measure, you choose what’s important and you drive people to think about that, and when it aligns with the reason why people go into this work in the first place, you get more satisfaction … that leaders are thinking about clinical care and not how fast you can drive the ambulance.”

REFERENCES

1. National EMS Information System (NEMSIS). https://nemsis.org/
2. National EMS Quality Alliance (NEMSQA). https://www.nemsqa.org/
3. Redlener M, Buckler DG, Sondheim SE, et al. A national assessment of EMS performance at the response and agency level. Prehosp Emerg Care 2024;Feb 12:1-8. doi: 10.1080/10903127.2023.2283886. [Online ahead of print].
4. Kupas DF. Lights and siren use by emergency medical services (EMS): Above all do no harm. Washington, DC: National Highway Traffic Safety Administration Office of Emergency Medical Services; 2017.
5. Jarvis JL, Hamilton V, Taigman M, Brown LH. Using red lights and sirens for emergency ambulance response: How often are potentially life-saving interventions performed? Prehosp Emerg Care 2021;25:549-555.
6. Centers for Medicare & Medicaid Services. Emergency Triage, Treat, and Transport (ET3) Model. https://www.cms.gov/priorities/innovation/innovation-models/et3