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EMS Patient Safety in the Field

July 28, 2021
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Introduction

Emergency medical services (EMS) personnel serve a critical role within the care continuum. They are in the unique position of providing medical care, often critical or emergent, outside of a healthcare facility. As such, personnel have to act very independently, without the safety net of additional staff or equipment, to rapidly assess and implement any necessary care in the field, and then safely transport the patient, if necessary.1 EMS personnel often have to work in very challenging, time-sensitive situations with limited information about the patient and with other external factors such as weather, physical space, and geographic distances affecting how they are able to perform patient care.2

Patient Safety Concerns

EMS patient safety concerns in the field encompass both operational and clinical components of care delivery, as well as the safety of EMS personnel. Not only must care be performed correctly and safely, but for a subset of patients experiencing time-sensitive events such as severe trauma, stroke, or myocardial infarction, the timeliness of this care is a critical factor in determining patient outcomes.3,4

Operational Concerns

Given that the nature of EMS is to provide emergent services, efficient and effective response following a 911 call is the first step in ensuring patient safety and positive patient outcomes. Following the 911 call, the 911 center personnel must triage the call to ensure that, based on the information provided, the right level of care is sent in response.5,6 Staff that comprise an EMS response can vary in their level of training, and with that comes variation in the types of services and level of care they can provide. The National EMS Scope of Practice Model establishes four different levels of EMS licensure: Emergency Medical Responder (EMR), Emergency Medical Technician (EMT), Advanced EMT (AEMT), and Paramedic. Prior to 2007, there was not a standard system to define EMS personnel licensure.1 The creation of the National EMS Scope of Practice Model was part of an overarching effort to improve patient safety and standardize patient care, while at the same time, allowing individual EMS systems the flexibility to address the unique needs of the local communities they serve.1

Once responders are on the scene, they have to ensure that the right patient is identified or, with time-sensitive conditions like trauma, that all patients are identified. Following in-field assessment and any treatment, appropriate transportation of the patient must occur to the right hospital. During the transportation process, EMS personnel must ensure the safe transition of the patient, as well as maintaining the safety of bystanders by operating the transport vehicle safely.1

Clinical Concerns

Once the patient—or patients— is/are identified in the field, EMS personnel must accurately assess whether there is immediate care that should be provided (e.g., drug administration, oxygen, automated external defibrillator [AED]). Additionally, personnel must determine the most appropriate care destination, which may require performing more detailed diagnostic procedures (e.g., stroke assessment, or use and interpretation of an electrocardiogram [EKG]). It is critical that clinical assessments and procedures be performed correctly and safely to reduce the risk of further patient deterioration or additional harm. To assist EMS personnel in decision making in high-pressure situations and to support standardized care, the profession commonly utilizes medical protocols that guide responders through evidence-based recommendations for managing patients with specific symptoms or diagnoses.7 However, determining which protocol to apply is an essential first step, the accuracy and timeliness of which can impact patient outcomes.

Worker Safety

Following dispatch and throughout the response to a 911 call, the safety of EMS personnel is of paramount importance and of great concern due not just to a desire to protect workers, but also to the impact poor worker safety can have on patient safety, once a patient is in EMS care. One example is injuries personnel can sustain from slipping or tripping when lifting and moving equipment and patients.8 An injury can harm not only the worker, but also the patient, if, for example, the patient is dropped during transfer. Another example is transportation-related events. These events are the primary cause of death among EMS personnel, and they stem from inadequate protection through vehicle design (plywood versus steel used for the ambulance body) and inconsistent use of restraint harnesses for both personnel and patients.8

Quality Assurance in EMS

Quality assurance in EMS is a systematic process for auditing and evaluating the care that patients receive while under the care of EMS personnel. A quality assurance evaluation can be prompted in several ways. First, systems may be in place that have a process for regular auditing of patient charts. This could include a randomly selected percentage, or a 100% chart review.9 Second, a review of a specific patient chart may be triggered if a safety event occurs. Finally, EMS personnel may preemptively request a quality review if an unusual circumstance in a patient interaction necessitated deviation from an existing protocol. The quality assurance process can help to ensure that EMS personnel are consistently meeting high standards of care and compliance with medical protocols.9 The process can also serve to support quality improvement efforts by identifying areas where the medical protocols are lacking guidance or where included guidance does not align with the realities of care in the field.

Role of Education

As previously mentioned, EMS personnel have different levels of licensure which require varying levels of education. The National EMS Education Standards define core competencies for each of these four levels, but specific curricula are defined by each state. In addition, as with other medical professions, EMS personnel are required to perform continuing education.10 Through the initial education associated with licensure and continuing education requirements, personnel are taught processes and procedures in alignment with established protocols and diagnostic decision making, but also fundamental patient safety topics such as teamwork, infection prevention, medical device maintenance, gurney safety, and transport safety.11 Increasingly, EMS systems have advanced their patient safety focus by including concepts such as creating a Just Culture and the importance of safety incident reporting.11,12,13,14 Simulations are an effective technique that can help personnel learn from incidents that occurred in their jurisdictions, incorporate elements tailored to their unique localities, or help personnel to prepare for other potential patient safety events.15

Historically, EMS is a very unique area of healthcare that operates primarily outside of a healthcare facility. Individual states have responsibility for certifying personnel and designing the requirements of EMS provider agencies and EMS reporting requirements. The National Highway Traffic Safety Administration’s Office of EMS provides federal oversight and develops systems for education and certification. This is in contrast to other healthcare settings along the care continuum that align with the U.S. Department of Health and Human Services and its overarching priority setting. As a result, a consistent national approach for system design and reporting of patient safety events has not developed in the same way as has been seen in other care settings. As such, this is still an emphasis that is up and coming in this space. Simultaneously, policymakers and individual EMS organizations are considering the expansion of EMS’ role to provide more direct care in the community with the objective of not only reducing unnecessary transfers, but also facilitating public health and safety initiatives. Broadening the scope of EMS services outside of the hospital setting may further increase the types of patient safety events that EMS personnel need to be aware of and equipped to mitigate.

Authors

James Augustine, MD
National Director of Prehospital Strategy
US Acute Care Solutions
Naples, FL

Eleanor Fitall, MPH
Senior Research Associate, IMPAQ Health
IMPAQ International
Washington, DC

Kendall K. Hall, MD, MS
Managing Director, IMPAQ Health
IMPAQ International
Columbia, MD

Kate R. Hough, MA
Editor, IMPAQ Health
IMPAQ International
Columbia, MD

Appendix

Table 1: Levels of EMS Licensure

Emergency Medical Responder1

  • Initiates immediate lifesaving care to critical patients.
  • Possesses basic knowledge and skills needed to providing lifesaving interventions while waiting for additional EMS response.

Emergency Medical Technician1

  • Provides basic emergency care as well as transportation for critical and emergent patients.
  • Can provide interventions with basic equipment included on the ambulance.

Advanced Emergency Medical Technician1

  • Provides basic and limited advanced emergency care as well as transportation for critical and emergent patients.
  • Can provide interventions with basic and advanced equipment included on the ambulance. This includes oxygen administration, bag valve ventilations, and administration of some medications.16

Paramedic1

  • Allied health professional who provides advanced emergency care for critical and emergent patients.
  • Can provide interventions with basic and advanced equipment included on the ambulance. This includes interpreting an EKG, administering medications, placing intravenous lines, and providing advanced airway management.16

References

  1. National Association of State EMS Officials. National EMS Scope of Practice Model 2019. Report No. DOT HS 812-666. National Highway Traffic Safety Administration; 2019. Accessed May 13, 2021. https://www.ems.gov/pdf/National_EMS_Scope_of_Practice_Model_2019.pdf
  2. National Association of Emergency Medical Technicians (NAEMT) EMS Workforce Committee. Guide to Building an Effective EMS Wellness and Resilience Program. NAEMT; 2019. http://www.naemt.org/docs/default-source/ems-preparedness/naemt-resilience-guide-01-15-2019-final.pdf?Status=Temp&sfvrsn=d1edc892_2
  3. Holmén J, Herlitz J, Ricksten SE, et al. Shortening ambulance response time increases survival in out-of-hospital cardiac arrest. J Am Heart Assoc. 2020;9(21):e017048. doi:10.1161/JAHA.120.017048
  4. Shrader D. Do EMS response times matter? EMS1. January 21, 2016. https://www.ems1.com/paramedic-chief/articles/do-ems-response-times-matter-dfXVRm8yC8DxriBc
  5. Clawson JJ, Dernocoeur KB. Principles of Emergency Medical Dispatch. Priority Press; 2003.
  6. Cone D, Brice JH, Delbridge TR, Myers JB., eds. Emergency Medical Services: Clinical Practice and Systems Oversight. Vol 1 and 2. John Wiley & Sons; 2014.
  7. EMS protocols all paramedics should follow. EMS1. August 16, 2019. https://www.ems1.com/ems-education/articles/ems-protocols-all-paramedics-should-follow-7c1zyNEC6v1SjDQM/#:~:text=The%20purpose%20of%20EMS%20protocols,assessing%20and%20treating%20a%20patient
  8. Dabba JM. Provider safety: what are the big threats? EMS World. March 1, 2020. https://www.emsworld.com/article/1223890/provider-safety-what-are-big-threats
  9. Bauter R. Building a quality QA system. EMS World. October 7, 2010. https://www.emsworld.com/article/10319185/building-quality-qa-system
  10. Emergency medical technician recertification information. National Registry of Emergency Medical Technicians. https://www.nremt.org/EMT/Recertification#:~:text=The%20National%20Component%20requires%20EMTs,meet%20the%2020%20hour%20requirement
  11. National EMS Safety Council. Guide for developing an EMS agency safety program. http://www.naemt.org/docs/default-source/ems-health-and-safety-documents/nemssc/ems-safety-program-guide-10-11-17.pdf?status=Temp&sfvrsn=0.13715842522823762
  12. Center for Patient Safety. EMS: PS-10; the ten patient safety topics that will move EMS forward in 2016. 2015. https://cdn.ymaws.com/aams.org/resource/resmgr/emsforward-ps-10.pdf
  13. Bloom, AJ, Womble MM. Safety culture in EMS. JEMS. September 8, 2015. https://www.jems.com/ems-insider/safety-culture-in-ems
  14. Erich J. Creating a culture of safety. EMS World. November 26, 2012. https://www.emsworld.com/article/10833708/creating-culture-safety
  15. LaVelle BA, McLaughlin JJ. Simulation-based education improves patient safety in ambulatory care. https://www.ahrq.gov/downloads/pub/advances2/vol3/Advances-Lavelle_33.pdf
  16. What’s the difference between an EMT and a paramedic? UCLA Center for Prehospital Care. https://www.cpc.mednet.ucla.edu/node/27
This project was funded under contract number 75Q80119C00004 from the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services. The authors are solely responsible for this report’s contents, findings, and conclusions, which do not necessarily represent the views of AHRQ. Readers should not interpret any statement in this report as an official position of AHRQ or of the U.S. Department of Health and Human Services. None of the authors has any affiliation or financial involvement that conflicts with the material presented in this report. View AHRQ Disclaimers
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