Improving Patient Care Through Evidence Based Performance Measures

Transcription

1 Improving Patient Care Through Evidence Based Performance Measures Robert R. Bass, MD, FACEP Chair Steering Committee Retired State EMS Director, Maryland

2 History of EMS Data & PI 2009 NASEMO EMS Performance Measures 1997 Leadership Guide to Quality Improvement 2001 NEMSIS 1994 V.1 Uniform Prehospital Dataset

3 Key Aims of the Project Develop a process to build evidence based performance measures Develop and test a core set of meaningful measures Continue to build support for the transition of EMS to a culture of performance improvement Develop a sustainable model for the initiative

4 EMS Compass is not: Developing measures in order to punish poor performers or discredit them in their communities Submitting measures to the NQF or CMS Proposing that measures be used for anything other than improvement of patient care and safety Directing how local, state or federal agencies or payers may choose to utilize the measures once they become available Developing a comprehensive list of measures to address every aspect of EMS

5 Overall Org Chart Steering Committee (Bob Bass, MD) Federal Partners Evidence Review Group (Alex Garza, MD) Project Execution Group (Dia Gainor, MPA) Measure Design Group (Dave Williams, PhD) Project Staff: Nick Nudell, MS, NRP Project Manager Zoe Renfro, BA Project Staff Technology Developers Group (Debbie Gilligan) Stakeholder Communication Group (Keith Griffiths, BA)

6 The Process Evidence Review Development Priority Evidence Review Testing Final approval, Publication, Implementation Call for Measures Public Input Revisions Measure Identification Measure Design Implementation

7 Organization of Measures Measurement Domain Clinical Area Family of Measures Structure Process Measure Formula Topic Outcome Balancing Denominator Numerator =Score

8 Performance Measure Example: Stroke-7 Bundle of Care* Outcome Process Structure Suspected Stroke Receiving Prehospital Stroke Assessment Stroke-7 Stroke Bundle of Care Stroke-1 Stroke-2 Stroke-3 Stroke-4 Blood Glucose for Positive Prehospital Stroke Assessment Notification of stroke team Positive stroke Assessments transported to Stroke Center Stroke-6 For positive stroke assessment, average time from LKW to arrival at stroke center Stroke-5 Documentation of LKW *For illustration only. This does not represent a final measure and may change significantly before it becomes finalized.

9 Domains Patient and Family Engagement Example Possible Clinical Areas & Topics EMS Compass Domains Patient Safety Care Coordination Population/Public Health Efficient Use of Healthcare Resources Customer satisfaction, parent/family involvement, patient experience Stretcher drop rate, adverse event rate, deteriorating patient (early warning) Matching care to need, access Requests per capita, clinical diagnosis per capita Cost per capita/patient, tax dollars per capita, patient utilization rate, patient contact time reliability, crash scene time Clinical Process/ Effectiveness Stroke, STEMI, SCA, trauma, pediatric respiratory care, hypoglycemia, seizures Provider Safety* Injury rate, lost work days rate, near miss reporting Vehicle Integrity & Safety* Crashes per vehicle miles traveled (VMT) Data Quality* NEMSIS submission rate, data integrity *EMS Convenience Domains that are outside the NQF original six but may prove to be necessary for EMS performance measurement.

10 Core set of priority measures Priority measures Time critical conditions (stroke, STEMI, cardiac arrest, trauma, and pediatric condition TBD) Steering Committee January 2015 Ambulance safety MDG has other measures under development status seizures, hypoglycemia, fleet, data, and population health

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13 Comparison of Measures

14 EMS Core Measures EMS Compass Priority Criteria Importance to measure Validity and reliability Feasibility Usability and use Comparison to related or competing measures.

15 Other Issues and Challenges Using evidence as a foundation for measure development and integrating into the process Balancing multi-disciplinary interests Streamlining the development process Missing data elements Access to hospital outcomes (legal and data) Buy in from the EMS community Sustainability of the project

16 Five Clinical Conditions 1.Cardiac Arrest 2.Hypoglycemia 3.Status Seizures 4.STEMI 5.Acute Stroke

17 Hypoglycemia Hypoglycemia is a condition characterized by low blood glucose (blood sugar) levels Symptoms vary from dizziness and shakiness to confusion and unconsciousness Severe hypoglycemic episodes can lead to cell injury and death Caused by many different conditions

18 DENOMINATOR NUMERATOR Hypoglycemia Treatment administered Total number of patients receiving treatment aimed at correcting hypoglycemia (food, oral glucose, dextrose, or glucagon) emedications.03 Medication Given = ( Glucagon (IN generic) Glucose (IN generic) D D D D5W D5 ½ NS OR eprocedures.03 contains Provision of food (procedure) Giving oral fluid (procedure) Total number of patients identified as being hypoglycemic by blood sugar <60mg/dl OR Provider Impression of hypoglycemia WHERE evitals.18 Blood Glucose Level < 60 OR esituation.11 Provider s Primary Impression contains (ICD-10 codes: E16.2 or E13.64) OR esituation.11 Provider s Secondary Impression contains (ICD-10 codes: E16.2 or E13.64)

19 Status Epilepticus Continuous seizure lasting more than 30 min, or two or more seizures without full recovery of consciousness between any of them. Generalized seizures that last more than 5 min should be treated to minimize complications and are frequently referred to as status seizures There are many causes and types of seizures Cherian, A., & Thomas, S. V. (2009). Status epilepticus. Annals of Indian Academy of Neurology, 12(3),

20 DENOMINATOR NUMERATOR Status Epilepticus Blood Glucose Evaluation Total number of patients receiving an evaluation of blood glucose evitals.18 Blood Glucose Level is not null. Total number of patients meeting criteria for status epilepticus Where: esituation.11 Provider s Primary Impression contains (ICD-10 codes: G40.901) OR esituation.12 Provider s Secondary Impression contains (ICD-10 codes: G40.901)

21 DENOMINATOR NUMERATOR Status Epilepticus Patient Received Intervention Total number of patients receiving EMS intervention (i.e. benzodiazepine) aimed at terminating their seizure emedications.03 Medication Given ([Diazepam], 3322 [Valium], [Versed], 6960 [Midazolam], 6960, [Midazolam Hydrochloride], , [Ativan], 6470 [Alprazolam], 596) Total number of patients meeting criteria for status epilepticus Where: esituation.11 Provider s Primary Impression contains (ICD-10 codes: G40.901) OR esituation.12 Provider s Secondary Impression contains (ICD-10 codes: G40.901)

22 Stroke (Brain Attack) Brain cell death attributable to ischemia (blockage of blood flow) A leading cause of death and disability Early recognition and treatment can improve outcomes Sacco, R. L., Kasner, S. E., Broderick, J. P., Caplan, L. R., Connors, J. J., Culebras, A.,... & Hoh, B. L. (2013). on behalf of the American Heart Association Stroke Council, Council on Cardiovascular Surgery and Anesthesia, Council on Cardiovascular Radiology and Intervention, Council on Cardiovascular and Stroke Nursing, Council on Epidemiology and Prevention, Council on Peripheral Vascular Disease, and Council on Nutrition, Physical Activity and Metabolism. An updated definition of stroke for the 21st century: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 44,

23 DENOMINATOR NUMERATOR Stroke Suspected Stroke Receiving Prehospital Stroke Assessment Total number of suspected stroke Patients who had a stroke assessment performed (CPSS, LAMS, etc). evitals.30 - Stroke Scale Type is not null ( Cincinnati Los Angeles Massachusetts Miami Emergency Neurologic Deficit (MEND) NIH F.A.S.T. Exam) OR evitals.29 Stroke Scale Score = is not null Total number of patients with a provider impression of stroke. WHERE esituation.11 Provider s Primary Impression contains (ICD-10 codes: I63% or G45%) OR esituation.12 Provider s Secondary Impression contains (ICD-10 codes: I63% or G45%)

24 DENOMINATOR NUMERATOR Stroke Hospital Diagnosed Stroke Not Identified Prehospital Total Number of Patients who did NOT have a prehospital clinical impression of stroke. esituation.11 Provider s Primary Impression contains does not(icd-10 codes: I63% or G45%) AND esituation.12 Provider s Secondary Impression does not contains (ICD-10 codes: I63% or G45%) Total number of hospital diagnosed stroke patients transported by EMS WHERE ' code system is ICD10 = '433.*,'I60.*','I61.*,'I63.*,'I65.*,'I66.*,'I67.*'

25 Initiative Activity Schedule Oct. 2014: Project Started Jan July 2016: 24 work meetings May 2015: Call For Measures Open : Measure Development Summer 2016: Submit to peer review journal Fall 2016: Conduct Blue Ribbon Panel Fall 2016: Publish NASEMSO document Winter 2016: Completion of this phase

26 For more information please contact: Nick Nudell Project Manager EMS Compass Initiative (760) EMSCompass.org #EMSCompass