Quality assurance (QA) concerns the performance of EMS providers, while Continuous Quality Improvement (CQI) pertains to system wide metrics. QA is integral to scope of practice waivers as noted in CDPHE regulation 6 CCR 1015-3, Chapter 2, Section 12.1, which reads, in part:
- Any EMS agency medical director may apply to the Department for a waiver to the scope of practice set forth in these rules for EMS providers under his or her supervision in specific circumstances, based on established need, provided that on-going quality assurance of each EMS provider’s competency is maintained by the medical director.
This regulatory provision is operationalized during the waiver application process by requiring EMS medical directors to submit documentation describing how quality assurance will be conducted for the specific waivered act/medication. EMPAC reviews the description of each agency’s QA program description during the initial waiver application process and every three years thereafter when the waiver is up for renewal.
This state practice aligns with a 2016 NAEMSP position statement, which provides:
- The primary role of the EMS medical director is to promote continuous quality improvement and patient centered delivery of medical care by the EMS service. The EMS medical director should be involved and integrated with all aspects of out of hospital health care delivery from initial patient contact, including contact via telecommunications with emergency dispatch operators, to definitive patient care.
Current ketamine quality assurance programs provide for chart review by the EMS medical director or designee of every ketamine administration, and for some level of remediation of paramedic performance when ketamine is not being used in accordance with the EMS agency protocol.[64] Some QA program descriptions mention the review of aggregate data by a multidisciplinary team for the purposes of system improvement. The NAEMSP states that “use of restraint protocols should undergo quality improvement review with specific filters for: 1) appropriateness of restraint for the patient, 2) the type of restraint(s) utilized, 3) the care provided to the patient during transport, and 4) documentation of the episode of care. EMS agencies should consider reviewing every case of patient restraint for compliance with the restraint protocol.”[65(p.2)]
Medical directors perform some QA functions and delegate others. Which staff members perform QA varies, depending upon the number of agencies a medical director oversees, the number of EMS providers overseen, the type of EMS system, and the EMS agency’s available resources. Urban EMS agencies typically have more resources than rural ones and hospital-based medical directors often have additional hospital staff that can assist with their QA activities. For example, paramedic shift supervisors can sometimes be dispatched to the receiving hospital to assist with ketamine patient hand-offs and to act as the medical director’s “eyes and ears.” Urban medical directors may also rely on hospital EMS liaisons who conduct the chart reviews for ketamine calls and consult with the EMS medical director when a problem is encountered.
Rural medical directors do not typically have the same level of resources to assist with their QA responsibilities. The panel learned from one rural medical director that his agency’s QA program focuses on chart review, which he conducts on every ketamine-associated chart. This rural medical director has an EMT-I who serves as a QA supervisor and assists with administrative functions.
PANEL RECOMMENDATIONS
EMS agencies should review recorded chemical restraint care encounters to improve paramedic verbal de-escalation skills. If EMS agencies are unable to record their paramedics’ de-escalation efforts, they should obtain available portions of police video footage that portray these efforts.
EMS agencies should engage in a quality review of each case of ketamine use for chemical restraint.
Law enforcement and EMS agencies should conduct quality improvement sessions together, whenever possible.