EMSC Power Point Presentation

The Background

• In May 2007, the National EMSC Data Analysis Resource Center and the EMSC National Resource Center provided a site visit to Texas to review the federal requirements for the…

Emergency Medical Services for Children (EMSC) State Partnership Grant

EMSC State Partnership Grant

• The EMSC Grant for Texas is located in the Texas Department of State Health Services

• The state must meet EMSC Program goals or targets each year of the grant

• The targets are based on federal performance measures as outlined in the original grant guidance

EMSC Performance Measures

The EMSC Performance Measures were developed in 2005 in order to demonstrate national outcomes for the EMSC Program and to improve the delivery of emergency care for pediatric patients at the local level.

• Certain measures require the collection of data in order to describe the current state of emergency medicine in relation to children

• NEDARC helped develop representative samples and surveys to help Texas meet their grant requirements

Data Collected

NEDARC developed two surveys:

1 – for EMS Agencies

2 – for Hospitals with an ED

Goal of SurveysThese surveys needed to answer the following questions in relation to

the following performance measures:

3. Performance Measure 66a – The percent of prehospital providers who have access to on-line and off-line medical direction.

4. Performance Measure 66b – The percent of EMS agencies that have essential pediatric equipment and supplies, as outlined in the AAP Joint Guidelines for BLS and ALS ambulances

3. Performance Measure 66d – The percentage of hospitals that have written inter-facility transfer agreements & guidelines that specify alternate care sites that have the capabilities to meet the clinical needs of critically ill and injured pediatric patients.

Purpose of our Site Visit

1. Report the findings of these surveys

2. To encourage Texas to increase the response rate for these surveys for year two of your grant

3. To show national data in comparison to Texas’ data

Survey Deve loped for EMS Agencies

General Information

EMS Agency Survey

The Sample

• Simple Random Sample to represent:

– BLS Services

– ALS Services

• Sampling Frame – “entire list of EMS agencies in Texas”**

** The list was current to Feb. 07

BLS Agencies Original SampleALS Agencies Original Sample

Response Rate based on Sample

• Agency Response Rate = 25.0%– 212 Agencies Sent Surveys

(130 ALS, 82 BLS)– 54 Responded (41 ALS, 13 BLS)

DISCLAIMER!!

Due to a 25% response rate, from the representative sample, this data is not generalizable to the state of Texas.

A high response rate is needed to have a high level of confidence in the results. The EMSC program goal is 100% response rate, at a minimum at least an 80% response rate.

Only DATA Analyzed!

The only data that was analyzed for this presentation was from the advanced level services as there was not enough basic level service responses.

The following slides are based on the very little data we have from ALS services. This data cannot be generalized to all Texas EMS agencies.

ALS AgencyDemographics

General Information

EMS Agency Survey

Agency Capabilities-(Classified as ALS)

(could select all that apply, n=41)

BLS ALS MICU ALS Capable MICU Capable(n=15) (n=11) (n=20) (n=4) (n=23)

Advanced servicewith basic services also

Note: Numbers are based on a 32% response rate from ALS providers.

Agency Type(could select all that apply, n=41)

Emergency 911 Responder Non-Emergency 911Responder

Other(n=39)

(n=9)(n=5)

Agency Classification(n=41)

Public - Government

Entity71%

Private - Not For Profit

7%Private - For Profit

Other12%

(n=5)(n=29)

Agency Staffing Classification(n=41)

Combinationpaid/volunteer

Volunteer12%

Paid61%(n=25)

(n=11)

Agency’s Primary Response Area(n=41)

12%We serve urban and rural areas somewhat equally (n=5)

15%75% or more of your EMS runs are in a frontier area (n=6)

29%75% or more of your EMS runs are in an urban area (n=12)

44%75% or more of your EMS runs are in a rural area (n=18)

Pediatric Incidents(per year, n=41)

9> 300

11116 - 300

1350 - 115

Num AgenciesRange

Minimum = 2Maximum = 8,288 Number of pediatric

incidents from one agency!

Youngest Pediatric Age Definition(n=41)

2356%1

1741%0

Number of Agencies

(n)Percent

Youngest Age

Defined As…

*Agency with the largest number of pediatric incidents reports youngest age as 1 year

Oldest Pediatric Age Definition(n=41)

1230%18

922%17

717%16

717%12

Number of Agencies

(n)Percent

Oldest Age Defined

* Largest num. incidents reports oldest age as 15 years{Why such a

variation in definition?

66 a Performance Meas ure Data

On-line & Off-line Medical Direction

EMS Agency Survey

ONLY ALS DATA USED FOR THIS PRESENTATION

66a. By 2011, 90% of pre-hospital providers agencies will have on-line and off-line pediatric medical direction at the scene of an emergency for Basic Life Support (BLS) and Advanced Life Support (ALS) ambulances.

On-line Pediatric Medical Direction: an individual available 24/7 on the phone, radio, or email to EMS providers who need online medical direction when transporting a PEDIATRIC patient to a hospital. This person must be a medical professional (e.g., nurse, physician, physician assistant, EMT) deemed to have PEDIATRIC expertise by the hospital in which they work.

If the EMS provider does not know the PEDIATRIC expertise of the person providing medical direction, the EMS provider should feel confident in the information given by the medical professional.

Off-line Pediatric Medical Direction: treatment guidelines and protocols used by EMS providers to ensure the provision of appropriate PEDIATRIC patient care, available in written or electronic form in the ambulance or with a provider, at the scene of an emergency.

EMSC Program Definitions

Data Collection for PM 66a

• Implementation manual requires data collection through:

– Ambulance inspection reports (best source)

– Surveys to an appropriate target population

• Additional requirements to ensure quality of data

At what level is the on-line medical direction controlled or provided for your EMS agency?

(n=41)

2%State (e.g. GETAC) (n=1)

5%Other (n=2)

7%We have no formal on-line medical direction for our agency (n=3)

10%Regional Advisory Council (n=4)

76%Local (local hospital or other medical personnel) (n=31)

Has your EMS agency established some type of formal arrangement or agreement with an acute care facility or other professional medical

personnel to provide on-line (real-time) pediatric medical direction to your ALS care providers at the scene of an emergency? (n=41)

Yes No In Process Not Applicable(n=26) (n=11) (n=3) (n=1)

Agency reported no formal policy with a specific facility exists

Credentials of Individual Providing On-line Medical Direction (n=41)

First Available Individual• EMS Fellowship• Emergency Medicine• Pediatric Emergency

Medicine• Family Practice• Not Known• Other• Pediatrics

Second Available Individual• EMS Fellowship• Other• Emergency Medicine• Pediatric Emergency

Medicine• Not Known• Family Practice• Pediatrics

24%27%

12%10%

State ProtocolsOnly

Other ProtocolsOnly

CombinedState/Other

No Protocols

Adopted

Carried By All *

Availability of Off-line Medical Direction (n=41)

(n=10) (n=11) (n=15)

* Protocols are Carried by All Providers or Ambulances

Reported to EMSC Program

“The percentage of pre-hospital provider agencies that have on-line and off-line pediatric medical direction at the scene of an emergency for BLS and ALS providers.”

21.6%Note: Number reported is

based on the 25% response rate from ALS and BLS

providers.

So how did Texas compare to the yearly EMSC program targets for performance measure 66a?

2006/2007 Grant Year TargetsCompared with Texas Reporting for 2006

21.6%20%

% Texas reported in 2006 2006 Yearly Target 2007 Yearly Target

Note: Number reported is based on the 25% response rate from ALS

and BLS providers.

National Level Comparison(% of States that Meet the 2011 Target Already)

(2007 change in reporting - separate)

63% of the 45 states/ territories in the current grant cycle met the 2011 target that 90-100% of pre-hospital providers in their State/Territory have access to on-line and off-line medical direction at the scene of an emergency.

82%21.6%

National Average %**

% Texas Reported

**Thirty-eight states had analyzable data for this calculation.

Action Items for Measure 66aGrant requirement: Goal 100% response rate, at a

minimum at least an 80% response rate.

• How will Texas increase the response rate?

• How can this advisory board help the TX EMSC program collect data?

• How can Texas improve the quality of their current dataset (sampling frame) for licensed EMS agencies in order to ensure data accuracy?

• How can this advisory board help share the message of the importance of pediatric-specific on-line and off-line medical direction?

66PM b

Pediatric EquipmentAAP/ACEP Recommended List

EMS Agency Survey

66b. By 2011, 90% of pre-hospital providers agencies will have the essential pediatric equipment and supplies, as outlined in the ACEP Joint Guidelines for BLS and ALS ambulances.

Data Collection for PM 66b

– Ambulance inspection reports (best source)

– Surveys to an appropriate target population

• Additional requirements to ensure quality of data

Top Pieces of Missing Pediatric Equipment(by ambulance, n=180)

1. Pediatric Backboard (59%)

2. Pediatric Stethoscope (57%)

3. Nasogastric tubes: 8F-16F (37%)

4. Transport Monitor (14%)

5. Suction catheters: tonsil-tip and 6F-14F

Why Missing Equipment?(by agency, could select all that apply, n=41)

Certainpediatricitems areused too

infrequentlyto justify the

expense

Other No state/localequipment

requirementsexist

Funding isvery limited

Certainpediatric

items are notreusable and

are tooexpensive to

replace

Don’t believeseparatepediatric

equipment isnecessary for

adequatecare

(n=16)(n=15)

(n=1)(n=2)

“The percentage of pre-hospital provider agencies that have the essential pediatric equipment and supplies as outlined in the ACEP Joint Guidelines for BLS and ALS ambulances…”

54.2%Note: Number reported is

based on the 25% response rate from ALS and BLS

providers.

So how did Texas compare to the yearly EMSC program targets for performance measure 66b?

2006/2007 Grant Year Target for 66bCompared with Texas Reporting for 2006

% Texas reported in 2006 2006 Yearly Target 2007 Yearly Target

Note: Number reported is based on the 25% response rate from ALS

and BLS providers.

47% of the 45 states/ territories in the current grant cycle met the 2011 target that 90-100% of pre-hospital agencies in their State/Territory have the essential pediatric equipment and supplies as outlined in the ACEP Joint Guidelines for BLS and ALS ambulances.

70%54.2%

National Average %**

% Texas Reported

**Thirty-eight states had analyzable data for this calculation.

Action Items for this MeasureGrant requirement: Goal 100% response rate, at a

• How can this advisory board help improve data collection?

• How can Texas improve the quality of their current dataset (sampling frame) for licensed EMS agencies in order to ensure data accuracy?

• How can this advisory board help share the message of the importance of the availability of pediatric equipment at the scene of an emergency?

Survey Deve loped for Hos pitals

General Information

Hospital Survey

The Sample

• Representative stratified random sample

by hospital designation level

• Sampling frame – entire list of designated hospitals in Texas

YELLOW = Original Sample

Response Rate based on Sample

• Hospital Response Rate = 72.7%– 130 Hospitals Sent Surveys– 95 Responded

Note: Hospitals have different weights depending on which designation level they have, so the response rate is not directly 73.1% as you would calculate by taking 95/130.

YELLOW = Original Sample, GREEN = Respondents

DISCLAIMER!!

Due to a 72.7% response rate this data is may not be generalizable to the state of Texas.

A high response rate is needed to have a high level of confidence in the results. The EMSC program goal is 100% response rate, at a minimum at least an 80% response rate.

Hos pitalDemographics

General Information

Hospital Survey

7% 6%1%

L4 L3 L2 L1 LeadLevel 3

Self-Reported Hospital Designation(n=95)

(n=57) (n=24) (n=7) (n=6)(n=1)

Note: Numbers are based on a 72.7% response rate.

Hospital Location(n=95)

Urban40%(n=44)

Frontier3%(n=2)

Rural57%(n=49)

57% Rural Location (n=49)

Weighted

Percent Represented

Number Represented (n)

Hospital Level

Level 1

Level 2

Level 3

Level 4

40% Urban Location (n=44)

Weighted Percent Represented

Hospital Level

Level 1

Level 2

Level 3

Level 4

3% Frontier Location (n=2)

Weighted Percent Represented

Hospital Level

Level 1

Level 2

Level 3

Level 4

Pediatric Incidents(per year, n=95)

28> 8000

233001 – 8000

251200 - 3000

19< 1200

Num HospitalsRange

Minimum = 1Maximum = 95,000

Youngest Pediatric Age Definition(n=95)

3234%1

5860%0

Number of Hospitals

Weighted Percent

Youngest Age

Defined As…

Oldest Pediatric Age Definition(n=95)

2730%18

2425%17

1820%16

910%14

Number of Hospitals

Weighted Percent

Oldest Age Defined

66PM dPediatric Inter-facility Transfer Guidelines

Hospital Survey

66d. The percentage of hospitals that have written pediatric inter-facility transfer guidelines.

Inter-facility Transfer Guidelines: Hospital-to-hospital, including out of State/Territory, guidelines that outline procedural and administrative policies for transferring critically ill pediatric patients to facilities that provide specialized pediatric care.

Data Collection for PM 66d

– Survey of tertiary care centers/trauma program that account for 100% of all pediatric transfers

– Survey of all hospitals with an ED Department

– Combination of methods

Hospitals with Written Pediatric Inter-facility Transfer Guidelines

(that contain all six EMSC requirements (changed in 2007), n=95)

Yes No(n=44) (n=51)

Percentage of Hospitals with Written Transfer Guidelines by

Hospital Designation Level(that contain all six EMSC requirements (changed in 2007), n=44)

Level 1 Level 2 Level 3 Level 4(n=2) (n=4) (n=13) (n=25)

Written Guidelines DetailsLanguage in the guideline covers (changed in 2007)…

(Have Written Guidelines, n=65)

Roles and responsibilities of the referring facility and referral center

Level 1: 100%

Level 2: 100%

Level 3: 86%

Level 4: 89%

Process for requesting consultation and patient transfer

Level 1: 75%

Level 2: 100%

Level 3: 81%

Level 4: 91%

Specific sections of the patient’s medical record to be sent to the referral center

Level 1: 100%

Level 2: 80%

Level 3: 90%

Level 4: 91%

Process for obtaining informed consent for transfer by the patient’s parent(s) or legal guardian

Level 1: 100%

Level 2: 100%

Level 3: 90%

Level 4: 89%

Process for selecting the most appropriately staffed transport service to match the patient’s acuity level

Level 1: 75%

Level 2: 100%

Level 3: 81%

Level 4: 80%

Level of care to be provided to the patient during the transfer

Level 1: 75%

Level 2: 80%

Level 3: 76%

Level 4: 86%

“The percentage of hospitals that have written pediatric inter-facility transfer guidelines that specify the six requirements outlined in the manual.”

So how did Texas compare to the yearly EMSC program targets for performance measure 66d?

2007 Grant Year Target for 66d Compared with Texas Reporting for 2006

% Texas reported in 2006 2007 Yearly Target

There is no real comparison for Texas at a national level for this measure. The survey Texas distributed was based on 2007 expectations and not on the 2006 expectations for which other states surveyed. This happened based on the timing of the Texas survey dissemination.

• All hospitals in Texas with an emergency department must be included in the sampling frame.

• How can the advisory board collaborate with the TX EMSC program to improve data collection and reporting? (i.e. system change for data collection, and mandates or statutes)

• Survey must include new requirements for 2007 (see handout)

2007 Changes to Survey(language must be in place)

1 - Defined process for initiation of transfer including the roles and responsibilities of the referring facility and referral center

2 - Process for selecting the appropriate care facility

3 - Process for selecting the appropriately staffed transport service to match the patient’s acuity level

4 - Process for patient transfer (including obtaining informed consent)

5 - Plan for transfer of:

a) patient medical record

b) copy of signed transport consent

c) personal belongings of the patient

d) provision of directions and referral institution information to family

6 - Process for return transfer of the pediatric patient to the referring facility as appropriate

66PM ePediatric Inter-facility Transfer Agreements

Hospital Survey

66e. The percentage of hospitals that have written pediatric inter-facility transfer agreements.

Inter-facility Transfer Agreements: Written contracts between a referring facility (e.g., community hospital) and a specialized pediatric center or facility with a higher level of care and the appropriate resources to provide needed care required by the child. The agreements must formalize arrangements for consultation and transport of a pediatric patient to the higher-level care facility.

Data Collection for PM 66e

– Survey of tertiary care centers/trauma program that account for 100% of all pediatric transfers

– Survey of all hospitals with an ED

– Combination of methods

Hospitals with Written Pediatric Inter-facility Transfer Agreements

(that contain all four EMSC requirements (changed in 2007), n=95)

Yes No(n=33) (n=62)

Percentage of Hospitals with Written Transfer Agreements by

Hospital Designation Level(that contain all four EMSC requirements (changed in 2007), n=33)

29% 29%

Level 1 Level 2 Level 3 Level 4(n=2) (n=2) (n=11) (n=18)

Inter-facility communication between physicians at the referring facility and referral center for consultation and to gain referral center consent for the transfer

Level 1: 75%

Level 2: 100%

Level 3: 89%

Level 4: 93%

Written Agreements DetailsLanguage in the agreement covers (changed in 2007)…

(Have Written Agreements, n=55)

Transportation of the patient to an appropriate pediatric referral that matches the level of care needed by the patient

Level 1: 100%

Level 2: 100%

Level 3: 95%

Level 4: 100%

Transfer of patient information (e.g., medical record, copy of signed consent for transport) and personal belongings of the patient

Level 1: 100%

Level 2: 100%

Level 3: 89%

Level 4: 96%

Return transfer of the pediatric patient to the referring facility as appropriate

Level 1: 50%

Level 2: 40%

Level 3: 58%

Level 4: 67%

“The percentage of hospitals that have written pediatric inter-facility transfer agreements that specify the four requirements outlined in the manual”

So how did Texas compare to the yearly EMSC program targets for performance measure 66e?

2007 Grant Year Target for 66e Compared with Texas Reporting for 2006

% Texas reported in 2006 2007 Yearly Target

There is no real comparison for Texas at a national level for this measure. The survey Texas distributed was based on 2007 expectations and not on the 2006 expectations for which other states surveyed. This happened based on the timing of the Texas survey dissemination.

• How can the advisory board collaborate with the TX EMSC program to improve the percent of level 2, 3, & 4 hospitals with written pediatric transfer agreements?

• All hospitals in Texas with an emergency department must be included in the sampling frame.

• Survey must include new requirements for 2007 (see handout)

2007 Changes to Survey

• Do these written agreement(s) contain language that covers critically ill or injured PEDIATRIC patient transfer to alternate care sites that have the capabilities to meet the clinical needs of critically ill and injured pediatric patients?

Legal agreements in place only, no specific language.

Overall NationalPerformance

General Information

2006 Grant Year - Texas Comparison

100.0%

66a 66b 66c 66d 66e 67 68a 68b

2006 Yearly Target % Texas reported in 2006

2011 Target 2011 Target

No 2006 Target

Texas did not meet 2006 target of establishment

So how did Texas compare to the yearly 2006 EMSC program targets for all performance measures?

Where is Texas headed in comparison to the yearly 2007 EMSC program targets for all performance measures?

2007 Grant Target

100.0%

66a 66b 66c 66d 66e 67 68a* 68b

2007 Yearly Target % Texas reported in 2006

2011 Target 2011 Target

Texas needs to meet the 2006 target of establishment

Percentage of States Meeting the 2011 Targets

66a 66b 66c 66d 66e 67 68a 68b

Texas included

Not Measured in

National Level Comparison(% of States that Meet the 2011 Targets Already)

66e – The percentage of hospitals that have written pediatric inter-facility transfer agreements.

68d – Integration of EMSC Priorities into existing EMS or hospital/healthcare facility statutes/regulations.

68c – Establishment of a full time equivalent (FTE) EMSC Coordinator that is dedicated solely to the EMSC Program.

68b – Pediatric representation on the EMS board.

68a – Establishment of an EMSC advisory committee (8 required core members).

67 – The adoption of requirements by the State for pediatric emergency education for the recertification of Paramedics and Basic Life Support (BLS) providers.

66d – The percentage of hospitals that have written pediatric inter-facility transfer guidelines (includes six specific guidelines).

66c – The existence of a statewide, territorial, or regional standardized system that recognizes hospitals that are able to stabilize and/or manage pediatric medical emergencies and trauma (trauma only is not sufficient).

66b – The percentage of pre-hospital provider patient care units that have the essential pediatric equipment and supplies, as outlined in the AAP Joint Guidelines for BLS and ALS ambulances (reporting modified).

66a – The percentage of pre-hospital provider agencies that have on-line and off-line pediatric medical direction at the scene of an emergency for BLS and ALS providers (reporting modified).

EMSC Performance Measures (as written for 2007 grant year)

Advisory Committee Core Members

• Nurse with emergency pediatric experience

• Physician with pediatric training (e.g., pediatrician or pediatric surgeon)

• Emergency physician (a physician who primarily practices in the emergency department; does not have to be a board-certified emergency physician)

• Emergency Medical Technician/Paramedic who is a currently practicing pre-hospital provider

• EMS state agency representative (e.g., EMS medical director, EMS administrator)

• EMSC PI

• EMSC Grant Manager

• Family Representative

EMSC Resource Center Contacts

• EMSC National Resource Center (NRC), Tasmeen Singh, NREMT, MPH, Executive Director, 202-884-6866 or tsingh@emscnrc.com

• National EMSC Data Analysis Resource Center (NEDARC), Michael Ely, MHRM, Director, 801-585-9761 or michael.ely@hsc.utah.edu www.nedarc.org

EMSC Program Contacts

• Dan Kavanaugh, MSW, LCSW-CCAPT. USPHSSenior Program Manager (301) 443-1321 or Dan.Kavanaugh@hrsa.hhs.gov

• Christina Turgel, BSN, RN, BCNurse Consultant (301) 443-5599 or Christina.Turgel@hrsa.hhs.gov

http://mchb.hrsa.gov/emsc

Contact:

Patricia SchmuhlNEDARC Texas Liaisonpatricia.schmuhl@hsc.utah.edu

801-213-3216

Website: http://www.nedarc.org

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