12-Lead
ECG
Process to be Measured:
1. Use and documentation of the 12-Lead ECG in emergency transports.
Define the Process:
1. The appropriate use and documentation of the 12-Lead electrocardiogram
based upon the patient’s condition.
2. Documentation of reasons for being unable to use the 12-Lead ECG
other than time.
Data Verification:
1. Data will be collected through a retrospective review of Maine
EMS run reports.
2. The Quality Management Operations Coordinator will be responsible
for collecting and reporting the results of the study to the Clinical
Standards and Practices Team and the individual provider.
3. The indicator formula will calculate the percentage of those charts
meeting the success criteria versus those that meet the inclusion
criteria.
Measurement (Inclusion) Parameters: (Denominator
Value)
1. Any patient being treated for cardiac symptomology, regardless
of transport time.
2. In the patient that is 30 to 50 years old, a chief complaint of….
• Acute onset, non-traumatic, non-specific abdominal pain.
• Non-traumatic chest pain.
• Non-specific dyspnea without anxiety history.
…….with a transport time greater than 9 minutes.
3. In the patient that is 50 years old or more, a chief complaint
of……
• Acute onset, non-traumatic, non-specific abdominal pain.
• Non-traumatic chest pain.
• Non-specific dyspnea without anxiety history.
• General weakness.
• Vertigo/Dizziness.
• Diabetic Reaction.
• Nausea/Vomiting.
• Syncope.
……..with a transport time greater than 9 minutes.
Success/Failure Parameters: (Numerator Value)
1. Inclusion of a copy of the 12-Lead ECG with the patient care record.
2. Documentation of the Date of Service and the Maine EMS Run Report
number to allow for correlation between the 12-Lead ECG and the run
report.
Frequency of Measurement:
1. Data will be collected on an ongoing basis.
Standard of Care Compliance Threshold:
1. The minimum standard for compliance will be 80%.
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12-Lead
ECG | Glucometer Use| Pain
Management | Spinal Assessment
Aspirin Administration | Patient
Refusals | Capnography | Airway
Glucometer
Use in Patients with Altered Mental Status
Process to be Measured:
1. Glucometer use in patients with altered mental status.
Define the Process:
1. Measurement of blood glucose levels in patients with altered mental
status.
2. Glucose measurement will be defined as…….
• Documentation of the use or attempted use of a blood glucose
measurement process.
Data Verification:
1. Data will be collected through a retrospective review of Maine
EMS run reports.
2. The service director or a designated representative will be responsible
for collecting and presenting the service’s data to the service’s
Regional QI Committee representative.
Measurement Inclusion Parameters: (Denominator Value)
1. All emergency responses where there is documentation that indicates
that the patient is experiencing acute or recent onset of altered
mental status.
• This may include, but is not limited to complaints or descriptions
using the words unresponsive, lethargy, confusion, aphasia, weakness,
dizziness, dementia, seizure activity and paresis, or
• A Glasgow Coma Scale (GCS) less than 15.
Success/Failure Parameters: (Numerator Value)
1. Success will be defined as clear documentation of the measurement
or attempted measurement of a blood glucose level
2. Success will also be defined as clear documentation of the competent
patient’s refusal to allow blood glucose measurement.
Frequency of Measurement:
1. Data will be accumulated by each regional service on an ongoing
basis.
2. Data will be reported to the sub-regional QI coordinator when requested
for the period requested as determined by a consensus of the Regional
QI Committee.
3. The sub-regional QI coordinator will report the performance of
each service in their catchment area when requested by the Regional
Medical Director or the Regional QI Committee.
Format for Reporting-Numerical:
1. Round calculations of compliance percentages to the nearest whole
number.
2. Report in table format:
• License number of the service participating,
• Total number of calls meeting the inclusion criteria,
• Total number of calls determined to be successful, and
• Percentage of success. (success # / inclusion # = percent
of success)
Format for Reporting Graphical:
1. A bar graph indicating each service’s percentage of compliance
and the Region’s overall performance will be generated and distributed
to all Regional services.
Standard of Care Compliance Threshold:
1. The goal of each service should be to demonstrate continual improvement
as compared to past service performance and average Regional performance
levels.
2. Trends indicating difficulty in demonstrating continual improvement
will be addressed through system and root cause analysis.
3. Process improvements that may rectify identified deficiencies may
include….
• Procedural changes;
• Equipment or supply changes;
• Development of process/procedure resources such as algorithms,
charts, graphs, or IT resources;
• Educational initiatives.
top
12-Lead
ECG | Glucometer Use| Pain
Management | Spinal Assessment
Aspirin Administration | Patient
Refusals | Capnography | Airway
Pain
Management
Process to be Measured:
1. Pain management.
Define the Process:
1. The pre-hospital management of pain for patients with suspected
traumatic injuries to the extremities and associated complaints of
pain.
2. Pre-hospital pain management will be defined as…..
• Documentation of the consideration of patient needs with regard
to the presence of pain, the intensity of pain, and the need for the
use of pain management techniques.
• Documentation of the use o pain management techniques.
3. Pain management techniques will be defined as…….
• The use of fixation devices (splints) to prevent movement
of the extremity;
• The application of cold, and/or
• The administration of analgesics, and/or
• A request made to on-line medical control (OLMC) for the administration
of analgesics.
4. Extremities will be defined as……
• The arms, from the shoulder girdle to the phalanges.
• The legs, from the hip to the phalanges.
Data Verification:
1. Data will be collected through a retrospective review of Maine
EMS run reports.
2. The service director or a designated representative will be responsible
for collecting and presenting the service’s data to the service’s
Regional QI Committee representative.
Measurement Inclusion Parameters: (Denominator Value)
1. All transports to the emergency department where there is…..
• Documentation of traumatic injuries to the extremities, and
• Where the patient has a complaint of pain secondary to the
traumatic injuries.
Success/Failure Parameters: (Numerator Value)
1. Documentation of an assessment of the patient’s needs for
pain management, and
2. The use of pain management techniques.
3. Documentation of reassessment and responses to pain management.
Frequency of Measurement:
1. Data will be accumulated by each regional service on an ongoing
basis.
2. Data will be reported to the sub-regional QI coordinator when requested
for the period requested as determined by a consensus of the Regional
QI Committee.
3. The sub-regional QI coordinator will report the performance of
each service in their catchment area when requested by the Regional
Medical Director or the Regional QI Committee.
Format for Reporting-Numerical:
1. Round calculations of compliance percentages to the nearest whole
number.
2. Report in table format:
• License number of the service participating,
• Total number of calls meeting the inclusion criteria,
• Total number of calls determined to be successful, and
• Percentage of success. (success # / inclusion # = percent
of success)
Format for Reporting Graphical:
1. A bar graph indicating each service’s percentage of compliance
and the Region’s overall performance will be generated and distributed
to all Regional services.
Standard of Care Compliance Threshold:
1. The goal of each service should be to demonstrate continual improvement
as compared to past service performance and average Regional performance
levels.
2. Trends indicating difficulty in demonstrating continual improvement
will be addressed through system and root cause analysis.
3. Process improvements that may rectify identified deficiencies may
include….
• Procedural changes;
• Equipment or supply changes;
• Development of process/procedure resources such as algorithms,
charts, graphs, or IT resources;
• Educational initiatives.
top
12-Lead
ECG | Glucometer Use| Pain
Management | Spinal Assessment
Aspirin Administration | Patient
Refusals | Capnography | Airway
Spinal
Assessment
Standard
1. All hemodynamically stable patients presenting with a trauma mechanism
will be assessed using the Maine EMS spinal assessment algorithm.
2. Appropriate spinal immobilization measures are utilized for patients
who are not reliable, have distracting injuries, are positive for
pain and/or tenderness, or who have neurological deficit.
3. Documentation reflects assessment and findings of reliability,
presence of distracting injuries, findings of pain, tenderness, or
neurological deficit.
4. This audit applies to all MEMS Licensed Services.
Indicators
1. Documentation reflects trauma mechanism with a hemodynamically
stable trauma patient.
2. Documentation reflects assessment and findings of reliability,
presence of distracting injuries, findings of pain, tenderness, or
neurological deficit.
3. Documentation reflects appropriate spinal immobilization procedures
utilized.
4. Documentation reflects re-assessment of CSM after spinal immobilization.
Defining Compliance
1. Successful compliance with the study will be defined as 100% of
the indicators present on the run report.
Frequency of Measurement
1. Service QI committee members will separate out all run reports
where a patient had a trauma mechanism and keep them in a separate
location.
2. All studies will be retrospective looking back no more than 6 months.
3. Service QI committees will receive notification on which study
will be done and for what period of time.
4. Run reports only need to be kept separate for a period of 6 months.
Format for Reporting
1. Services will be notified by the Regional office which audits will
be reviewed and for what period of time.
2. The service QI committee should then review all run sheets that
fall within the standard for that particular audit.
3. The service should report the information to their local QI Nurse
using the approved form.
4. The service will receive a report back showing their results as
compared with the rest of the region. Individual service results will
not be shared with any other service.
top
12-Lead
ECG | Glucometer Use| Pain
Management | Spinal Assessment
Aspirin Administration | Patient
Refusals | Capnography | Airway
Aspirin
Administration in Patients with Chest Pain of Suspected Cardiac Origin
Process to be Measured:
1. Aspirin administration in patients with chest pain of suspected
cardiac origin.
Define the Process:
1. Administration of aspirin by pre-hospital personnel to patients
with chest pain of suspected cardiac origin.
2. Aspirin utilization will be defined as…..
• Documentation of pre-hospital administration of aspirin.
• Documentation of assisting of a patient with the self-administration
of aspirin.
Data Verification:
1. Data will be collected through retrospective review of Maine EMS
run reports.
2. The service director or a designated representative will be responsible
for collecting and presenting the service’s data to the service’s
Regional QI Committee representative.
Measurement Inclusion Parameters: (Denominator Value)
1. All transports to the Emergency Department where there is a ……
2. Chief Complaint: “Chest Pain”, this may also be indicated
by “chest pressure”, “heart attack”, or any
other complaint that indicates a patient’s suspicion or presentation
that a cardiac event is taking place.
3. The provider has a suspicion, due to clinical presentation and
documentation of a cardiac related suspected problem that a cardiac
event is taking place.
Success/Failure Parameters: (Numerator Value)
1. Success will be defined as clear documentation of aspirin administration
or self-administration as a response to the event.
2. In the event that a patient shows clearly defined contraindications
for the use of aspirin, documentation of these contraindications will
constitute aspirin utilization.
Contraindications will be limited to….
• A stated or documented allergy to aspirin.
• Active bleeding.
• Signs or symptoms of an active CVA.
3. The documentation of a patient refusing to take aspirin as recommended
by pre-hospital provider will be treated as a success for purposes
of this study.
Frequency of Measurement:
1. Data will be accumulated by each regional service on an ongoing
basis.
2. Data will be reported to the sub-regional QI coordinator when requested
for the period requested as determined by a consensus of the Regional
QI Committee.
3. The sub-regional QI coordinator will report the performance of
each service in their catchment area when requested by the Regional
Medical Director or the Regional QI Committee.
Format for Reporting-Numerical:
1. Round calculations of compliance percentages to the nearest whole
number.
2. Report in table format:
• License number of the service participating,
• Total number of calls meeting the inclusion criteria,
• Total number of calls determined to be successful, and
• Percentage of success. (success # / inclusion # = percent
of success)
Format for Reporting Graphical:
1. A bar graph indicating each service’s percentage of compliance
and the Region’s overall performance will be generated and distributed
to all Regional services.
Standard of Care Compliance Threshold:
1. The goal of each service should be to demonstrate continual improvement
as compared to past service performance and average Regional performance
levels.
2. Trends indicating difficulty in demonstrating continual improvement
will be addressed through system and root cause analysis.
3. Process improvements that may rectify identified deficiencies may
include….
• Procedural changes;
• Equipment or supply changes;
• Development of process/procedure resources such as algorithms,
charts, graphs, or IT resources;
• Educational initiatives.
top
12-Lead
ECG | Glucometer Use| Pain
Management | Spinal Assessment
Aspirin Administration | Patient
Refusals | Capnography | Airway
Patient
Refusals
Define the Process to be Measured:
1. Accurate identification of patients capable of exercising their
right to refuse treatment or transport, to include…..
• Adult patients that are fully oriented to person, place, and
time;
• Emancipated minor patients that are fully oriented to person,
place, and time;
• Patients that have not expressed suicidal ideation;
• Individuals that are identified by their obvious condition;
• Individuals that identify themselves as a patient or are identified
by another individual at the scene as being ill, injured, or requiring
evaluation.
2. Appropriate documentation of patient refusals, to include…..
• Documentation of the treatment offered;
• Documentation of the patient’s statement of refusal;
• Documentation that the patient was informed of the risks of
refusal and benefits of treatment.
• Documentation of the patient’s reason for refusal.
• Documentation of the patient’s signature or a statement
that the patient refused to sign.
Measurement Parameters:
1. All ambulance or first responder service responses where a patient
is identified and the patient refuses treatment or transport.
Data Verification:
1. Data will be verified through retrospective review of Maine EMS
run reports by the service director or a designated representative.
Defining Success/Failure:
1. Successful compliance with the study parameters will be defined
as the documentation of….
• Accurate identification of patients capable of making informed
decisions about their own care.
• Complete documentation of the patient’s refusal including
the elements outlined above.
Frequency of Measurement:
1. All responses that meet the inclusion criteria of the study will
be evaluated.
2. Data will be accumulated on an ongoing basis.
3. Data will be reported to the sub-regional QI coordinator when requested
for the period requested.
Format for Reporting for Sub-Regional QI Coordinators:
1. Round calculations of compliance percentages to the nearest whole
number.
2. Report the license number of the service participating, total number
of calls meeting the inclusion criteria, the total number of calls
determined to be successful, and the percentage of success.
3. Reports per sub-region should conform to the following reporting
format….
• Service license number.
• Total calls included in the study.
• Total calls with accurate identification.
• Percentage of accurate identification.
• Totals calls with complete documentation.
• Percentage of complete documentation.
• Comments.
Standard of Care/Compliance Threshold:
1. The minimum standard for compliance will be 80%.
top
12-Lead
ECG | Glucometer Use| Pain
Management | Spinal Assessment
Aspirin Administration | Patient
Refusals | Capnography | Airway
Capnography
Process to be Measured:
1. Capnography utilization in intubated patients.
Define the Process:
1. Utilization of capnography by pre-hospital personnel in intubated
patients.
2. Capnography utilization will be defined as……
• Documentation of an End-Tidal CO2 (ETCO2) monitoring device
being applied to an intubated patient
• Documentation of waveforms and recorded values of ETCO2
Data Verification:
1. Data will be collected through a retrospective review of Maine
EMS run reports.
2. The QI Coordinator will be responsible for collecting the data.
3. Data collected will be presented to the Clinical Standards and
Practices Team, as
well as to individual providers.
Measurement (Inclusion) Parameters:
(Denominator Value)
1. All patients where:
• The provider attempts an intubation and seeks final confirmation
of tube placement.
• The intubation was performed by either an in-hospital practitioner
or another EMS provider, and care is now taken over by the EMS provider.
Success/Failure Parameters: (Numerator Value)
1. Successful compliance with the study parameters will be defined
as documentation by the EMS provider of capnography utilization.
Frequency of Measurement:
1. Data will be collected on an ongoing basis.
Standard of Care Compliance Threshold:
1. The minimum standard for compliance will be 80%
2. This minimum will apply to those providers with a minimum of five
(5) inclusions
top.
12-Lead
ECG | Glucometer Use| Pain
Management | Spinal Assessment
Aspirin Administration | Patient
Refusals | Capnography | Airway
Airway
Standard:
1. All patients with airway compromise will have their airway appropriately
managed based upon need, level of licensed personnel on the call,
and available equipment.
2. This audit applies to all services.
3. For the purposes of this audit, “airway management”
will mean any time a provider has to manually clear the airway, use
BLS or ALS adjuncts to secure the airway, or assist with ventilations.
Indicators:
1. When appropriate, provider documents an airway assessment.
2. When indicated, the airway is appropriately managed based upon
patient need, provider license level, and available equipment.
3. Provider documents results of airway management procedures, effect
on the patient, and patient re-assessment.
4. Provider completes a Maine EMS Airway Management Data Form, submits
it to the Regional EMS office, and maintains a copy with the run report.
Defining Compliance:
1. Successful compliance with the study will be defined as 100% of
the indicators listed above are present on the run report when appropriate.
Any standard that is not applicable will be marked as such and will
be considered compliant.
Frequency of Measurement:
1. Service QI committee members will separate out all run reports
where a patients airway is managed and keep them in a separate location.
2. All studies will be retrospective looking back no more than 6 months.
3. Service QI committees will receive notification on which study
will be done and for what period of time.
4. Run reports only need to be kept separate for a period of 6 months.
Format for Reporting:
1. Services will be notified by the regional office which audits will
be reviewed and for what period of time.
2. The service QI committee should then review all run sheets that
fall within the standard for that particular audit.
3. The service should report the information to their local QI nurse
using the approved form.
4. The service will receive a report back showing their results as
compared with the rest of the region. Individual service results will
not be shared with any other service.
