The Best of the Best, of the Best with Honors.
My EMS service is high-speed, staffed with top notch providers who are chock full of knowledge, our progressive protocols are on the cutting edge. The providers at my service subscribe to the idea of being clinicians as opposed to technicians, many employees express an interest in getting a critical care certification, and we function with a high degree of autonomy. Many times at shift change there are discussions about the latest podcast or things only an ECG nerd could appreciate, we are a service that is well above average, we are the EMS elite.
The service I work for is a smaller rural service with a call volume of less than 3,000 a year. This allows me to read every single report in our QA process. I do find a few things here and there to improve upon but I would say 80% of the issues are documentation errors.
I should have warned you from the start. If you follow my advice you may end up leaving a few bruised egos. If you have a decent non-punitive, just-culture based quality improvement program the amount of bruised egos should be minimal but there will be a few.
Until recently most of our training was based around on high acuity-low frequency events like RSI and ventilator transports. There was a recent training on vaso-active medications including things such as how to whip up an epi drip, giving push dose pressors, and why dopamine is old and busted. This was some upper level paramedic stuff, and why should it not be? We had paramedics that were highly functioning (so I thought) and this stuff was the icing on the cake.
Just don’t ask us to perform the most basic ACLS calls because we cannot. This is my fault.*
Hubris
I decided to institute ACLS competencies. I figured we would breeze through them. That was not the case; in fact it was far from it.
Paramedics chose a number and drew a scenario. The scenarios were fairly straight forward, a pediatric sudden cardiac arrest, an adult sudden cardiac arrest, chest pain with a STEMI that deteriorates in to an arrest, a symptomatic beta blocker overdose and symptomatic atrial fibrillation.
Some of the things I witnessed during the competencies were:
IN narcan given for a known beta blocker OD
IM glucagon given for a known beta blocker OD
CPR on an adult patient with a pulse
People not defibrillating a sudden cardiac arrest w/ bystander CPR
Nitroglycerin given to a profoundly bradycardic patient
Improper pacing – this probably needs a separate post
Not using a Broselow on a pediatric arrest
Giving 1.3mg of epinephrine to a 2 year old, Yes 1.3mg of epi
No CPR on an apneic 2 year old with a weak carotid pulse of 22/min
When our agency was put to the test we were all blown away by the results. I would love to blame the providers for this shortcoming, or really anyone else I can lay the blame on but the cold hard truth is it is my fault.
Reading reports everything seemed like it was going well. We had some good patient outcomes but there is now a seed of doubt planted in my mind, are the good outcomes happening in spite of our not so good care? Are the providers in my service suffering from the Dunning-Kruger effect? Am I, as the CQI officer, suffering from an outcome bias? If I don’t see the bad outcomes then surely we are doing everything right, right? Wrong.
If your QA looks good ask yourself if either of the following conditions could occur.
- Providers are unaware that they are committing mistakes so they aren’t documenting these mistakes.
- The opportunity for these mistakes to happen simply has not presented itself yet.
Lessons Learned
The providers did not know what they did not know…and I did not know what they did not know because until we did these competencies I never went probing for the weaknesses in our system. I assumed everyone had the basics of ACLS down. I was wrong, which is actually great because it is now something we have fixed before it reached the patients.
Go probing for weaknesses in your system, assume nothing, take nothing for granted and make sure you have a good cake before you put that icing on it.
*If you haven’t read Extreme Ownership, well you should.
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