In Conversation With... James Augustine, MD
Editor’s Note: James Augustine, MD, is the National Director of Prehospital Strategy at US Acute Care Solutions where he provides service as a Fire EMS (Emergency Medical Service) Medical Director. In his professional role, he participates in regional, state, and national development of EMS best practices, performance measures, and quality reporting systems, and in the development of new systems of prehospital care. We spoke with him about threats and concerns for patient safety for EMS when responding to a 911 call.
Kendall Hall: Could you please introduce yourself and your current roles in emergency medicine and EMS [emergency medical services]?
James Augustine: I have multiple roles, like many emergency physicians. My name is James Augustine, MD, and I am an active emergency physician and fire EMS medical director. My current role with my physician group is as the National Director of Prehospital Strategy for US Acute Care Solutions. I also serve as a clinical professor in the Department of Emergency Medicine at Wright State University, and I serve in medical director positions for EMS systems in the Dayton, Ohio area, in the Atlanta, Georgia area, and as an associate medical director for an excellent fire EMS system in Naples, Florida. I have previously served on the Board of the American College of Emergency Physicians, and I have served in various roles with ASTM [American Society for Testing and Materials]. I serve as a subject matter expert with CDC [the Centers for Disease Control and Prevention] in emergency responses to Ebola and COVID and have had a long career in emergency department data analysis, with a group called the Emergency Department Benchmarking Alliance.
KH: What is the role of a medical director in EMS? Is it safe to say that is the role you have that intersects most with patient safety?
JA: That is very safe to say. As a medical director for a fire EMS system, you are there to write protocols that allow the EMS personnel under you (paramedics, advanced EMTs [emergency medical technicians], and EMTs) to provide services in the field. You are there to provide guidance for actions that occur outside of those medical protocols, such as a situation where the patient has a combination of medical problems that the medics don’t know how to manage. You're there to do quality assurance and quality improvement, as needed, as the system changes, and as medical knowledge changes. You are there to interact with the hospitals in the area, particularly during emergency events, to make sure that care and transition of care go very smoothly. You participate in regional efforts to do disaster and major incident preparedness. Finally, you interact with the community at large by assisting in public relations efforts, public education efforts, and efforts with public health professionals to educate the community about better health.
KH: Can you speak to where the EMS field currently stands in terms of how it approaches patient safety in the field? Is this something that is done at a national level with guidance or at a local level? Is it more of a homegrown activity?
JA: Kendall, really it is all of those things. There are really good opportunities to work with national groups to look at quality at the highest level and to make sure that you stay abreast of any new measures developed, particularly those that look at very time-sensitive diseases, and apply them in your community and with your hospitals. Locally, in America, we don't have one standard of care and one approach to patients. I see that as a good thing. But it means that we have different approaches to care that can take place for MIs [myocardial infarctions], strokes, trauma, burns, pediatrics, and other important issues. There is not a single way in which care is most effectively delivered, but as we develop practices that clearly do look to work better, you have the opportunity at the national level to share those and for others to apply them. At the regional level, most states have developed some definitions and some quality measures. In many cases, they have developed a state reporting system that has basic elements required in patient care reports and for necessary reports that go to the state. In some cases, then, the state can report back to you on how you deliver care, and whether some of those measures are appropriately met or not.
At the local level, you have to look at how well care is delivered at specific addresses and in specific types of situations. In this country, the standard of care for MIs can be different according to where you are on the map, and what the weather and traffic conditions are. In those local areas, the protocol may be written that delivers the patient to the specialty hospital under most circumstances. But if weather and/or traffic conditions would significantly delay the delivery of the patient to the specialty hospital, then the EMS team would need to transport the patient to the closest hospital for certain interventions that can be done there. Those types of considerations and protocols are all things that have to be developed at the local level. However, all of them have the same goal in mind: to provide the timely care needed by emergency patients, that can be delivered safely by the people taking care of them, and to take into account the situations that occur in that community.
KH: Can we go back to the regional and state-level reporting programs you mentioned? Can you talk more about those reporting systems?
JA: So, nationally, we have an EMS system that has definitions that allow people to understand what the various types and demographics of calls are. At the state level, the state determines what kind of information it wants gathered. In some cases, data is just collected for high-priority and high-sensitivity calls. In other cases, data is collected for all calls, and a patient care report and the demographics of the call are all delivered to the state for each 911 activation. Then in some states, they add on elements to the report that allow them to look at time-sensitive and critical diseases, to know how that agency was able to deliver care on those specific types of calls.
KH: When you are getting these data back and you are seeing trends, how are you using that information? What does quality assurance look like in EMS? What does quality improvement look like?
JA: So, first there are the basic parameters by which a fire EMS service measures itself. Do they have rapid processing of an emergency call and get appropriate EMS resources en route quickly? Do they arrive safely and in a timely manner to those calls? Are there the appropriate people on the call needed to provide service? And then, how does the service itself perform in identifying critical patients and moving them to the correct site of care?
There are system issues. There is the responsibility of personnel to be in the station, to be dressed, to get on the apparatus, to respond safely, to drive safely. There are very, very important elements of an EMS system that have everything to do with the technical delivery of vehicle and people to the right scene, at the right time, without hurting other people by getting in a crash.
Number two, are we safely applying the resources that we have so that we get the right crews to the scene on time? Many EMS systems have multiple elements that need to arrive to deliver care to patients. A typical model for EMS in America at this time is that, when a high-priority call is received at the 911 center, an engine and an ambulance are dispatched at similar times. The basic model of delivery in most communities includes that. The performance of the 911 center and its ability to triage calls to get accurate information when it is available is another element of medical direction and quality assurance and improvement. Does the 911 center deliver all the right information that they can get from the patient, as difficult as that can be at times? So, the very beginning elements are getting those right resources to the scene and in some cases, this involves different agencies. In some cases, you can have a first response agency that is fire-based. This may be a BLS [basic life support]-level response. You can have an ALS [advanced life support]-level response. You can have an air ambulance response. You can begin to set up rendezvous for those people. There's a huge number of ways to get the right resources to the patient at the right time for their condition, and then set them up in a position where the patient can be transferred to the right hospital for further care when needed. That’s just the beginning of the process.
KH: Does everybody on the engine and the ambulance have training for basic assessment at the scene? Are they all EMT-certified?
JA: At this point in this country, we still have agencies that have First Responder-trained personnel who do not have EMT certifications, but who do have the basic knowledge and skills needed to provide immediate lifesaving care. You have the First Responder level, you have the EMT level, you have the Advanced level, and you have the Paramedic level. Those are the basic elements defined by the National Registry of EMTs [NREMT]. Many municipal departments have evolved to the point where everybody in the department is at least an EMT, or an Advanced EMT, and then an appropriate ALS-level Paramedic-level responder is also available. A number of rural communities don't have the ability to staff at those levels and use First Responders only. But in most metropolitan areas, we begin with EMT-level responders and then an ALS-level responder coming in secondarily.
KH: Being at the ALS level, the provider can administer meds? Meaning, the paramedic can administer medications, provide airway management, things that the rest of the group can't?
JA: Right, we build the skills in that way, but we do keep moving skills down to lower levels of certification. We have AEDs [automated external defibrillators] that can now be applied by First Responders and by EMTs, we have self-administered medicines that we can assist in providing even at the BLS level. We have basic airway devices and oxygen that can be applied to patients by individuals with lower levels of certification. We have EpiPens® that can be administered at a lower level. All of this results in more timely care. In many states, the Advanced EMTs also have a number of important medicines that they can deliver, like nitroglycerin, albuterol, dextrose, and epinephrine.
KH: Are there standardized processes around quality and quality assurance for all of these different models? Who manages these processes?
JA: The department itself manages its people, its resources, its timeliness, and the safety of things like driving vehicles and lifting patients, etc. The very basic operations that are needed for safe service and to make sure that they are getting the right number of trained staff to the scene at the right time. So, the department itself has responsibility for those basic technical and operational elements. What the medical director adds on top of that is the assessment of when medical interventions are needed, are they done and done correctly? Are they done in a timely manner? And then for the time-sensitive conditions, have they identified all of the patients? The proper triage of trauma patients includes you over-calling so that you're sensitive more than specific. The same with stroke, the same with acute MIs, the same with delivering babies, the same with very sick children. The quality system will accept an over-call as a way of doing business. There are more concerns with under-calls where timely care can’t be delivered, and where you may not have activated the right hospital or the right people at the hospital to deliver care that the patient needs.
For the span of care that's within the emergency system, we are accountable for getting the right patients to the right facility, and for allowing that facility to be as ready to go as possible. For example, in the case of an incident that resulted in a trauma patient, the EMS system should facilitate timely access to the 911 activation system; that responders got to the scene as quickly and safely as possible; that the highest level of personnel assessed the patient and began to deliver timely care; that the extrication of the patient took place; that the patient was transported; and that the EMS personnel managed his or her airway and circulatory problems, and immobilized the patient appropriately. The trauma center was activated and ready for the patient and moved them through the emergency department as quickly as needed. So, within that entire span of care for that individual, did we do our part in getting it set up correctly? We could go through similar pathways for strokes, and STEMIs [ST-segment elevation myocardial infarctions], and delivering babies, and taking care of burn patients, and other things.
KH: For the quality assurance aspect of this, would that be you going back through and doing audits of charts? Or how do you become aware of things that are outside of the norm, or outside of protocols, or outside of the timeliness?
JA: The role of the medical director is to be so visible to people that they know what the medical director would say when they come upon a certain circumstance. A medical director who participates actively in training, who knows the situations that the EMS personnel get into, is a valuable member of the quality team. The medical director can provide protocols and training that guide the actions with the patient. In a system with active medical direction, EMS personnel would know when they need to report a quality issue shortly after it occurred, or when something is falling out of their usual case management. For example, we frequently have patients who stutter into a disease, things like a stroke or an MI. And I happened to be reviewing one of those today, so it's fresh in my mind. A patient had some symptoms and then didn't, and then had symptoms again, and when the EMS group happened to arrive, they were asymptomatic. They spent a little time talking with the patient and telling them what they thought might be going on, and then made the decision to transport them towards a local facility rather than the tertiary care facility that is defined for this disease process. As they got to the local facility, the patient had significant symptoms again, and the ED [emergency department] staff said, “Why didn't you take this patient right away to the stroke center?” The EMS crew not only explained it to the ED personnel when they turned over the patient for care, but then wrote their report and sent a note to me, the Medical Director, to further explain what their decision-making process was that caused them to make the decision that they did. There are also times when they call me from the scene and say, “I've got a problem. I don't know how to address it. This is something that isn’t written in our protocols anywhere. Would you please assist me in making a decision?” In some cases, EMS personnel will even hand the phone to the patient and have the patient talk to me, the doctor. At times, I also go to the scene and assist in managing patients, and, in critical situations, get involved in patient care. EMS quality improvement begins when the EMS providers know what would happen in ideal circumstances but are always prepared for unusual circumstances where external factors influence how care is delivered to an individual patient.
KH: How normal is that for you to be so involved in care? Is that standard across medical directors? Does it vary on the relationship with the EMS groups?
JA: There is variation. We don't have a single standard for medical director performance in EMS systems. I think now that we have EMS fellowship-trained physicians, and many of them have had prior EMS careers, that we will see more consistency in the actions of EMS medical directors. As we continue to share best practices and move towards better ways of dealing with time-sensitive conditions, we can begin to hold medical directors more accountable.
KH: You know, over the past year we've been paying more and more attention to telemedicine and thinking about community paramedicine. When you're on that phone call, is there an opportunity to bring telemedicine into EMS?
JA: Thank you for bringing that up. There very clearly are improvements in our communication systems and the ability to link the providers, wherever they are, with the people who can help them. That not only carries to the medical director, but also in some circumstances, that iPad can carry information right to the specialty team that will be providing care of the patient. We have long been developing ways to share electronic data so that the 12-lead EKG [electrocardiogram] can be shared with the cardiac receiving center, but now we are adding elements where video linking is done and where the patient can actually be interviewed by the cardiologist who is on call at the cardiac center. The last year has seen dramatic growth in our ability to provide EMS care with an audio and video link between the patient and a skilled provider. We won't go backwards, and that ability will significantly improve how we deal with specialty patients.
KH: How do you start training people to use these other technologies in the delivery of care? I imagine it must improve the timeliness of care, particularly if, as soon as the patient arrives at the hospital, it means that the hospital staff are already prepped and ready to go.
JA: We now have our younger providers who are so used to using technology that they bring to old medical directors, like me, a huge skill in being able to apply technology to provide better care to the patient. Training has evolved with the technology over the years and our new emergency physicians are very skilled with ultrasound, a tool that I barely know how to use, but which can be critical in the hands of people who know how to interpret it rapidly, particularly for big decisions in time-sensitive patients. And those skilled physicians can teach EMTs to administer and use ultrasound and transmit the images so that even if the EMT or paramedic isn't skilled with ultrasound themselves, they are immediately linked to someone who can interpret it, or help the paramedics make adjustments to improve the quality of the image. There is continually improving technology that can be applied at all levels that we didn't have a chance to use a couple of years ago. We have CT [computerized tomography] scanners now moving around in mobile units in the field doing stroke diagnosis. In some cities with hospitals that have developed that level of sophistication, they now put CT scans in the front of the patient cabin area, and those stroke units are dispatched to appropriate patients by the 911 center. Those patients get scanned very quickly, and then highly skilled providers make a rapid decision to administer thinning drugs in the back of the rig, or to take them to the definitive care center for the particular kind of bleed that was demonstrated on the CT scan. All of those are tremendous applications of technology.
KH: What you're describing is the evolution of care in that front-end, prehospital space, of the continuum. How has this evolution changed your relationship with facilities when you’re transitioning people to the ED?
JA: Some of this is evolution and you know, I'm 40 years in the business now. We began by thinking EMS was a very important part of the emergency system. In the early days, we began to use basic interventions like IV [intravenous] fluid and cardiac monitoring. Many regional systems of care have been developed. We are beyond what is “emergency care,” and we now call it “unscheduled care.” And on all ends of the continuum, we have people who are really skilled at knowing how to look at events that are occurring that are unplanned and how we can best apply community resources. For low-acuity patients, we can apply resources to allow the EMS providers to deliver care and not transport the patient. We have patients on the other end of the continuum who have needs in the palliative care system and have documents in place that limit life-sustaining treatment. When these end-of-life patients access the EMS system, they are evaluated and palliative care resources are activated, and the patient is appropriately not moved into the acute care system.
In this country, we have seen the development of excellent regional programs for strokes, trauma, burns, pediatric care, and MIs. Where those outstanding regional systems are in place, they have a positive influence on the care of every patient who may have a time-critical disease. They help lead targeted public education programs that help members of the public avoid the bad event (exercise and stop smoking to reduce the risk of a heart attack); teach the public how to react when a possible bad event is occurring (if you have chest pain, don’t delay in seeking care); develop a system for all emergency departments to evaluate patients using high-quality processes; and get the appropriate MI patients moving to the skilled intervention centers for timely intervention.
KH: I think that what you're describing is to get away from the idea that everyone needs to be transferred and to really take the care to the people. Is it safer to do that?
JA: We have learned this year, it's much safer. If people don't need to go to the hospital, if the hospital won't benefit them, we should take the care to where they live. Some people have really bad outcomes because they go to a place where a bunch of other sick people are, and I think we've had our community say, “We want other alternatives.” It's also important for mental health and chemical abuse populations. The hospital may not the right place for individuals who have needs in those situations.
KH: Agree. If you had to do one thing to help build and foster this, this care continuum and taking the care to the people, what do we need to do? Where should we be putting our energy, whether it’s in terms of research, exploration, is it technology?
JA: First of all, technology is one piece of it. We also really need to be patient-centric—what would the patient really want and benefit from, and not what's easiest for us. The ability to use correct data systems and quality measures, not over-apply quality measures, and not set the expectation of a hundred percent positive outcomes. There are always unexpected situations and circumstances that quality measures are not designed to take into account that do not allow perfect outcomes.
KH: I’d like to wrap up by talking about patient safety education and training. We've talked about residents and fellows, but what about that training across EMS providers? How are you educating them about available technology, or the protocols, or standards of care, or unusual cases? Is it through the use of simulation? Is it using data that people are tracking to provide feedback?
JA: All of the above! In the past we tried to use “typical” cases as our method of presenting education to our EMS providers and ourselves. And now, taking a patient-centric approach, we define what group of patients might present as an MI, or stroke, or trauma, etc., and then discuss the basic approaches that we use to get to the right outcome for those patients. We try not to use textbook definitions of cases because that is never the reality. This past year, with our need to social distance, we have developed a lot of distance learning policies and procedures and have made a lot better use of simulation. Simulation isn't everything, and it can be detrimental if providers in training are not skilled at putting their hands on patients. We still need hands-on training in the emergency system that results in skilled providers who know what a pulse feels like, and what capillary refill is, and what respiratory distress looks like. We cannot simulate everything, but the use of simulations has been critically important and allows us to go through circumstances that the providers are going to encounter very, very rarely—for example, childbirth, which is not something that most EMS providers are going to see a lot. We work through both physical and audiovisual simulators to demonstrate to providers what childbirth is in normal circumstances, but also what to do if a foot comes out first. Most providers are only going to see that once in their career. So, there is a sweet spot in the use of better teaching and routine patient care simulators, and the use of simulation for high-risk but low-frequency conditions. Simulators are safe and effective ways to train on “what if” scenarios. What if that trauma patient all of a sudden decompensated? What if, all of a sudden, their airway obstructed? What if, all of a sudden, they were bleeding from something that had not been bleeding before? What do you do? You can “what if” into a whole range of scenarios that improve the process for providers’ training, and for those doing continuing education. Finally, feedback from the hospitals is really important so that they know how their interventions changed the outcome of the patient.