Is Your EMS System Leading the Way in Emergency Care?

This discussion was recorded on March 13, 2024. This transcript has been edited for clarity.

Robert D. Glatter, MD: Hi, and welcome. I'm Dr Robert Glatter, medical advisor for Medscape Emergency Medicine. Joining me today to discuss the results of a recent study of the national performance of emergency medical services (EMS) is Dr Benjamin (Ben) Weston, associate professor in the Department of Emergency Medicine at the Medical College of Wisconsin. Also joining us is Dr Paul Pepe, a nationally recognized expert in EMS, resuscitation, and event medicine. Welcome, gentlemen.

Paul E. Pepe, MD, MPH: Thanks.

Benjamin (Ben) Weston, MD, MPH: Thank you.

Glatter: The reason we're gathered here today is to comment about a study that was put out by Mount Sinai School of Medicine (Redlener et al) titled "A National Assessment of EMS Performance at the Response and Agency Level," and there are some critiques of the study that we'll get into.

Also, Ben, you have a study that's going to be published in EMS World in the spring. It's called "An Achilles Heel in EMS' Mission of Public Service: The Need to Prioritize Disparities Research, Awareness and Related Care Delivery." Paul, you're a coauthor on this, as well as Elijah Dahlstrom, a fellow working with you, Ben. I think it's important that we touch upon your study in the context of this recent Mount Sinai study.

Examining Variability in EMS Quality

Ben, I'll let you start with the Mount Sinai study. Can you break it down for us and what you see as some of the critiques, how the design goes, the methodology, and so forth?

Weston: This was looking at a huge dataset, the National Emergency Medical Services Information System (NEMSIS) database; we are talking like 10,000 agencies and 26 million events analyzed. It's challenging when you're looking at those huge datasets. The investigators looked at different quality metrics, and they found that there's a large amount of variability, maybe not surprisingly, across 10,000 agencies. There's a lot of variability in quality of care, so they pointed to that as an opportunity to improve quality systems — continuous quality improvement — in EMS systems.

Glatter: When you're comparing EMS systems across the board, it's very difficult to account for variability between urban, rural, suburban, and wilderness EMS systems. It's a challenge and they took it on. It doesn't, in my opinion, allow us to really effectively make a clear delineation between the care that that they've evaluated among these systems. Paul, would you agree?

Pepe: Part of it is that this is looked at in a very oversimplistic fashion because there are so many variables that happen on scene. For example, in one of the cases, they talk about hypoglycemia. They say a person has hypoglycemia, but how do they know that? Did they measure it, or did it show up later at the hospital? I don't know from this study that that's how they knew it.

Let's assume the person had symptomatic hypoglycemia. I assume that the paramedics found it. I find it really hard to believe that they wouldn't have treated that case, or that the patient was already treated by the family and was getting better — those kinds of things.

You don't know what happens in individual scenes. That's one of the things. For me, true quality assurance is actually being there, seeing what's going on with your troops, and getting a better feel for the variables that could happen in some circumstances on an individual basis that may not be accounted for here.

This is a brilliant attempt to try to start looking at quality. The question for me, is how do you define the variables you are looking at? I can drill down on this a little bit more.

Finally, what are the outcomes? Just the fact that you treated somebody, I think that's an outcome. That's a good point. But did they get better? I'm more interested in quality from that point of view. Is the patient happy? Are we happy? Was the outcome good in the end?

Exploring Sociologic Disparities in EMS Care

Glatter: Your paper looks at sociologic-based disparities in care and acknowledging them. You did a nice meta-analysis that really hits the nail on the head, first of all in recognizing that these disparities exist (sex, race, age, gender, ethnicity, and so forth) and trying to make a dashboard, which Paul brought to my attention, in doing so. I'd love to hear more about your work in this regard.

Pepe: Dr Weston is an outstanding person here to be talking to you about this because of several things. One, during COVID, it was recognized that he has a really good EMS system, and he has a sense about who they're responding to. He was really good during COVID, and they made him the health advisor for the whole county that he lives in there in the Milwaukee area.

He really was sensitive because he knows what's going on in the streets and how the various populations were treated. What he found out is largely socioeconomic. He created dashboards to look at this carefully, and hopefully he can describe some of those, because those are the things that others are now emulating and wanting to pick up on.

I was at a meeting recently with leaders in the fire service who want to address these issues, and they turned to Ben. I'm sorry if I embarrass you, Ben, but you deserve it. Again, he is a leader in this area.

Weston: I appreciate that, Paul, especially coming from you. When we think about quality in our EMS systems — I'm in Milwaukee County, with about a population of 1,120,000 patient encounters a year — there are a few different ways to measure quality. We could have someone like Paul, who has decades of experience, just ride along in the med unit for an hour, and he'll probably get a pretty good idea of what the quality is in our system. For the rest of us, we depend on dashboards, benchmarks, and things like that.

When we look at our dashboards that we've put together (for example, we have a cardiac arrest dashboard in Milwaukee County), we can say we do really well in this aspect of cardiac arrest. It turns out when you break that down by race and ethnicity, we do really well for a segment of our population. We don't do quite as well for a different segment of our population, and that's where we get into these discussions of equity and care.

It's important to point out that a lot of people think, "Equity and care. Yeah, it's interesting, but it's kind of a niche issue." You add together the folks that we've seen who are not equitably cared for in the EMS system (women, folks of advanced age, kids, people of color), what percentage of your population is that? It's probably about 70% of your population when you add all that up together, so this is not a niche issue. This is the majority of patients you serve.

Pepe: Let me interrupt you there and qualify that a little bit because it sounds like, "Oh, the EMS system is not taking care of those people well." The answer is yes, if you think of the EMS system as a whole public health realm. In other words, have we been training everybody and doing bystander CPR?

For example, is there a language barrier if you're in the Hispanic population? Therefore, you didn't learn CPR, you didn't get it, or you don't know how to use the system as well. Recently, some systems have developed ways for paramedic to do assessments in Spanish, for example, for stroke.

The other biggest problem is not so much the EMS system with stroke as much as the average person knowing when to call emergency departments (EDs). We have to do better education. Part of it is education, and much of that is socioeconomically driven, as you said.

The other thing is that you have to also know the data that you're looking at. If you drill down on, let's say, cardiac arrest, at first glance it looks like men might have better outcomes. When you drill down on that a little bit better and you find out that men are more apt than women to have ventricular fibrillation, and then you compare them and stratify it according to shockable rhythms vs nonshockable or asystole, ironically, it turns out that women, especially those under 50, have better outcomes.

Part of it is understanding your data and not jumping to a conclusion based on this very binary thing, like who did better, men or women? You need to know the background to that, such as how many received bystander CPR and that kind of thing.

Implicit Bias and Cultural Sensitivity in EMS Care: Addressing Disparities

Glatter: That's a great point you make, Paul. Another thing I want to extend this to is the idea of implicit bias and being culturally sensitive, as you mentioned in your paper, which really is the beginning and a jumping-off point of treatment by EMS. That in and of itself is important.

Weston: It's the jumping-off point for the entire conversation. That's what we do in our system. We start talking about what is equity; how is it different from equality, for example; and why does it matter?

When we look at research around the country and when we look at research with our own system, we can see that disparities exist. Then, like Paul was alluding to, we start talking about why they exist. If you go out and talk to EMS providers, no matter what their patient looks like or what their patient's history is, they're trying to do what's best for that patient. Like Paul mentioned, there's this entire cultural and social structure that surrounds the patient care that's provided, and all of that influences it. By recognizing these disparities, we can start pulling it apart and understand why is it that African American patients are less likely to receive pain control, Hispanic patients are less likely to have their stroke recognized, and all these different things. How can we tease it out, and how can we address it?

Enhancing Equity Through EMS Training

Glatter: Do you have training modules that you incorporate into your systems? I'm just curious — is that something that you're looking to do or have done?

Weston: Absolutely. We have training modules. We started off again with just defining it. What is equity, and why does it matter? What do we see in EMS systems around the country? We're working now to get multisystem research together as opposed to just single system, which is most of what's out there right now. That's really the first step.

The second step is looking introspectively, and our system has been very supportive. Our fire chiefs, our county executive, and everybody's been very supportive of saying, "What can we do better?" When we find issues in our own system, we're going to talk about them and we're going to publish them. We're going to say, "We can do better here, here, and here." If we don't, we're never going to do better.

Pepe: One of the issues that Ben's talking about is making you aware of some of the issues that are there. The paramedics are well intentioned, but sometimes will not perform as well because they didn't know that they may be distrusted because they're so trusted in some other realms.

What Ben and many of us have done is make sure we have classes and education that are sometimes interactive, which is kind of cool. People really feel like they're part of it, and it has helped. Some of the people who have done a fantastic job in this arena (eg, Meg Marino, medical director of New Orleans EMS), and I can go on a whole list of people. They start off by saying, "Hey, how can we do better?" It wasn't "what are we doing wrong?" It was, "How can we do better?" It's been very positive for us.

EMS systems are getting better, but there are so many other factors as well because sometimes EMS systems aren't doing well. As Ben alluded to, I'm out on the streets in various places around the country, and within a very short period of time, I can tell you about the training or the oversight that they have on those systems.

Global Perspectives on EMS Disparities

Glatter: We're in our own backyard here, but let's extend this globally. Do you find that we're in a similar position as other countries in Europe or Asia?

Pepe: Ben's going to tell you in a few minutes about some studies he's looked at that were conducted in other places around the world. From my point of view, overall, we're doing well. Some places, I could say maybe we're doing better. In many parts of Europe, there are physicians who are expert not only in the intensive care unit but also in the streets. They'll go on the streets, and they're very good about making sure that people are performing well. They're out there with their troops.

It's not just the technical aspects of when to give a drug or what procedure you do next. Part of it is how you behave in a compassionate manner and exude care for the population you are treating. They've done very well in some areas where you have great leadership. Again, if you don't have good leadership, it may be just the opposite under those circumstances. It's like any other industry — it can be variable.

Let's apply back to the hospital as well. Sometimes the EMS systems are affected by how patients are received, and if there is a good continuity of care there as well. Ben, what would you say about that?

Weston: Just to touch on Rob's question about the international picture, broadly, there's not much disparities research out there. There's a study by Farcas and colleagues that looked at everything there was for disparities research. It's interesting to look at, but it's not that many articles. There are some that speak to the global picture. There's a study by Grubic and colleagues, where they talked about bystander interventions and found a similar sort of thing. In low-income countries, there's fewer bystander interventions.

There's just not much globally out there. It's important to remember that the majority of countries around the world do not have robust, established prehospital systems of care. Parts of North America, South America, Europe, and Asia have them, but most countries don't. It's really hard to judge the disparities in those areas as well, but I'm sure they're there.

Final Thoughts

Glatter: I wanted to have some takeaways from our discussion. I'll let you start, Paul, and I want to follow up with you, Ben.

Pepe: One of the things that people don't appreciate, and some of it's counterintuitive, is what creates quality? For example, if you think I have a paramedic (paramedics being defined as the people who do advanced life support, IVs, drugs, other procedures like that), the feeling was that, "Hey, paramedics save lives. Let's get one on every corner."

It turns out that as much as 90% of what we get called off for 911 can be handled by a basic emergency medical technician (EMT), and therefore, many systems that have done well have fewer paramedics. They keep a smaller cadre of highly skilled paramedics who frequently use their skills, so they are much better at it. We've learned that you don't want to make every hospital a trauma center. You want to have a certain place that's a specialized area that gets really good because they do it all the time.

It seems counterintuitive that with fewer paramedics we have a better system, but the outcomes seem to be better because those folks are often not only well skilled because they get to do it often, but they're also wiser and have had much more experience with the sicker cases. There are subtle things that could create a really good-quality system. People may say, "Oh, don't take away our paramedics," but an important part of this is the understanding.

There are many subtleties to all this that go well beyond looking at how many people we responded to, how many got taken to a trauma center, or whatever it may be under those circumstances.

Weston: Coming back to the first point of our discussion on this article, it points out the need for a continuous quality improvement system within your EMS agency. Much of that in many EMS agencies is about looking at individual cases, talking to the provider, and talking through what went well and what didn't. This education is critical. I think benchmarking data and understanding of your system as a whole, how that performance is, can be just as critical.

The take-home point I would put is when you do that benchmarking, make sure that you're understanding the disparities that exist in your system, whether they're racial and ethnic, gender-based, age-based, or geographic. If you have many departments, what sort of disparities are in your system? Try to tease out those benchmarks a little bit, and that'll help you to target your education and target that quality improvement more effectively.

Glatter: This has been a great discussion. Thank you again for joining us. I really appreciate it.

Robert D. Glatter, MD, is an assistant professor of emergency medicine at Zucker School of Medicine at Hofstra/Northwell in Hempstead, New York. He is a medical advisor for Medscape and hosts the Hot Topics in EM series.

Paul E. Pepe, MD, MPH, is an adjunct professor of internal medicine, surgery, pediatrics, public health, and emergency medicine at University of Texas Health Science Center in Houston. He's also a global coordinator of the US Metropolitan Municipalities EMS Medical Directors ("Eagles") Coalition.

Benjamin (Ben) Weston, MD, is an associate professor in the Department of Emergency Medicine at the Medical College of Wisconsin. He is also the chief medical director at the Milwaukee County Office of Emergency Management.

Comments

Commenting is limited to medical professionals. To comment please Log-in.

Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.