Generic Prehospital Assessment Form

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					EMS Outcomes Research:
  Defining our Future
         Todd Hatley, MBA, MHA, REMT-P
                Assistant Professor,
   PreMIS – Clinical Research Associate Director
       Department of Emergency Medicine
     University of North Carolina – Chapel Hill
                President, NEMSMA
               thatley@med.unc.edu
              www.unc.edu/~thatley
        Outcomes Research

• “What Works”
• Do particular treatments or procedures
  affect outcomes?
               Reasons
• To improve the knowledge base of
  medicine
• To provide accountability
• To make marketing decisions



                         Understanding Healthcare Outcomes Research – Kane 1997
                   Problems
• Outcomes may be due to numerous factors
• Outcomes do not always point directly to
  process changes that need to occur
• Usually require extra effort and cost to collect
• Outcomes are essentially probability statements
• Long term project
• Outcome may be in distant future
             Kane, R.L. Understanding Health Care Outcomes Research
             Donabedian
• Structure – training, equipment,
• Process – what was done
• Outcomes – results of the action
              Study Designs
• Randomized Control Trials
  – Difficult to coordinate
  – Costly
  – Restricted to target group
  – Rely on random allocation
  – Trade internal validity for external validity
              Study Design
• Epidemiological approach
  – Applied to observational data
  – Inability to be sure that differences are not
    from unobservable variation
  – Substantial amount of inference in analysis
    but easier transition to practice
The Algebra of Effectivenss
                                                              CLINICAL FACTORS
                                       Principal
                                       diagnosis


                                                                                         Severity/extent
                                                                                           of principal              Complications,
                                                   Severity/extent
                                                                                         diagnosis and                 iatrogenic
                 Comorbid illness                   of principal
                                                                                          comorbidities                  illness
                 severity/extent                     diagnosis



                                                        Acute clinical         Acute clinical
    Physical                                            stability                stability                                 Physical
   functional                                                                                                             functional
     status                                                                                                                 status


                                                        Age, sex
                                                                                 Survival




                Patient Factors
                                                      Treatment                                               Outcomes
                                         +           effectiveness       +   Random events        ---->



                                                 Patient
                                             attitudes and
  Health-related                             preferences
  quality of life
                                                                                    Resource use
                                                                                                                     Health-related
                                                                                                                     quality of life
                     Cultural,
                                         Psychological,
                    ethnic, and
                                           cognitive,
                 socioeconomic
                                         psychosocial
                attributes, beliefs,
                                          functioning
                  and behaviors                                NON-CLINICAL FACTORS                   Satisfaction




                           Lisa Iezzoni - Risk Adjustment for Measuring Healthcare Outcomes.
          Outcome Measures
• Generic Measures – comprehensive measures
  that assess the overall effects on health status
• Condition Specific – focus on symptoms and
  signs that reflect the status of a given medical
  condition
• Satisfaction – the patient’s response to his/her
  evaluation of the healthcare providers
  performance
 Outcome Measures
Measurement Scale                                                                 High




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                                                               Testa, MA and Simonson DC, NEJM, 334;835-840, 1996
  Generic Outcome Measures
• Unidimensional
  – Index of ADL
  – Comprehensive Older Person’s Evaluation
  – Self-rating anxiety scale
  – Self-rating depression scale
  – Mental status questionnaire
  – Social Health Battery
  Generic Outcome Measures
• Multidimensional
  – 36 item Short Form Health Survey
  – Sickness Impact Profile
  – Nottingham Health Profile
  – Duke-UNC Health Profile
  – Dartmouth COOP Charts
 Generic Outcomes Measures
• Four D’s
  – Death
  – Disease
  – Disability
  – Discomfort
  Condition Specific Measures
• Symptoms
• Signs
• Test
               Satisfaction
• Group Health Association of America
  Consumer Satisfaction Survey
  – Assessment of Health Plans
• Picker/Common Wealth Survey
  – Assessment of Hospital Satisfaction
• Patient Satisfaction Scale
  – Assessment of patient’s perception of
    physician
            Risk Adjustment
• “..Effort to create a level playing field.”
• Many factors can influence outcome of
  care.
• Some refer to as case-mix adjustment
     Classes of Risk Adjusters
• Severity
• Co-morbidity
  – Heart disease
  – Diabetic
• Demographics
  – Age (young, old)
  – Sex
  – Race and Ethnicity
        Measurement
Outcome = f (baseline, patient clinical
      characteristics, patient
    demographics/psychosocial
 characteristics, treatment, setting)
                   Conceptual Model
                       Treatment
                       •Specific Medication
Clinical Factors
                       •Diet
•Cardiac Output
                       •Exercise
•Severity
                       •Case Management
•Duration
•Etiology
•Co-morbidity
•Prior Status
                                              Outcomes
                                              •Cardiac Output
                                              •Symptoms
Patient Factors
                                              •Function
•Age
•Gender                                       •Complications
•Occupation                                   •Quality of life
                                              •Employment/work loss
  How do we assess the
effects of care provided in
    the out-of-hospital
      environment?
Callaham M. Quantifying the
scanty science of prehospital
emergency care. Ann Emerg
  Med. 1997;30:785-790.
        Where’s the evidence
•   Prehospital fluids
•   Response time 90% 8:59
•   Epinephrine
•   Atropine
•   Lidocaine
•   Amiodarone
•   Ventilator rates
   “Measuring Morbidity
Outcomes in EMS” workshop
        NHTSA 1994
 EMSOP Objectives and Goals
• Identify conditions that should take precedence on EMS
  outcomes research;
• Determine the appropriate risk adjustment measures for
  the priority conditions identified;
• Determine the appropriate outcome measures for the
  priority conditions identified;
• Identify stakeholders and constituencies important for
  EMS outcomes research;
• Develop a research dissemination plan.
• (Identify Datasets that are available.)
  The Episode of Care Model

                              EMERGENT

    PREHOSPITAL    ED        SUBSPECIALTY     INPATIENT         FOLLOW-UP

        CARE      CARE           CARE           CARE               CARE




Precipitating
Event                                                     Care complete

                         “Units of Service”
      The Episode of Care Model
  Prehospital         Emergency        Emergent                 Inpatient         Follow-up
     Care             Department      Subspecialty                Care              Care
                        Care             Care
RA    T    OUT
                 RA      T   OUT
                                    RA      T    OUT
                                                         RA        T   OUT
                                                                             RA      T   OUT


                               RA = Risk Adjustment
Precipitating Event            T= Therapeutic Intervention(s)          Long-Term Outcomes
                               OUT = Outcome Measures
   Prehospital Unit of Service Model
     for EMS Outcomes Research
   Prehospital        Emergency         Emergent            Impatient            Follow-up
      Care            Department       Subspecialty           Care                 Care
                        Care              Care




                                   Prehospital Care

                  Assessment   Scene Treatment    Patient Removal         Transport
                    Interval       Interval            Interval            Interval



Precipitating       Risk
                                Intervention(s)         Intervention(s)      Outcome
   Event         Adjustment
                                                                             Measures
                Measurements
    Core Risk Adjustment Measures
               (RAMs)
•   Age
                                     •   Final level of responsiveness
•   Sex                                  (at time of transfer of care)
•   Race & Ethnicity                 •   Initial Glascow Coma Scale
•   Initial vital signs              •   GCS before and after
•   Vitals before and after major        intervention
    intervention                     •   Final GCS
•   Final vital signs (at time of    •   Event to treatment interval
    transfer of care)
                                     •   Prehospital treatment interval
•   Initial level of consciousness
                                     •    EMS provider impression of
•   Level of responsiveness              presenting condition
    before and after an
    intervention
     RAMs Requiring Linkage
• Principle Diagnosis ( Primary ICD-9 Code)
• Patient Co-Morbidity (Secondary ICD-9
  Codes)
     Core Outcome Measure
• Medically Meaningful
• Readily available in the prehospital
  environment
• Used in other healthcare settings
• Agreed to by EMSOP and consultants
 Generic EMS Outcome Measures
• Six D’s
  – Death (Survival)
  – Disease (Impaired Physiology)
  – Disability
  – Discomfort
  – Destitution (Cost)
  – Dissatisfaction
                        Death
• Should be evaluated in the following settings:
  – Prehospital interval
  – Emergency Department interval
  – After hospitalization before discharge
• Disposition should also be considered
  –   Treat/release at scene
  –   Treated/released from ED
  –   Treated in the ED and admitted to hospital
  –   Discharged alive from hospital
               Disability
• None recommended
• Lack of validation
• Not routinely obtained on emergency
  patients
              Discomfort
• Most relevant
• May be the area of greatest impact
         Patient Satisfaction
• Indicator of quality care
• Can be used to assess the performance at
  the organization, unit and individual level
• No generic model has been developed for
  EMS
                     Cost
• Cost-effectiveness analysis
  – Measured in natural units such as disability
• Cost-benefit analysis
  – Measured by cost
• Cost-utility analysis
  – Measured in quality adjusted life years
      EMSOP Priority Conditions
• Adults                     • Pediatrics
  –   Minor trauma             –   Minor trauma
  –   Respiratory Distress     –   Major trauma
  –   Chest Pain               –   Respiratory distress
  –   Major Trauma             –   Airway obstruction
  –   Airway Obstruction       –   Respiratory arrest
  –   Cardiac Arrest           –   Cardiac arrest
          Minor/Major Trauma
       Condition Specific Measures
• Risk adjuster      • Outcome
   –   RTS             – TRISS
   –   GCS             – FIM (Functional
   –   ASI               Independence Measure,
   –   ISS               not applicable to minor
                         trauma)*
   –   NISS
                       – SF-36 (Medical Outcomes
                         Short Form 36 item)*
                       – SIP (Sickness Impact
                         Profile)
       Respiratory Distress
    Condition Specific Measures
• Risk Adjusters            • Outcome Measures
  – PEFR (Peak                – No outcomes measure
    Expiratory Flow Rate)       could be used for all
  – Oxygen saturation           patients
  – Dyspnea scale             – Oxygen saturation
     • Visual analogue        – PEFR
                              – Dyspnea scale
Maybe we need to redefine
      our mission
         “Saving Lives”
               vs.
     “Relieving Discomfort”
            Research Needed
• Studies to substantiate or refute the
  appropriateness of the previous measures;
• Studies to determine the feasibility and reliability
  of using outcomes measure among all levels of
  prehospital provider;
• Studies to determine if feasibility and reliability
  vary based on condition and/or core risk
  adjustment measures.
CPR-Only Survivors of Out-of-Hospital Cardiac
 Arrest: Implications for Out-of-Hospital Care
                      and
    Cardiac Arrest Research Methodology

                 Valerie De Maio
  ANNALS OF EMERGENCY MEDICINE 3 7 : 6 JUNE 2001
       Performance Measures
Major/Minor Trauma: 90% of pts with moderate or
greater pain will have a decrease in the NRS
Chest pain: 90% of patients will have decrease of
chest pain upon arrival at ED
Respiratory Distress: 90% of patients will have
decreases of the VASD upon arrival at ED
Pediatric Seizures: 90% of pts will not be actively
seizing on ED arrival
Cardiac Arrest: 20% W/VF discharged alive and N
intact
RA/AO: 90% adequately ventilated on arrival to ED
                   My Bias
• Evidence Based practice
  – OPALS
• Performance Improvement
  – Six sigma improvement
  – Statistical process control
• Benchmarking
  – Sharing of Best practices
Questions
            References
• Understanding Health Care Outcomes
  Research by Robert l. Kane, Aspen
  Publishing , 1997.
• NHTSA Outcomes Research Final Report
• Donabedian
• Harvard Course Healthcare Outcomes
  Design

				
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