Data Collection and EMS Research

CHAPTERCHAPTER

Management of EMS

Data Collection andEMS Research

16

Bruce E. Evans • Jeff T. Dyar — Management of EMS Copyright © 2010 by Pearson Education, Inc. Upper Saddle River, NJ 07458

Learning Objectives

16.1 Evaluate the different types of research. 16.2 Understand the domains of EMS

research. 16.3 Deploy specific research methodologies

to the prehospital setting. 16.4 Define validity and reliability in scientific

research and data.


Learning Objectives (Cont.)

16.5 Apply GIS concepts to EMS-related activities.

16.6 Recognize the federal, state, and local data-collection systems.

16.7 Link data to quality-improvement initiatives in EMS.


EMS and the Research Agenda

• Despite years of dedicated service, EMS systems are treating and transporting patients with almost no evidence that the care provided is effective and efficient

• Very little scientific research on EMS management procedures has been produced, and efforts to sustain an EMS journal devoted to the management sciences have yet to be established


EMS and the Research Agenda (Cont.)

• As health-care costs increase and every expense becomes scrutinized by private insurance, federal, state, and local governments’ money will be put toward services that prove their worth in making an impact on patient outcomes

• The EMS Agenda for the Future identified the need for advancing quality research in the field of EMS


EMS Reports and Collection Techniques

• EMS reports connect patient care with dispatch data and patient outcomes

• They serve as a defense mechanism for litigation and help reduce patient-care errors by ensuring a smooth transition of the patient-care information from EMS provider to hospital


EMS Reports and Collection Techniques (Cont.)

• Three are three basic types of EMS reporting technology– Optically scanned reports

Forms are filled out in the field by EMS providers and sent to a clerical person, who in turn feeds the form into an optical scanner that tabulates the data and enters it into the computer



• Three are three basic types of EMS reporting technology– Manual-entry method

Personnel manually enter specific data elements from PCR’s generated in the field



• Three are three basic types of EMS reporting technology– Paperless system

This type of data collection relies on pen-based or laptop computers

Many use software that has a point-and-click data-entry system

Ensures a consistent narrative format and allows the EMS provider to narrate the information



• Three are three basic types of EMS reporting technology– Paperless system

Automated processes help reduce the time on task for EMS crews

Drop-down menus in the computer-based programs help standardize the data


Integrated Informational Management Systems

• Integrated information management system (IIMS)– System that collects data for an EMS

system– IIMS manages databases that are a

collection of records and that must be organized


Integrated Informational Management Systems (Cont.)

• Integrated information management system (IIMS)– Must establish validity by managing

information that is related to the EMS agency’s needs

– Information must be produced in a timely and accurate fashion to establish reliable data


TABLE 16.1


Domains of EMS Research

• There are three areas of interest in the EMS research community that should be applied to an EMS organization:– Clinical research

Involves the study of direct patient-care activities.


Domains of EMS Research (Cont.)

• There are three areas of interest in the EMS research community that should be applied to an EMS organization:– Systems research

Studies the effects of EMS systems designs and operational methods on resource utilization

– Educational research Examines the methods of preparing,

remediating, and providing recertification activities to EMS providers


Types of Research

• Research can be qualitative or quantitative– Qualitative research

Often anecdotal, composed of soft data that does not have enough numerical or objective measurements to be statistically significant


Types of Research (Cont.)

• Research can be qualitative or quantitative– Qualitative studies

Often based on observation of a single phenomena or a case study

Composed from material from interviews and reviews of documents

Often has problems with reliability



• Mixed method– Is becoming the most common type of

research, it uses one type of research to set up the other



• Quantitative research– Is based on objective and measurable

factors– Are one of three types

Experimental design• Defines a population and applies a treatment,

intervention, or change, then measures the effects



• Quantitative research– Are one of three types

Quasi experiment• Measures a population that has already been

treated or received an intervention, and then measures the difference between groups

Non-experiment• Measures the difference between two groups

without identifying the intervention, change, or treatment applied to the groups


Research Methodologies

• Several different methods are used by drug companies, medical-equipment manufacturers, epidemiologists, and quality-improvement professionals

• Most often EMS managers need to refer to publications on research

• A case study is the beginning of what is considered scientific research and is usually a factual account of an event described in detail


Research Methodologies (Cont.)

• When reviewing information on the science of EMS, managers should look for the most expensive and complex research method, known as the randomized control trial



• Case-control studies are observational designs in which a group of individuals or events are chosen according to whether they do or do not have a characteristic or risk factor of which the cause is to be studied; those individuals or events are compared with controls that share important characteristics with the group being studied.



• A cohort study involves a group of individuals with common characteristics or exposures that are observed over time– The case group is exposed to the injury

problem and the comparison group is not– Cohort studies allow for incident rates to be

determined



• A cross-sectional study makes an observation of a group during a certain period of time


Central Tendency• Measures of central tendency provide a single

summary figure that best describes the central location of an entire distribution

• The three most common measures of central tendency are the mode, the median, and the mean – Mode is the value that occurs most frequently in a

distribution – Mean is also known as the arithmetic mean or

average. – Median is defined as the middle value (50th

percentile) of a distribution


Central Tendency

• The three most common measures of central tendency are the mode, the median, and the mean – Mode is the value that occurs most

frequently in a distribution – Mean is also known as the arithmetic mean

or average. – Median is defined as the middle value (50th

percentile) of a distribution


Measures of Dispersion

• Measures of dispersion provide a summary of the variability or spread of the values in a distribution– Express quantitatively the extent to which

the values in a distribution scatter about or cluster together


Measures of Dispersion (Cont.)

– The three main measures of dispersion are the range, variance, and standard deviation Range is the most basic measure of dispersion Variance is the measure of the variability of a

distribution Deviation is the difference between the values in

a distribution and its mean


Data Entry and Data Quality

• Research and data on fire incidents and casualties relies very heavily on the street-level paramedic or EMT entering information into the computer and the inputs being available for analysis

• While manual analysis certainly is possible, it usually is avoided because the tedious calculations quickly overwhelm the ability to perform analysis in any significant manner


Data Entry and Data Quality (Cont.)

• The advantage of a computer is that it processes data quickly and accurately

• Any program you purchase should contain a good error-checking routine

• Data quality is always a problem, and the old adage “garbage in, garbage out” certainly applies to EMS organization reports


Data Entry and Data Quality (Cont.)

• The entry program should, for example, check each item to make sure a valid code has been entered

• Whenever the program encounters an error, it should give an opportunity to correct the error before it becomes part of the database


National EMS Information System

• National EMS Information System (NEMSIS)– A fully implemented and useful EMS

database that resides or is controlled at a local, state, and national level

• The purpose was to evaluate patient and EMS system outcomes, facilitate research, and develop a nationwide EMS training curriculum


FIGURE 16.3National EMS Information System (NEMSIS).

(Source: NEMSIS, www.nemsis.org. Reprinted with permission.)


EMS Outcomes Project

• EMS Outcomes Project (EMSOP)– A major research initiative funded by the

National Highway Traffic Safety Administration designed to measure patient outcomes from EMS interventions

– The goal is to identify the frequency of EMS events, the impact of EMS treatments, and the clinical outcomes of the treatment provided

– The EMS Outcomes Project is being managed by the National Association of State and EMS Administrators


Trauma Registry

• Trauma registry– Set of data collected on trauma-center

patients– A level-one trauma center designation

requires that the trauma center conduct research in trauma care As part of this system, each EMS provider is

given a designation number, and outcome scores are correlated with each agency based on the injuries the patient receives

Prehospital factors such as response time, scene time, and transport times are all analyzed


Motor-Vehicle Crash Data

• Motor-vehicle crash data is collected and maintained through state departments of transportation and law- enforcement agencies

• Crash Outcomes Data Evaluation System (CODES)– Data in 25 states from law-enforcement,

EMS, and emergency departments– Helps generate outcome data for collisions

and aids in developing highway traffic- safety programs


Cardiac-Arrest Data

• Utstein criteria– The gold standard for measuring cardiac-

arrest survival since 1991– Data on cardiac arrest is generally collected

and reported as a registry for quality improvement and as a research report that looks at outcomes and the interventions that are related to those outcomes


Cardiac-Arrest Data (Cont.)

– Criteria help EMS managers conduct quality-improvement activities and compare arrest statistics against other systems

– Outcome data after a cardiac arrest is dependent on critical interventions like defibrillation, CPR, and advanced life support

– Reporting template in an algorithm format that instructs a quality-improvement coordinator or EMS researcher on which cardiac-arrest patients to include in the database


FIGURE 16.5Time Elements for Cardiac Arrest Applied to Utstein Criteria.


FIGURE 16.6Utstein Criteria for Measuring Cardiac-Arrest Outcomes.


Managing GIS

• EMS managers need to periodically review and budget for upgrades in GIS

• Expect to budget for and manage increases in data-collection cost, computer memory, upgrades in video cards, larger data storage, color printers, and increased processor speeds


Managing GIS (Cont.)

• State-of-the-art GIS programs have high-end computers, a large sever, and digitizing tablets for run reports and inventories

• High-end systems may need laser printers and a larger printer called a plotter, used to print maps


Managing GIS (Cont.)

• The common GIS software packages on the market are ESRI ArcView, MARVLIS, MapInfo, Caliper, Intergraph, and Tactician

• A common application of GIS is to use the technology and data to create a fluid deployment plan or assist the communication center with the dispatch of the unit closest to the call


Resource Outcomes

• Once data is collected, a key component of that data is defining in the research what an outcome is and how it is measured

• The most common research terms are morbidly and mortality– Mortality is a death– Morbidity is often seen as a disability or loss

that does not result in death


Literature Reviews

• When reviewing research that is involved with drugs or equipment, it is important to consider evidence-based practice

• Evidence should come from a credible source and with predetermined criteria in human studies, if possible with sound methodology

• There are eight steps or levels involved with medical scientific research


FIGURE 16.12National Institutes of Health (NIH) Steps in Clinical research


Evidence-Based Medicine

• Once clinical evidence and research have been reviewed, drugs, medical procedures, and equipment are classified into seven different categories

• The American Heart Association uses these terms to classify the effectiveness based on evidence-based medicine


FIGURE 16.13American Heart Association Classification of Therapies.


Run Chart

• When data about a work process is collected, the results can be displayed in a graph

• A run chart is one type of graph that is used to see if work is performed in a consistent way


Run Chart (Cont.)

– Can be prepared for any point of a work process that is to be measured and evaluated

– Data for a process measure are plotted either after several events of work are done or as work is completed over a period of time; for example, the number of IV starts per paramedic


FIGURE 16.15How to Construct a Run Chart.


FIGURE 16.16Analysis of Run Charts.

(Source: Department of Transportation EMS Quality Improvement Manual.)


Run Chart (Cont.)

• Run charts are used to determine if a process is performing as expected and whether there are changes in a process characteristic in a sequence or over time

• Run charts are also used to identify early patterns and outliers among the observed data


Histogram

• Histogram– A column graph where the height of the

bars indicate the relative numbers or frequencies for a given values of a variable

– The values can be numeric, such as response time, or non numeric, such as days of the week


Histogram (Cont.)

– Help to show how EMS crews are doing at the present time

– Data are grouped into defined intervals and displayed according to their frequency of occurrence in each interval

– This method provides insights about performance and, in particular, the variation that normally occurs in work


FIGURE 16.18Steps to Construct a Histogram.


Histogram (Cont.)

• A picture of the data distribution that includes a spread and shape

• This can provide clues about the variation that exists in the work performed


Histogram (Cont.)

• Distributions can have either a positive skew (tail of the distribution to the right) or negative skew (tail of the distribution to the left) direction from the center

• By examining the spread and shape of a distribution, the extent of variation in a work process can be determined


FIGURE 16.19Histogram Sample.


Bar Charts

• One of the simplest and most effective ways to display data

• A bar is drawn for each category of data, allowing for a visual comparison of the results– The horizontal dimension gives the percent,

while the vertical dimension shows the category labels


Pie Charts

• An effective way of showing how each component contributes to the whole

• The entire pie chart accounts for all of the categories


Pie Charts (Cont.)

• In developing pie charts, one should follow these rules: – Convert data to percentages – Keep the number of wedges to six or fewer – If there are more than six, keep the most

important five and group the rest into an “Other” category


Pie Charts (Cont.)

• In developing pie charts, one should follow these rules: – Position the most important wedge starting

at the 12-noon position– Maintain distinct color differences among

the wedge


Cause-and-Effect Diagram

• Is used to show the causes of a problem • They can be used to uncover the root

causes of a problem and when the root causes are identified, how much each cause contributes to a problem can be evaluated.


FIGURE 16.22Flowchart for Field C-Spine Clearance. (Source:ADA County EMS.)


Flowcharts

• A flowchart illustrates the activities performed and the flow of resources and information in a process; two types of flowcharts are particularly useful: high level and detailed – High-level flowchart

Illustrates how major groups of related activities, often called subprocesses, interact in a process


Flowcharts (Cont.)

– Detailed flowchart Shows the sequence of the work and includes

most or all of the steps, including rework steps that may be needed to overcome problems in the process


Pareto Diagram

• Type of bar chart in which the bars representing each problem cause are arranged, or ranked, by their frequency in descending order

• Useful in interpreting data and confirming the relationships that are suggested in cause-and-effect studies

• Approach is based on the idea that 80% of the problem comes from 20% of the causes


FIGURE 16.23How to Construct a Pareto Diagram.


Summary

• Research is critical to EMS as an industry for several reasons:– It validates what we do– It provides specific information to manage

quality– It informs internal and external customers

and groups of trends that affect EMS service delivery

– It provides a body of knowledge to define a profession


Summary (Cont.)

• There are a variety of organizations that support EMS with data, including NHTSA, NIST, the CDC, NAEMSP, and the IAFF

• By participating in research and data collection, EMS organizations contribute to their future by validating their efforts


Summary (Cont.)

• Consider the fact that the past 30 years of EMS have produced very little research that proves the efforts have been effective

• If EMS is going to gain the respect that other allied-health professions enjoy, research will be key

Data Collection and EMS Research

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