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California EMS SystemCore Quality MeasuresData Years 2012/2013Emergency Medical Services AuthorityCalifornia Health and Human Services AgencyEMSA #166 - Appendix EEMS System Quality Improvement Program Guidelines

California EMS System Core Quality Measures 2HOWARD BACKER, MD, MPH, FACEPDIRECTORDANIEL R. SMILEYCHIEF DEPUTY DIRECTORTOM MCGINNISCHIEF, EMS SYSTEMS DIVISIONEMSA #166 – Appendix EReleased – January 2013Updated November 2013Funded byCalifornia HealthCare FoundationProject #16933April 1, 2012 - June 30, 2014

3 California EMS System Core Quality MeasuresAcknowledgementsCalifornia Emergency Medical Services Authority StaffHoward Backer, MD, MPH, FACEP, DirectorDaniel Smiley, Chief Deputy DirectorTom McGinnis, Division Chief, EMSTeri Harness, Assistant Division Chief, EMSHailey Pate, Data Program Analyst, EMSAdam Davis, Staff Analyst, EMSTask Force MembersJoe Barger MD, Medical Director, Contra Costa County EMSDavid Chang PhD MBA, Director of Outcomes Research, Department of Surgery, UCSan Diego School of MedicineCathy Chidester RN, Director, Los Angeles County EMSCraig Stroup, Quality Improvement Coordinator, Contra Costa County EMSKarl Sporer MD, Medical Director, Alameda County EMSJan Ogar RN, Services Manager, San Mateo County EMSLaura Wallin RN, Quality Improvement Coordinator, Riverside County EMSDana Solomon, Program Director, California Ambulance AssociationDennis Carter, Clinical Education Services Manager, American Medical ResponseRic Maloney RN, CQI Manager, Sacramento Metro FireJason Vega, EMS Specialist, Santa Clara County EMSSusan Mori RN, Quality Improvement Coordinator, Los Angeles County EMSTroy Peterson, EMS Specialist, Marin County EMSBJ Bartleson RN, Vice President, California Hospital AssociationBill Bogenreif, Director of Information Technology, NorCal EMSEd Hill, Senior EMS Coordinator, Kern County EMSKara Davis RN, EMS Systems Director, NorCal EMSChris Clare RN, Data Systems Manager, Los Angeles County EMS

California EMS System Core Quality Measures 4Table of ContentsEMS System Core Quality Measures ProjectStatutory Authority . 5Project History . 6Introduction to Core Measures . 7Instructions for Running Reports . 9Chart of Core Measures for California . 10Core Measures Specification SheetsTRA-1 Scene time for severely injured trauma patients . 13TRA-2 Direct transport to designated trauma center for severely injured trauma patientsmeeting criteria . 16ACS-1 Aspirin administration for chest pain/discomfort rate . 20ACS-2 12 lead ECG performance . 22ACS-3 Scene time for suspected heart attack patients . 24ACS-5 Direct transport to designated STEMI receiving center for suspected patientsmeeting criteria. 26CAR-2 Out-of-hospital cardiac arrests return of spontaneous circulation . 28CAR-3 Out-of-hospital cardiac arrests survival to emergency department discharge . 30CAR-4 Out-of-hospital cardiac arrests survival to hospital discharge . 32STR-2 Glucose testing for suspected acute stroke patients . 34STR-3 Scene time for suspected acute stroke patients . 36STR-5 Direct transport to stroke center for suspected acute stroke patients meeting criteria. 38RES-2 Beta2 agonist administration for adult patients . 40PED-1 Pediatric asthma patients receiving bronchodilators . 42PAI-1 Pain intervention . 44SKL-1 Endotracheal intubation success rate . 46SKL-2 End-tidal CO2 performed on any successful endotracheal intubation . 48RST-1 Ambulance response time by ambulance zone (Emergency) . 50RST-2 Ambulance response time by ambulance zone (Non-Emergency) . 52RST-3 Transport of patients to hospital . 54

5 California EMS System Core Quality MeasuresSTATUTORY AUTHORITYThe California EMS Authority (EMSA or authority) is charged with creating a “statewidesystem for emergency medical services” and the responsibility for the “coordination andintegration of all state activities concerning emergency medical services” (HS 1797.1).Moreover, the authority is required to assess each EMS area or the system’s servicearea, utilizing regional and local information, for “the purpose of determining the needfor additional emergency medical services, coordination of emergency medical servicesand the effectiveness of emergency medical services” (HS1797.102). And local EMSagencies are required to plan, implement, and evaluate an EMS system (HS 1797.204).Health and Safety Code 1797.103 identifies that one of the required elements of anEMS system is data collection and evaluation. Additionally, the development of qualityimprovement guidelines must be established (HS 1797.174). As a result of thisstatutory mandate, EMSA has developed regulations requiring the system datacollection and evaluation, collection of prehospital care reports (CCR, Title 22, Division9, Chapter 4, Section 100147, 100169, 100170).Additionally, EMS system quality improvement regulations have been established(CCR, Title 22, Division 9, Chapter 12) that define the requirements for local EMSagencies, EMS service providers, and base hospitals in their role as part of the EMSsystem. These requirements include, but are not limited to the implementation of anEMSA approved EMS Quality Improvement program (EMS QI) and the use of definedindicators to assess the local EMS system as found in EMSA #166, Appendix E. Thisevaluation and EMS QI information must be submitted annually to EMSA, as part of itsrequired EMS plan (HS 1797.254), in order to allow EMSA to evaluate if the planeffectively meets the needs of the persons served.A report to the Legislature must be made on the effectiveness of EMS systems annuallyrelated to the EMS system’s impact on death and disability (HS 1797.121).In order to achieve this mandate to evaluate system impact on patients, the continuumof care from dispatch to pre-hospital to hospital disposition must be connected. Only inthis way, we can begin to understand how care provided by EMS personnel translatesto improved outcomes and system effectiveness.

California EMS System Core Quality Measures 6PROJECT HISTORYThe purpose of the EMS system core measures project is to increase the accessibilityand accuracy of pre-hospital data for public, policy, academic and research purposes tofacilitate EMS system evaluation and improvement through a grant from the CaliforniaHealth Care Foundation (CHCF). Ultimately, the project highlights opportunities toimprove the quality of patient care delivered within an EMS system.During the 1 year period, from July 31, 2013 to June 30, 2014, The California EMSAuthority (EMSA) is performing the following activities to deliver a set of publiclyavailable data reports:1. Create a formal data system profile and written analysis to identify areas for dataquality improvement and inform an action plan to address the issues.2. Work to reveal opportunities for both short-term and long-term data improvementplans.3. Focus on achieving reliable measures that are high value and feasible within a shortterm time frame.4. Refine and publish core measure sets that describe the coordination andeffectiveness of EMS utilizing regional and local information for California. This projectfocuses upon the following core measure sets: TraumaAcute Coronary Syndrome/Heart AttackCardiac ArrestStrokeRespiratoryPain InterventionPediatricSkill Performance by EMS ProvidersEMS Response and TransportPublic Education Bystander CPR5. Conduct data workshops for local EMS agencies across the state to implementimproved data collection and reporting practices with those Local Emergency MedicalServices Agencies who participate in California Emergency Medical ServicesInformation System.

7 California EMS System Core Quality MeasuresWHAT ARE CORE MEASURES?They are the use of standardized – or core – performance measures or qualityindicators in examining an EMS system or treating an identified patient condition.CORE MEASURES DEFINITIONThe preliminary California EMS Core Measures were derived largely from a set ofquality indicators developed through a project by the National Quality Forum.Additionally, NHSTA has published Performance Measures for emergency medicalservices. These California core measures will begin to benchmark the performance ofEMS systems, perform recommended treatments determined to get the best results forpatients with certain medical conditions, and transport patients to the most appropriatehospital. Information about these treatments are taken from the pre-hospital carereports and converted into a percentage.The measures are based on scientific evidence about processes and treatments thatare known to get the best results for a condition or illness. Core Measures helpemergency medical services systems improve the quality of patient care by focusing onthe actual results of care.COMPARING PERFORMANCEEmergency medical services systems across the state will be measured and comparedon their performance in these Core Measures. There will be a delay between when datais reported from EMS systems and when it is available for review. This is becauseEMSA will have to wait for all local systems in the state to be compiled before it canpost its quality data for a given period. This way, EMS systems and consumers cancompare California program from the same time period.In the future, EMS providers should utilize these core measures to assist in continuousquality improvement activities.SYSTEM EVALUATIONThe recurring theme in evaluation of the EMS system using these core measuresconsists of: Arrival at the scene in a timely manner,Timely, focused patient assessment,Delivery of time-sensitive prehospital therapy, andTransport to a hospital capable of providing necessary care

California EMS System Core Quality Measures 8FUTURE CORE MEASURESIt is anticipated that the proposed EMS system cores measures may be modified andfuture core measures added in the future.CORE MEASURES TASK FORCEA task force has been convened to review the core measures and makerecommendations. The task force consists of key data and quality leaders from localEMS agencies, medical directors, hospitals, and pre-hospital EMS providers.QUALIFYING DATAThe data derived for all measures will come from the calendar years of 2012 and 2013.Reports will be run by calendar year to obtain longitudinal comparisons.STANDARD ELEMENTS FOR EVERY MEASUREThe following standard elements are necessary to sort by time and location: Date/Time E05 01 CountyE08 13 LEMSAC01 01REFERENCE INFORMATIONThe California EMS System Core Quality Measures contains various references andcoding from other documents. All data elements and values referenced in the CoreMeasures are coded using NEMSIS. Please refer to the following documents regardingthe codes found in each measure:NEMSIS 2.2.1 Data Dictionary – Updated nts/NEMSIS Data Dictionary v2.2.1 04092012.pdf)NHTSA: Emergency Medical Services Performance Measures – Updated 12/2009(www.ems.gov/pdf/811211.pdf)Utstein Definitions ull)Pediatric patients are defined throughout this document as being younger than age 14

9 California EMS System Core Quality MeasuresINSTRUCTIONS FOR RUNNING MEASURE REPORTS Run each core measure exactly as specified on each core measure specificationsheet. If the core measure cannot be run as specified, run the measure based on theintent of the core measure according to the question provided in the descriptionbox on the specification sheet. If a core measure is ran based on intent (as described above), the LEMSA mustprovide the methodology that was used, including all elements and values, toachieve a value for the core measure. This must be provided when submittingthe report to EMSA.SAMPLING Sampling may be used to generate a reportable value for a measure based onthe standard methodology of random sampling as follows: Identify the denominator population (this needs to be provided on thereporting spreadsheet) Identify numerator population based on core measure Assign unique ID number to all numerator records Using a random number generator, identify the records to be included inthe sample. Sampling size must be a minimum of 30 records. When submitting your report, it must be specified that sampling was used.

California EMS System Core Quality Measures 10EMS SYSTEM CORE MEASURES FOR CALIFORNIA - 2013CCR Title 22,Div 9, Chap 12SET NAME100404Trauma(n 2)Acute CoronarySyndrome(n 4)Cardiac ArrestSETIDTRA-1Scene time for severely injured trauma patients2013TRA-2Direct transport to trauma center for severelyinjured trauma patients meeting criteria2013ACS-1Aspirin administration for chest pain/discomfort2013ACS-212 lead ECG performance2013ACS-3Scene time for suspected heart attack patients2013ACS-5Direct transport to designated STEMI receivingcenter for suspected patients meeting criteria2013CAR-2Out-of-hospital cardiac arrests return ofspontaneous circulation2013CAR-3Out-of-hospital cardiac arrests survival toemergency department discharge2013CAR-4Out-of-hospital cardiac arrests survival tohospital discharge2013STR-2Glucose testing for suspected stroke patients2013STR-3Scene time for suspected stroke patients2013STR-5Direct transport to stroke center for suspectedstroke patients meeting criteria2013RES-2Beta2 agonist administration for adults2013PED-1Pediatric asthma patients receivingbronchodilators2013PAI-1Pain intervention(n 3)DClinical Careand PatientOutcomePERFORMANCE MEASURE NAMEYEARBEGIN TOBEMEASUREDStroke(n 3)Respiratory(n 1)Pediatric(n 1)Pain Intervention2013(n 1)(Continued)

11 California EMS System Core Quality MeasuresCCR Title 22,Div 9, Chap 12100404SET NAMEESkillsMaintenanceandCompetencyPerformance ofSkills(n 2)FTransportationand FacilitiesResponse andTransport(n 3)SETIDPERFORMANCE MEASURE NAMEYEARBEGIN TOBEMEASUREDSKL-1Endotracheal intubation success rate2013SKL-2End-Tidal CO2 performed on any successfulendotracheal intubation2013RST-1Ambulance response time by ambulance zone(Emergency)2013RST-2Ambulance response time by ambulance zone(Non-Emergency)2013RST-3Transport of patients to hospital2013

California EMS System Core Quality Measures 12Core Measures Specification Sheets

13 California EMS System Core Quality MeasuresSCENE TIME FOR SEVERELY INJURED TRAUMA PATIENTSMEASURE SET TraumaSET MEASURETRA-1ID #PERFORMANCEMEASURE Scene time for severely injured trauma patientsNAMEWhat is the 90th percentile for on scene time value for severely injuredDescription trauma patients (RTS 5) who were transported from the scene by groundambulance?Type ofProcessMeasureReporting ValueTime (Minutes and Seconds)and UnitsTime (in minutes) from time ground ambulance arrives at the scene until theContinuoustime ambulance departs from the scene for Trauma patients, meetingVariablecriteria for transport to a trauma center (using revised trauma score orStatementRTS 5), who received transport by ground ambulance to a hospital by EMS(Population)personnel (EMT, AEMT, and Paramedic).InclusionCriteriaCriteriaData Elements All events for which E02 04 “type Type of Service Requestedof service requested” has value 30(E02 04)“911 response (scene),”; and Response mode to scenevehicle type corresponds to ground(E02 20)ambulance; Arrived at Scene (E05 06) E02 20 “response mode to scene” Unit Left Scene (E05 09)has a value of 390 “lights and Provider Primary Impressionsirens”(E09 15) Values for “arrived at scene” Provider SecondaryE05 06 and “unit left scene”ImpressionE05 09 are present and logical;(E09 16) Patients with E09 15 “provider Revised Trauma Scoreprimary impression” value 1740(E14 27)“blunt injury” or 1741 “penetrating Systolic Blood Pressureinjury”, or E09 16 “provider(E14 04)secondary impression” value 1875 Total GCS Value“blunt injury” or 1876 “penetrating(E14 19)injury” and: Respiratory Rate patients with E14 27 “Revised(E14 11)Trauma Score” 5; Date of Birth(E06 16)OR Age Units(E06 15) All events for which E02 04 “type Ageof service requested” has value 30(E06 14)“911 response (scene),”; andvehicle type corresponds to ground

California EMS System Core Quality Measures 14ambulance; and E02 20 “responsemode to scene” has a value of 390“lights and sirens” and values for“arrived at scene” E05 06 and “unitleft scene” E05 09 are present andlogical;Patients with E09 15 “providerprimary impression” values 1740“blunt injury” or 1741 “penetratinginjury”, or E09 16 “providersecondary impression” values1875 “blunt injury” or 1876“penetrating injury”and:E14 19 “Total Glasgow ComaScore” value 14; andE14 04 “systolic blood pressure”value 90; andE14 11 ”respiratory rate” value 10 or 29 for patients aged 1 yearor older or E14 11 ”respiratoryrate” value 20 for patients lessthan 1 year of age ExclusionCriteriaCriteriaData le ofFinal ReportingValue (numberand units)SamplingThe formula is the 90th Percentile of the given numbers or distribution intheir ascending order.14 minutes, 34 seconds (14:34)YesAggregation YesBlinded YesMinimum Data30Values Retrospective data sources for required data elements includeData Collection administrative data and pre-hospital care records.Approach Variation may exist in the assignment of coding; therefore, codingpractices may require evaluation to ensure consistency.SuggestedDisplay Process control or run chart by monthFormat &

15 California EMS System Core Quality MeasuresFrequencySuggested 90th Percentile Measurement. Aggregate measure of central tendency andStatistical quantile (fractile) measurement to determine the span of frequencyMeasures lysis

California EMS System Core Quality Measures 16DIRECT TRANSPORT TO TRAUMA CENTER FOR SEVERELYINJURED TRAUMA PATIENTS MEETING CRITERIAMEASURE SET TraumaSET MEASURE ID # TRA-2PERFORMANCE Direct transport to trauma center for severely injured trauma patientsMEASURE NAME meeting criteriaWhat is the percentage of severely injured trauma patients (RTS 5)Description who were transported from the scene directly to a trauma center by aground ambulance?Type of Measure ProcessReporting Value(%) Percentageand UnitsDenominator All trauma patients, meeting trauma criteria (using a Revised TraumaStatement Score or RTS 5) for transport from scene to a trauma center(population)DenominatorInclusion Crite

Ed Hill, Senior EMS Coordinator, Kern County EMS Kara Davis RN, EMS Systems Director, NorCal EMS Chris Clare RN, Data Systems Manager, Los Angeles County EMS . California EMS System Core Quality Measures 4 Table of Contents EMS System Core Quality Measures Project

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