Roma Bhatia and Egor Buharin

Mentor: Zachary Meisel, MD

Pre-hospital emergency medical services (EMS) provide care for over 20 million patients annually.

Nearly all episodes of EMS care are completed when the provider “hands off” a patient to emergency department (ED) personnel.

◦Examine attitudes, beliefs among a diverse group of stakeholders and participants ◦Characterize perceptions of barriers to high quality handoffs; to identify variations in these perceptions by thematic factors. ◦Characterize perceptions of relative value of EMS handoffs as it relates to patient safety among a diverse group of stakeholders.

Job description

Salary

Education/training

Perform tests essential for the detection, diagnosis, and treatment of disease.

At times, assigned to aid nurses in the Emergency Department when exceptionally busy.

$26,000 annual salary

Bachelor of Science, majoring in clinical-laboratory science (4 year degree)

Assess injuries, administer emergency medical care, and extricate trapped individuals. Transport injured or sick persons to medical facilities.

$36,000 annual salary

140 hours course (often completed in 3-6

months)

Entirely encompasses EMTs scope of practice.

Paramedics are trained in the use of 30-40 medications, depending on the state.

Set-up IVs and administer advanced airway maintenance intervention.

$55,000 annual salary

1400 – 1800 hours training (2 year degree)

Treat patients, educate patients and the public about various medical conditions, and provide advice and emotional support to patients' family members. RNs record patients' medical histories and symptoms, help perform diagnostic tests and analyze results, operate medical machinery, administer treatment and medications, and help with patient follow-up and rehabilitation.

Mean salary: $72,000

Bachelor's degree, an associate degree, and a diploma from an approved nursing program (2 to 4 years)

Diagnose illnesses and prescribe and administer treatment for people suffering from injury or disease.

Examine patients, obtain medical histories, and order, perform, and interpret diagnostic tests. They counsel patients on diet, hygiene, and preventive healthcare.

Annual salary: $234,000

Undergraduate (4 yrs) + medical school (4 yrs) + residency (3 yrs) + fellowship (2 yrs) = 13 years

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Medical Tech EMT Paramedic Nurse

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Medical Tech $26,000 EMT $36,000 Paramedic $55,000 Nurse $72,000

Medical Tech $26,000 EMT $36,000 Paramedic $55,000 Nurse $72,000 ER Physician $234,000

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Medical Tech EMT Paramedic Nurse ER Physician

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Medical Technitians 4 EMT 0.5 Paramedics 2 ER Nurse 4 ER Physician 13

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Medical Technitians EMT Paramedics ER Nurse ER Physician

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Years of Initial Training of Healthcare Personel

Dispatched to fall incident.

Unresponsive 68 year old male.

Relative – Claims p/t suffers from history high BP

Show altered mental status (signs of stroke)

Hospital choice

Divert + Stroke Center vs Non-Divert hospital

Use of focus groups vs. surveys ◦ How are points of view constructed? ◦ How are points of view expressed?

7 X 1 hour focus group

transcripts

Focus groups divided by professional category

Participants offered refreshments and $25 gift card.

Annual Meeting of the National Association of EMS Physicians (NAEMSP) ◦ Includes: Physicians, paramedics, nurses,

administrators, educators, and researchers.

Conducted focus groups: EMS medical directors/physicians; Non physician EMS professionals; Nursing personnel.

EMS Today/JEMS Conference and Expo ◦ Largest national convention for EMS professionals—

with over 4,000 members in attendance.

Conducted Focus Groups: ◦ EMT paramedics-extensive training, broad scope of

practice. ◦ EMT basic/intermediate-limited training, limited

scope of practice ◦ Nursing personnel

Conduct separate groups ◦ To maximize the shared experiences ◦ Known authority gradient (e.g., between medical

directors who supervise paramedics and paramedics themselves)

Utilized sampling model to obtain variety of professionals in genders, races, and training levels.

Moderated by Dr. Zachary Meisel, MD (PI).

Explore how the handoff usually occurs. Examine positive or negative experiences

associated with handoff. Determine important components to

communicate/know in handoffs. Understand barriers to high quality handoff Evaluate the role of trust/perceived trust in

handoffs Assess global and relative value of handoff

process as compared to other key aspects of emergency care.

Roma

To obtain inter-rater reliability

Attitudes/judgments towards me Receptiveness Mannerisms/personality/professionalism Relationships/familiarity/socializing Competence

Structural Aspects Who? Where? When? How? How long?

Attitudes and beliefs

Process outcomes • Time to

Antibiotics • Door to

Balloon • tPA window

for stroke

Patient outcomes

• Training • Local

culture • Trust • Perceived

Trust Patient

Factors • Race • Age • Gender • Acuity

[paramedic referring to a specific hospital]

◦ “… I am pretty capable of convincing patients to not

make me take them to [Hospital X] because I don’t want to deal with the nursing staff there.”

◦ “There’s a hospital near me that I will not go to

because of the attitude unless it’s a trauma that you have to go there.”

◦ “I now feel much better knowing that they trust my

treatment, knowing that they trust my assessments and things of that sort and being able to handle…like it’s a lot easier going in there.”

The role of EMT’s in healthcare “And that we are not glorified taxi drivers.”

“Because I think there’s so many people that don’t

understand EMS that work in the hospital setting, and … having somebody that understands EMS and doesn’t just look at us as ambulance drivers that brought the patient, and realize what we can do in the field, to be able to interact on that level I think would really help as far as being able to relay information.”

Mod: So how often does that happen where you get to talk to even a doctor when you bring the patient in?

R: Not often enough.

R: Not often. You talk to a nurse more than anything. And

sometimes you don’t even get a nurse. Sometimes you get a…

R: Nursing assistant?…

R: Or yeah, an ER tech. Now pretty much an ER tech is our level…

R: The same level [as EMTs] and it’s not even worth it like to sign off because you’re not even really passing it to a person of higher authority.

◦ “Sick is sick. You’re a hospital. It doesn’t say at the

front door “We only take traumas only. Sick people go next door.” ◦ [referring to Trauma cases] “They’re the ones you had

your business for.”

◦ I came in with this lady, she was pretty bad, in her

eighties. And I came in and of course they [hospital] were on diversion… But so I walked in and they had no idea I was coming in and they just looked at me like a deer in the headlights, like “What are we supposed to do with the patient ?” They didn’t have anywhere to put it or… And I was just like “Help please!” And the doctor was very rude . She was just like “Why do you keep on coming here with these sick patients? We’re on divert.” I mean the hospital was like two blocks from her house so I really didn’t have a choice. And it didn’t make for a very good experience and the nursing staff was very nasty. They just kept on telling me “Don’t come back. Don’t come back again. Don’t come back.”

Mod: What do you guys do if there are…if you feel like you’re talking past each other I just reiterate why, my point, and then I laugh at them when they rush right up to CAT scan when they find something. And they come “Well oh, it was something.” Maybe next time you should listen to the paramedic, you know. [In response to hospital disrespect targeting EMS] Mod: So you think that some of that is personality trait or… And that’s when they have a personality… And I do a little

planning or games and ok, well now you’re getting the next fifteen patients ‘cause you ticked me off with this one. And that’s not the right thing to do, but unfortunately I think in all walks of life you have all… Depending on personalities…

Structural Aspects Who? Where? When? How? How long?

Attitudes and beliefs

Process outcomes • Time to

Antibiotics • Door to

Balloon • tPA window

for stroke

Patient outcomes

• Training • Local

culture • Trust • Perceived

Trust Patient

Factors • Race • Age • Gender • Acuity

Study is first evaluation of the pre-hospital to hospital transition of care.

Goal: inform local and large scale efforts to improve the process.

Next step: trials of quality improvement informed by the results of these studies.

Personality, professionalism, and mannerisms can drive patient outcomes.

Poor standardization of the healthcare system.

Modes of deriving statistical significance from qualitative data.

Job Descriptions: BLS.gov

Salaries: specified to the Philadelphia region – indeed.com

Hypothetical: Egor’s experiences in EMS

Dr. Zachary Meisel

Joanne Levy Lissy Madden Meagan Pellegrino Hoag Levins Renee Zawacki

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