Emergency medical services information systems and a future EMS national database

Description of the 2020 NEMSIS Public-Release Research Dataset

Background: The National Emergency Medical Services Information System (NEMSIS) is a federally funded program designed to standardize Emergency Medical Services (EMS) patient care reporting and facilitate state and national data repositories for the assessment and improvement of EMS systems of care. This manuscript characterizes the 2020 submissions to the National EMS Database, detailing the strengths and limitations associated with use of these data for public health surveillance, improving prehospital patient care, critical resource allocation, clinician safety, system quality assurance and research purposes.Methodology: Using the 2020 NEMSIS Public-Release Research Dataset (NEMSIS dataset), we evaluated the dataset completeness (i.e., presence of missing/null values), dataset content and assessed data generalizability. The analysis focused on 911 EMS activations resulting in the treatment and transport of a patient, except for out-of-hospital cardiac arrests for which all patients were included regardless of transport status.Results: In 2020, 43,488,767 EMS activations were reported to the National EMS Database by 12,319 agencies serving 50 states and territories. Of the 19,533,036 911 EMS activations reportedly treating and transporting a patient, the majority were attended by "non-volunteer" clinicians (77%) working in a fire-based EMS agency (35%) certified to offer Advanced Life Support (ALS) Paramedic service (80%) and located in an urban area (82%). 911 call centers most often dispatched EMS for "sick person" (20%), while EMS clinicians most likely reported asthenia (7%) as the patient's primary symptom as well as the clinician's primary impression (6%), and documented "fall on same level, slip, or trip" as the most common cause of injury (37%). The NEMSIS dataset demonstrates some "missingness" and element inconsistencies, but methods may be employed to mitigate these data limitations.Conclusions: The National EMS Database is a free and publicly available resource for evaluating EMS system utilization, response, and prehospital patient care. Understanding the characteristics of the underlying dataset and known data limitations will help ensure proper analysis and reporting of research and quality metrics based on nationally standardized NEMSIS data.

Understanding of Development Emergency Medical Services in Laos Emergency Medicine Residents

BACKGROUND: Rising death tolls from traffic accidents are quickly becoming an inescapable problem in almost all countries around the world. That being said, the World Health Organization has launched an ambitious campaign aimed at reducing the death rate from traffic accidents by 50% in the next 10 years. Development of emergency medical services (EMSs) was the tool to success the goals, especially in low- to middle-income countries including Laos. However, no studies regard perspective of training EMS in Laos emergency medicine residents. AIM: The aim of our work is to demonstrate the effect of EMS training for Laos emergency medicine residents to the development of the national policy in Lao’s EMS. METHODS: A cross-sectional study was conducted in two countries (Laos and Thailand) from January 2020. The project activities were establishment of a command-and-control center, development of EMS support system, and training for emergency care professionals. RESULTS: The eight Laos emergency medicine residents were enrolled between January and March 2020. After practicing as a dispatcher and emergency medical consultant in Thailand at Khon Kaen University, the participants from Laos found that all personnel gained experience and improved their knowledge of technology in EMS and organization management. This had a direct impact on improving confidence in their return to practice in Laos. CONCLUSIONS: The human resource development through international collaboration between Thailand and Laos is contributing the effective knowledge and expertise learning in Laos. Moreover, the result of this training may provide the most effective care system resulting in the much-needed drop in the mortality rate of traffic accidents in Laos.

The impact of the emergency medical services (EMS) automation system on patient care process and user workflow

Background

One of the important components of the health system is the emergency medical services (EMS) system. The EMS system was implemented at Kerman University of Medical Sciences teaching hospitals to communicate the situation of patients being transferred to the hospital by EMS and to provide facilities tailored to the patient's condition. The objective of this study was to investigate the impact of the EMS system on the patient care process and the workflow of users.

Methods

The hospital information system (HIS) report was used to investigate the impact of the EMS system on the patient care process and a questionnaire was distributed among 244 participants to determine its impact on the workflow of the users. Mann–Whitney U was used to analyze HIS reports, and Chi-square was used to analyze the data collected by questionnaires.

Results

The EMS system reduced the patient's stay in hospital by an average of 3 h and 45 min. It also increased the number of patients' discharge from the emergency room to 2.2% and reduced the death rate by 1.3% (p < 0.001). Besides, 78% of physicians, 75% of nurses and 83% of technicians stated that this system has positively influenced their workflow.

Conclusions

The EMS system reduced the patient's stay in hospital and mortality, and increased the speed of patient service, readiness of users to provide patient care and the number of discharged patients. However, problems such as inappropriate technical infrastructure of the EMS system should be solved to improve patients' recovery, reduce mortality and improve user satisfaction.

Data missingness in the Michigan NEMSIS (MI-EMSIS) dataset: a mixed-methods study

OBJECTIVE

The study was done to evaluate levels of missing and invalid values in the Michigan (MI) National Emergency Medical Services Information System (NEMSIS) (MI-EMSIS) and explore possible causes to inform improvement in data reporting and prehospital care quality.

METHODS

We used a mixed-methods approach to study trends in data reporting. The proportion of missing or invalid values for 18 key reported variables in the MI-EMSIS (2010-2015) dataset was assessed overall, then stratified by EMS agency, software platform, and Medical Control Authorities (MCA)-regional EMS oversight entities in MI. We also conducted 4 focus groups and 10 key-informant interviews with EMS participants to understand the root causes of data missingness in MI-EMSIS.

RESULTS

Only five variables of the 18 studied exhibited less than 10% missingness, and there was apparent variation in the rate of missingness across all stratifying variables under study. No consistent trends over time regarding the levels of missing or invalid values from 2010 to 2015 were identified. Qualitative findings indicated possible causes for this missingness including data-mapping issues, unclear variable definitions, and lack of infrastructure or training for data collection.

CONCLUSIONS

The adoption of electronic data collection in the prehospital setting can only support quality improvement if its entry is complete. The data suggest that there are many EMS agencies and MCAs with very high levels of missingness, and they do not appear to be improving over time, demonstrating a need for investment in efforts in improving data collection and reporting.

EMS Activations for School-Aged Children From Public Buildings, Places of Recreation or Sport, and Health Care Facilities in Pennsylvania

OBJECTIVES

To determine the etiology of emergency medical services (EMS) activations in 2011 to public buildings, places of recreation or sport, and health care facilities involving children aged 5 to 18 years in Pennsylvania.

METHODS

Electronic records documenting 2011 EMS activations as provided by the Pennsylvania Department of Health's Bureau of EMS were reviewed. Data elements (demographics, dispatch complaint, mechanism of injury, primary assessment) from patients aged 5 to 18 years involved in an EMS response call originating from either a public building, a place of recreation and sport, or health care facility were analyzed.

RESULTS

A total of 12,289 records were available for analysis. The most common primary assessments from public buildings were traumatic injury, behavioral/psychiatric disorder, syncope/fainting, seizure, and poisoning. The most common primary assessments from places of recreation or sport were traumatic injury, syncope/fainting, altered level of consciousness, respiratory distress, and abdominal pain. The most common primary assessments from health care facilities were behavioral/psychiatric disorder, traumatic injury, abdominal pain, respiratory distress, and syncope/fainting. When examining the mechanism of injury for trauma-related primary assessments, falls were the most common mechanism at all 3 locations, followed by being struck by an object. Of the 1335 serious-incident calls (11% of the total EMS activations meeting inclusion criteria), 61.2% were from public buildings, 14.1% from places of recreation or sport, and 24.7% from health care facilities.

CONCLUSIONS

Our identification of common EMS dispatch complaints, mechanisms of injury, and primary assessments can be used in the education of staff and preparation of facilities for medical emergencies and injuries where children spend time.

The role of the emergency medical dispatch centre (EMDC) and prehospital emergency care safety: results from an incident report (IR) system

Introduction

The role of the emergency medical dispatch centre (EMDC) is essential to ensure coordinated and safe prehospital care. The aim of this study was to implement an incident report (IR) system in prehospital emergency care management with a view to detecting errors occurring in this setting and guiding the implementation of safety improvement initiatives.

Methods

An ad hoc IR form for the prehospital setting was developed and implemented within the EMDC of Verona. The form included six phases (from the emergency call to hospital admission) with the relevant list of potential error modes (30 items). This descriptive observational study considered the results from 268 consecutive days between February and November 2010.

Results

During the study period, 161 error modes were detected. The majority of these errors occurred in the resource allocation and timing phase (34.2%) and in the dispatch phase (31.0%). Most of the errors were due to human factors (77.6%), and almost half of them were classified as either moderate (27.9%) or severe (19.9%). These results guided the implementation of specific corrective actions, such as the adoption of a more efficient Medical Priority Dispatch System and the development of educational initiatives targeted at both EMDC staff and the population.

Conclusions

Despite the intrinsic limits of IR methodology, results suggest how the implementation of an IR system dedicated to the emergency prehospital setting can act as a major driver for the development of a “learning organization” and improve both efficacy and safety of first aid care.

Prehospital electronic patient care report systems: early experiences from emergency medical services agency leaders

BACKGROUND

As the United States embraces electronic health records (EHRs), improved emergency medical services (EMS) information systems are also a priority; however, little is known about the experiences of EMS agencies as they adopt and implement electronic patient care report (e-PCR) systems. We sought to characterize motivations for adoption of e-PCR systems, challenges associated with adoption and implementation, and emerging implementation strategies.

METHODS

We conducted a qualitative study using semi-structured in-depth interviews with EMS agency leaders. Participants were recruited through a web-based survey of National Association of EMS Physicians (NAEMSP) members, a didactic session at the 2010 NAEMSP Annual Meeting, and snowball sampling. Interviews lasted approximately 30 minutes, were recorded and professionally transcribed. Analysis was conducted by a five-person team, employing the constant comparative method to identify recurrent themes.

RESULTS

Twenty-three interviewees represented 20 EMS agencies from the United States and Canada; 14 EMS agencies were currently using e-PCR systems. The primary reason for adoption was the potential for e-PCR systems to support quality assurance efforts. Challenges to e-PCR system adoption included those common to any health information technology project, as well as challenges unique to the prehospital setting, including: fear of increased ambulance run times leading to decreased ambulance availability, difficulty integrating with existing hospital information systems, and unfunded mandates requiring adoption of e-PCR systems. Three recurring strategies emerged to improve e-PCR system adoption and implementation: 1) identify creative funding sources; 2) leverage regional health information organizations; and 3) build internal information technology capacity.

CONCLUSION

EMS agencies are highly motivated to adopt e-PCR systems to support quality assurance efforts; however, adoption and implementation of e-PCR systems has been challenging for many. Emerging strategies from EMS agencies and others that have successfully implemented EHRs may be useful in expanding e-PCR system use and facilitating this transition for other EMS agencies.

A national model for developing, implementing, and evaluating evidence-based guidelines for prehospital care

In 2007, the Institute of Medicine's (IOM's) Committee on the Future of Emergency Care recommended that a multidisciplinary panel establish a model for developing evidence-based protocols for the treatment of emergency medical systems (EMS) patients. In response, the National EMS Advisory Council (NEMSAC) and the Federal Interagency Committee on EMS (FICEMS) convened a panel of multidisciplinary experts to review current strategies for developing evidence-based guidelines (EBGs) and to propose a model for developing such guidelines for the prehospital milieu. This paper describes the eight-step model endorsed by FICEMS, NEMSAC, and a panel of EMS and evidence-based medicine experts. According to the model, prehospital EBG development would begin with the input of evidence from various external sources. Potential EBG topics would be suggested following a preliminary evidentiary review; those topics with sufficient extant foundational evidence would be selected for development. Next, the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology would be used to determine a quality-of-evidence rating and a strength of recommendation related to the patient care guidelines. More specific, contextualized patient care protocols would then be generated and disseminated to the EMS community. After educating EMS professionals using targeted teaching materials, the protocols would be implemented in local EMS systems. Finally, effectiveness and uptake would be measured with integrated quality improvement and outcomes monitoring systems. The constituencies and experts involved in the model development process concluded that the use of such transparent, objective, and scientifically rigorous guidelines could significantly increase the quality of EMS care in the future.

The association between EMS workplace safety culture and safety outcomes

BACKGROUND

Prior studies have highlighted wide variation in emergency medical services (EMS) workplace safety culture across agencies.

OBJECTIVE

To determine the association between EMS workplace safety culture scores and patient or provider safety outcomes.

METHODS

We administered a cross-sectional survey to EMS workers affiliated with a convenience sample of agencies. We recruited these agencies from a national EMS management organization. We used the EMS Safety Attitudes Questionnaire (EMS-SAQ) to measure workplace safety culture and the EMS Safety Inventory (EMS-SI), a tool developed to capture self-reported safety outcomes from EMS workers. The EMS-SAQ provides reliable and valid measures of six domains: safety climate, teamwork climate, perceptions of management, working conditions, stress recognition, and job satisfaction. A panel of medical directors, emergency medical technicians and paramedics, and occupational epidemiologists developed the EMS-SI to measure self-reported injury, medical errors and adverse events, and safety-compromising behaviors. We used hierarchical linear models to evaluate the association between EMS-SAQ scores and EMS-SI safety outcome measures.

RESULTS

Sixteen percent of all respondents reported experiencing an injury in the past three months, four of every 10 respondents reported an error or adverse event (AE), and 89% reported safety-compromising behaviors. Respondents reporting injury scored lower on five of the six domains of safety culture. Respondents reporting an error or AE scored lower for four of the six domains, while respondents reporting safety-compromising behavior had lower safety culture scores for five of the six domains.

CONCLUSIONS

Individual EMS worker perceptions of workplace safety culture are associated with composite measures of patient and provider safety outcomes. This study is preliminary evidence of the association between safety culture and patient or provider safety outcomes.

Electronic collaboration: using technology to solve old problems of quality care

The participants of the Electronic Collaboration working group of the 2010 Academic Emergency Medicine consensus conference developed recommendations and research questions for improving regional quality of care through the use of electronic collaboration. A writing group devised a working draft prior to the meeting and presented this to the breakout session at the consensus conference for input and approval. The recommendations include: 1) patient health information should be available electronically across the entire health care delivery system from the 9-1-1 call to the emergency department (ED) visit through hospitalization and outpatient care, 2) relevant patient health information should be shared electronically across the entire health care delivery system, 3) Web-based collaborative technologies should be employed to facilitate patient transfer and timely access to specialists, 4) personal health record adoption should be considered as a way to improve patient health, and 5) any comprehensive reform of regionalization in emergency care must include telemedicine. The workgroup emphasized the need for funding increases so that research in this new and exciting area can expand.

Data based integration of critical illness and injury patient care from EMS to emergency department to intensive care unit

PURPOSE OF REVIEW

Describe the challenges and opportunities for an integrated emergency care data system for the delivery and care of critical illness and injury.

RECENT FINDINGS

Standardized data comparable across geographies and settings of care has been a critical challenge for emergency care data systems. Emergency medical services (EMS), emergency department (ED), ICU and hospital care are integrated units of service in critical illness and injury care. The applicability of available evidence and outcome measures to these units of service needs to be determined. A recently developed fully integrated, emergency care data system for quality improvement of EMS service delivery and patient care has been linked to ED, ICU and in-hospital data systems for myocardial infarction, trauma and stroke. The data system also provides a platform for linking EMS with emergency physicians, other healthcare providers, and public health agencies responsible for planning, disease surveillance, and disaster preparedness.

SUMMARY

Given its time-sensitive nature, new data systems and analytic methods will be required to examine the impact of emergency care. The linkage of emergency care data systems to outcomes based systems could create an ideal environment to improve patient morbidity and mortality in critical illness and injury.

National Emergency Medical Services Information System (NEMSIS)

The absence of emergency medical services (EMS) patient care data has hindered development and evaluation of EMS systems. The National Highway Traffic Safety Administration (NHTSA), in cooperation with the Health Resources and Services Administration (HRSA), has provided funding to the National Association of State EMS Directors to develop a National EMS Information System (NEMSIS). NEMSIS is being designed to provide a uniform national EMS dataset, with standard terms, definitions, and values, as well as a national EMS database, with aggregated data from all states on a limited number of data elements. Forty-eight of the states, the District of Columbia, and three territories signed a memorandum of agreement documenting support for the NEMSIS project and expressing a desire for full implementation of the NEMSIS dataset. NHTSA has agreed to house the National EMS Database at its National Center for Statistics and Analysis. NHTSA, in cooperation with HRSA and the Centers for Disease Control and Prevention, recently entered into a cooperative agreement with the University of Utah School of Medicine to operate a NEMSIS Technical Assistance Center that will provide related assistance to official EMS agencies and to commercial software vendors. The Technical Assistance Center will also biannually assess state and territorial capabilities to provide data to the national EMS database. NEMSIS will provide a uniform national EMS dataset, with standard terms, definitions, and values, as well as a national EMS database, with aggregated data from all states on a limited number of data elements. Many of the potential benefits of implementation of NEMSIS are enumerated in this report.

Linking children's health information systems: clinical care, public health, emergency medical systems, and schools

This article describes health information systems used for children in a variety of settings (eg, clinical care, public health, emergency medicine systems, and schools) and their current ability to exchange information. The potential benefits from linking these systems are considered, as well as the barriers to linkage. In addition, an example of efforts linking information systems together is summarized, and conclusions are drawn from this example for future efforts.

Analysis of data-collection methods for an acute stroke care registry

This study aims to assess and compare the completeness and reliability of data collected by prospective and retrospective methods for the Paul Coverdell National Acute Stroke Registry. The prototypes consisted of eight states that used the same data elements but differed in their collection approach. Three prototypes employed retrospective case ascertainment (n=1218), and five prototypes used prospective or a combination of prospective and retrospective case ascertainment (n=1602). RTI International performed an audit analysis of the eight prototypes. Completeness, exact match, and discrepancy analyses were performed with data elements grouped into 12 categories for this analysis. A sample of 2820 (37.6%) from a total of 7494 records from 91 hospitals was studied. The "in-hospital complications" section had the highest percentage of completeness (99.6%), followed by "demographic data" (97.7%), and "in-hospital diagnostic procedures" (93.4%). The section with the lowest percentage of completeness was "thrombolytic treatment" (53.5%), followed by "reasons for nontreatment with thrombolytics" (57.1%), and "signs and symptoms onset" (63.5%). Across all prototype elements, exact matches with audit data ranged from 62.8% to 95.9%. Documentation of the date/time of stroke onset and of arrival in the emergency department had a high number of discrepancies with audit data, with exact match percentages of 69.7% and 64.5%, respectively. No significant difference was found between retrospective and prospective case ascertainment in completeness or matching with audit data. Combined retrospective and prospective data-collection approaches for different types of data elements may be best in terms of both completeness and accuracy.

Evaluating state capacity to collect and analyze emergency medical services data

BACKGROUND

Centralized emergency medical services (EMS) data collection is critical to evaluating EMS system effectiveness, yet a general lack of EMS data persists at local, state, and national levels.

OBJECTIVE

To assess state capacity to collect, analyze, and utilize EMS data.

METHODS

Information was gathered through state site visits and surveys from 54 states and U.S. territories in spring 2003 regarding EMS data-collection systems. Survey results were used to create 11 broad indicators that assess state data system infrastructure, collection methods, compliance with data standards, and data uses.

RESULTS

States and territories on average met 59% of the EMS data system indicators, with four states meeting all 11 indicators and two states meeting none. Seventy-six percent of the states reported having state-level EMS data-collection systems, and 78% reported having authority to collect EMS data. However, most state EMS data sets were not capturing information on all EMS incidents, and only 46% of the states had data dictionaries containing at least three-fourths of nationally recommended EMS data elements. In addition, only 33% of the states had linked EMS data with other health data sets to analyze EMS system operations and patient outcomes.

CONCLUSION

While EMS data systems exist in the majority of states, continued attention and resources are needed for state-level EMS data system development to improve capacity for evaluation of emergency medical services.

Expected Annual Emergency Miles per Ambulance: An Indicator for Measuring Availability of Emergency Medical Services Resources

CONTEXT

To ensure equitable access to prehospital care, as recommended by the Rural and Frontier Emergency Medical Services (EMS) Agenda for the Future, policymakers will need a uniform measure of EMS infrastructure.

PURPOSE AND METHODS

This paper proposes a county-level indicator of EMS resource availability that takes into consideration existing EMS resources (ambulances), population health and demographics, and geographic factors. The indicator, the EXpected annual emergency miles per AMBulance (EXAMB), provides a basis for comparing ambulance availability across counties within states. A method for calculating the EXAMB indicator is demonstrated using data from 5 states.

FINDINGS

The EXAMB indicator was negatively correlated with ambulance availability per 100,000 population in 4 of the 5 states in the study. The indicator was positively correlated with rurality in 3 states. In Mississippi, South Carolina, and Wyoming, whole-county health professional shortage areas had median EXAMB values 45%-81% higher than those of the non-health professional shortage areas counties.

CONCLUSIONS

Future research should explore the relationship of the EXAMB to EMS outcomes, with the ultimate goal of developing a nationally recognized indicator of "adequate" EMS resource availability.

Advancing disaster epidemiology and response: developing a national disaster-victim database

BACKGROUND

The need to further disaster preparedness has resulted in a call for more comprehensive disaster research. Past disaster research has, for the most part, been limited by the inability to obtain complete medical data from victims of disasters. A national disaster-victim database (NDVD) can be developed that will facilitate collection and aggregation of disaster-victim medical data from health care facilities. Three aspects of the NDVD are discussed: DATA REQUIREMENTS: Medical records of disaster victims must be standardized before being uploaded from various databases into the NDVD. Existing data dictionaries provide formats in which data elements can become standardized. Once standardized, data sets from different facilities can be pooled and subjected to analyses. Database System. The three tiers of the NDVD system are: 1) medical data are collected at the point of care, 2) medical data are entered into databases and converted into a specific format, and 3) formatted data sets are uploaded to the NDVD. In order for this system to be viable, it must not add burden to health care workers; rather, it must benefit them and their facilities. REAL-TIME COLLECTION OF MEDICAL DATA: Capturing data on victims of a disaster, during a disaster, is ideal. This would allow for more victim data to be studied as well as for more accurate data to be collected. Technologic advancement has encouraged a real-time data-collection model in St. Louis that can act as a model for NDVD implementation.

The National EMS Research strategic plan

One of the eight major recommendations put forth by the National EMS Research Agenda Implementation Project in 2002 was the development of an emergency medical services (EMS) research strategic plan. Using a modified Delphi technique along with a consensus conference approach, a strategic plan for EMS research was created. The plan includes recommendations for concentrating efforts by EMS researchers, policy makers, and funding resources with the ultimate goal of improving clinical outcomes. Clinical issues targeted for additional research efforts include evaluation and treatment of patients with asthma, acute cardiac ischemia, circulatory shock, major injury, pain, acute stroke, and traumatic brain injury. The plan calls for developing, evaluating, and validating improved measurement tools and techniques. Additional research to improve the education of EMS personnel as well as system design and operation is also suggested. Implementation of the EMS research strategic plan will improve both the delivery of services and the care of individuals who access the emergency medical system.