Risk assessment
Assessing risk in health care involves identifying those things that place us at risk and then attempting to predict the frequency and severity of occurrences. It is important to know what to monitor. Activities classified as “high frequency, high risk” obviously should be monitored closely. Low-frequency, low-risk activities or even high-frequency, low-risk activities do not require as much of our attention. In fact, the costs of monitoring these types of activities may outweigh the benefits. The two high-risk activities that require most of our attention are intubations (low-frequency) and no-transports (high-frequency). We look at historical data to determine those activities that require frequent monitoring and typically the two mentioned above are the ones that every service wants to closely monitor [1].
Obviously we want to make as few errors in risk assessment as possible. The development of pre-loss and post-loss strategies is one way to achieve that goal. Pre- loss strategies include the use of effective protocols or guidelines, education (both initial and continuing) that is thorough and provides feedback to the field practitioners, good documentation, and an effective quality improvement program. Post-loss strategies include a good investigation, matching behavior to protocols or guidelines, and remediation/education as indicated [1].
Preemployment screening and orientation
If a potential EMS field employee received primary training outside the EMS system, it is important for this individual to be assessed in terms of medical knowledge and patient care skills before being released to function independently in the field. As a prehiring assessment, many systems use a written examination that may include tests of basic knowledge such as reading and math. Other assessments that are used include EMS knowledge-based written and skills testing, physical ability testing, interviews, and psychological screening. Most systems have standard administrative procedures, such as background checks [3].
New employees should receive field orientation and evaluation before functioning as patient care pro- viders. Orientation is provided in administration, operations, and medical areas, including protocols, equipment, and field performance standards.
Medical supervision
Assurance of quality prehospital health care is provided through the process of medical accountability [4]. The medical supervision of prehospital care is discussed extensively throughout this book. The vital role of the medical director in defining patient care standards, establishing protocols, approving the level of prehospital medical care that may be rendered by all individuals in the system, and positively affecting all the operational aspects that affect patient care cannot be overemphasized. In addition, the medical director should be directly involved in the risk management program.
Continuing medical education
Continuing medical education (CME) serves multiple purposes in an EMS system, including updating personnel on protocol changes, providing reviews, presenting medical information and technology, and evaluating knowledge and skills of field personnel. A number of studies have demonstrated deterioration of knowledge and skills in EMS providers. In 1980, Latman and Wooley demonstrated that personnel certified at the now-defunct Emergency Medical Technician-Ambulance (EMT-A) level lost 50% of their basic skills proficiency, and paramedics lost 61% of their basic skills proficiency within 2 years of training [5]. In 1987, Skelton and McSwain reported a correlation between the amount of technical skill deterioration and increasing length of time from completion of the training program [6]. One role of continuing medical education is to evaluate and enhance knowledge and skills of field personnel.
Other roles of CME include updates on protocol changes, patient care reviews, and new medical information and technology. CME also serves as a forum for EMS personnel to both provide and receive feedback regarding patient care. In 1990, Goldberg published a review of litigation in a large metropolitan EMS system and suggested that medicolegal continuing education could protect EMS systems and paramedics from future litigation [7].
Documentation
The Joint Commission (TJC, formerly JCAHO) requires that a medical record is established and maintained on every patient seeking emergency department care [8]. TJC mandates certain elements be included in the record; other elements may be added to conform with state regulations and hospital requirements. In comparing this with the prehospital arena, it is apparent that documentation requirements for EMS patient records vary widely. Patient records are required for all transported patients, yet specific elements of the record are far from universal. A number of states have standardized EMS patient records, but use of such a patient care report (PCR) may not be required.
Many systems maintain limited or no patient documentation if a patient is not transported. In 1992, Zachariah reported serious, even fatal, outcomes in patients not transported by EMS. Situations in which EMS personnel either denied transport or mutually agreed with the patient not to transport by ambulance were twice as likely to result in hospitalization than cases in which the patients declined transportation against the advice of the EMS personnel [7]. In 1990, Selden studied medicolegal documentation of prehospital triage and suggested that, rather than an abbreviated form or small section of the usual PCR, the release form (when a patient is not transported) must be at least as detailed as the usual incident report [9]. In 1985, Solar reported on the 10-year malpractice experience of a large urban EMS system and stated that a properly completed PCR is the best defense against a malpractice allegation [10]. Documentation remains one of our most critical areas for risk exposure.
Other important areas of documentation include the new employee’s application, pre-employment screening, and field orientation. Some systems document the new employee’s knowledge of written protocols, thus holding him or her accountable for the information and providing written evidence of that accountability. All aspects of patient care incident management should also be documented.
Quality management and risk management
Quality management (QM) of the patient care rendered in an EMS system may identify actual or potential risks to patients and the system. This identification allows for the proactive management of such risks, and takes the EMS system out of the reactive mode of dealing with problems in patient care. The QM loop forms a continuous action loop, starting and ending with protocols and education. Documentation of variance from or compliance with protocols forms the basis for analysis of the quality of care delivered [11].
Quality management and risk management are closely linked. The goals and objectives of a risk management program must be clearly understood, measurable, and attainable. There must be buy-in from all of the personnel within the organization. There are five principal steps in the development of an effective risk management program: (1) identifying risk exposure, (2) evaluating risk potential, (3) ranking and prioritizing risks, (4) determining and implementing control actions, and (5) evaluating and revising actions and techniques as needed. These steps include identifying and addressing those internal and external factors that create risk within the organization [12].
Other factors
Other incidents may occur in an EMS system that have potential effects on patients. If an ambulance is involved in an accident, the patient may receive injuries directly or have increased morbidity from a delay in transport. In 1992, Bowers reported on 182 incidents of alleged negligence involving prehospital care providers; 40% of the cases involved ambulance accidents (although some of these cases involved several identified categories of negligence) [13]. This is compared with 42% of the cases that were related to negligence involving treatment or care. A provider who is injured while extricating a patient may no longer be able to provide patient care at the scene, potentially affecting patient care. Equipment malfunctions such as defibrillator failure may have direct bearing on morbidity and mortality for a patient. Steps should be taken to identify and address potentially preventable occurrences, such as driver training programs and regular equipment checks.
