Evaluating EMS Door-to-CT Times Using an EMR Based Communication Tool
Christopher Rankin, MSN, RN, NREMT, CEN
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Session H presented Saturday, September 16, 2017
Purpose: Evidence-based standards of care in EMS and emergency nursing are well defined in clinical populations. Communication between pre-hospital and emergency departments (ED) required improvement by accrediting organizations at our hospital. The purpose of this IRB exempt quality improvement initiative was to compare the transcripts of calls with staff using an EMR evidence-based stroke template with those who using the template during calls to observe the effect on stroke-activation and door-to-CT times.
Design: This quality improvement process involved developing and implementing an EMR based stroke reporting template, facilitating evidence-based structured reports with EMS providers, measuring the effect of these changes quality indicators, and including EMS reports into the EMR. Each squad was asked for the time of symptom onset, Cincinnati assessment, glucose, 12-lead, and if an IV was placed. All nursing staff and paramedics were trained in the use of the template. Staff were requested, but not required to use the stroke template. All EMS calls are recorded, and patients with subsequent stroke activation were reviewed. The door-to-CT completion and average door-to-activation times were included.
Setting: This QI suburban level 2-trauma center ED based in Northeast Ohio connected to a major regional hospital system that receives 14,400 EMS calls and approximately 10,000 referring provider calls annually. Calls average 100 seconds in length, the majority received between 1100-1900 hours. The ED’s EMS catchment area includes many large retirement facilities.
Participants/Subjects: This QI project reviewed all patients who arrived to the ED via EMS with subsequent stroke activation. All ED nurses and paramedics were educated.
Methods: Nationally recognized quality markers were included for patients arriving via EMS with stroke activation. Stroke cases were reviewed for the inclusion of symptom onset, recorded/documented stroke assessment, and evaluation of differential diagnoses. 19 Cases were excluded as inter-facility transfers, outside of the therapeutic window, incomplete documentation, misleading pre-notification, trauma, or were full arrests.
Results/Outcomes: 51 patients were included in the study with an even split between those who used the template and those who did not. Results were measured every two weeks for eight weeks with the average door-to-activation times ranging from 1 to 4.25 minutes after arrival vs. 6.8 to 9.5 minutes post-arrival when the template was used. Staff using the template approximately halved the Door-to-CT time and had a signficant value of p < 0.05. Five patients exceeded the 25 minute door-to-CT time set by the AHA in non-template users compared with none in the template using population. Pre-hospital information is now permanently documented in the EMR. Staff satisfaction with pre-hospital report and triage decision-making has improved.
Implications: Early identification and reduction of stroke intervention time are known to improve patient mortality. Triage compliance for quality indicators can be enhanced and pre-hospital information permanently documented in the EMR by having trained emergency nurses hold EMS teams accountable for evidence-based standards of care. This quality improvement process has been shown improve patient outcomes and established a permanent record from EMS. Further, larger studies should be conducted on EMS call structure to measure improved triage, time to final testing, and patient outcomes.
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