FIRSTPASS CASE STUDIES - FirstWatch · improve patient care and the documentation of the care. The...

FIRSTPASS®

CASE STUDIES Jan 2017

Case Study 1: How a City EMS Agency Uses FirstPass

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Welcome to the Big City

Big City EMS Agency transports nearly 50,000 people a year. The agency runs its own dispatch center and has staff devoted to training, fleet maintenance, logistics, and billing. The entire agency takes part in a total quality management (TQM) process, continually examining internal processes in order to improve.


The primary user of FirstPass is Ted, the QI coordinator for Big City EMS. He uses FirstPass to help him identify calls where patients didn’t receive the desired care, where documentation was incomplete or incorrect, or where critical interventions were provided—all without having to read each and every of the hundred-plus patient care reports produced by the agency each day.

Large, urban EMS system

50,000 transports each year

Manages its own dispatch center

Has staff devoted to training, fleet

management, logistics and billing

One QA/QI Director uses

FirstPass to ID calls where:

Patients didn’t receive desired care

Where documentation was

incomplete or incorrect

Where clinical interventions were

provided

ABOU

T T

HE A

GENC

Y

The entire agency takes part in a total quality management (TQM) process, examining internal processes in order to improve, but reviewing every PCR is not an efficient use of resources. The solution: FirstPass

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Instead of trying to read more than 130 calls a day, Ted uses FirstPass to review each ePCR, running them through the bundles of clinical care or required documentation defined by the agency.

Any ePCR that shows a patient did not receive all of the components of the bundle for his or her clinical condition or is missing key parts of its documentation is flagged and dropped into a queue for Ted to review.

With the click of a button he can see why FirstPass flagged the call and easily review the narrative and relevant fields in the patient record.

Ted also has a FirstPass queue for the critical cases that he always wants to review, including cardiac arrest, pediatric patients who were transported emergency to the hospital, and anytime the new analgesic was administered.

130 Calls each day

FirstPass reviews PCRs

Across desired clinical care

requirements

PCRs missing key elements are flagged for review

Ted reviews flagged records

Big City EMS Process

Pictured here is Ted’s FirstPass queue which gives him easy views of flagged calls or the critical cases he always wants to review.


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Managing Flagged Records

Met Standard: Mark as passed Minor Issue: Can’t be corrected

Minor Issue: Can be corrected

Some of the calls met the standard of care and are marked as passed. Like the patient with chest pain who did not receive aspirin and was not allergic to it: Ted saw in the narrative that the patient’s religion forbids him from taking medications so he refused aspirin. Ted chose “Patient refusal” as the reason for the call not matching the FirstPass care algorithm.

.

Ted can keep track of what the reasons are for a protocol not being complied with. After reviewing and characterizing the records that did not clear the FirstPass algorithm, he can run reports that tell him how the agency is doing in each of the selected categories. For example, he knows that last month, in 249 cardiac arrhythmia cases, 230 had 12-leads documented. In the other 19, he knows what the reasons were for the lack of documentation, so he can find ways to improve.

If Ted finds a minor issue with an ePCR that cannot be corrected, he’ll usually just send an email to the ePCR author, reminding them to include a second set of vitals or a pain score in the future.

If it’s an issue that can be corrected, he’ll log it in an agency database and the ePCR author’s field supervisor will send the report back to the author through the ePCR software. If a member of the billing department finds an error, he or she can log it in that same database so it can be corrected.

Ted’s other options when choosing a disposition for a call in his FirstPass queue include:

• Equipment failure

• Contraindication

• Documentation error

• Care within guidelines

• Care outside guidelines

• Patient refused

Options: Characterizing Records

Other Actions: Follow-Up & Education Other cases inspire the need to follow up with education or coaching to help the crew provide better care on the next patient. When Ted finds an issue that he thinks needs to be discussed at a higher level, he refers it to the agency’s chief clinical coordinator, who can work with the Clinical Services Committee or the medical director to address it.


Case Study 2: How a Countywide EMS System Uses FirstPass

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One System, 19 Agencies

Jones County is a mix of urban, suburban and rural communities with EMS overseen by one county office of the medical director. The medical director and his colleagues are charged with overseeing a this EMS system including a private ambulance service and 18 individual local fire departments. Those agencies generate 800 to 1200 patient care records every day.

When the county implemented FirstPass, several organizations had to work together to create a system in which the individual agencies and the medical director’s office each understood their roles and how they would collaborate to ensure high quality EMS service is provided to the community.

Mix of urban, suburban & rural communities

120,000 9-1-1 transports per year and

50,000 non-emergency transports

each year

Results in 800-1,200 PCRs every day

One County Medical Director

Each agency has to access and

review records that are flagged and

placed in the FirstPass queue

Local agencies are encouraged to

address incidents but county director

can access all records

ABOU

T T

HE A

GENC

Y

EMS Services are provided by a private ALS transport agency and 18 local fire departments that deliver BLS and ALS first response.

Case Study 2: How a County EMS System Uses FirstPass

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Incorporating FirstPass into the system

To define how FirstPass would supplement the management activities in the county, the Jones County EMS system updated its Medical Quality Management Plan. The plan explains why and how FirstPass is being used and what the county medical director’s expectations are

from the individual EMS agencies.

“ FirstPass “checks each record to evaluate if defined core quality measured have been documented,” the plan says. “If a chart does not record the appropriate quality measures, the case must be evaluated by a reviewer.”


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Incorporating FirstPass into the system

Rules defined in the county’s quality management plan are used by FirstPass when analyzing patient care reports.

The initial implementation of FirstPass in the county included a Universal Protocol for criteria required in every ePCR.

UNIV

ERSA

L P

ROTO

COL Examines all PCRs for:

Two sets of vitals

SpO2 measured

If below 94%, was oxygen administered?

Pain score documented (if GCS = 15)

Chief complaint documented

Medical history, medications, allergies

documented

When Jones County went “live” with FirstPass, two protocols were implemented immediately: The Universal Protocol and the Acute Coronary Syndrome Protocol

ACS

Examines Acute Coronary Syndrome PCRs for:

12-lead performed

Aspirin administered (if not allergic)

NTG administered(if BP>90 and not

allergic)?

Final pain score < initial pain score

STEMI Alert and 12-lead transmitted


10 | AIRW

AY M

ANAG

EMEN

T Examines Airway PCRs for:

BVM Ventilation assistance provided 1st

Single airway type used

Confirmation with ETCO2

Airway re-confirmed

Multiple ETCO2 values PATI

ENT

REFU

SAL Examines Patient Refusal PCRs for:

Two sets of vitals and at least one GCS

Chief complaint documented

Medical history, medications, allergies documented

Witness signature obtained

Narrative > 150 characters and includes “Decisional capacity”

CARD

IAC

ARRE

ST Examines Cardiac Arrest PCRs for:

Pt transported (for trending)

EtCO2 monitored

Extraglottic airway used

Compressions initiated within 1 minute

Med Control contacted if no transport MAJ

OR

TRA

UMA

Once the medical directors, agency leaders and providers became familiar with FirstPass, the county implemented four additional protocols.

Examines Trauma PCRs for:

Scene time < 10 minutes

Oxygen delivered

IV established

Trauma Alert called

Spinal precautions performed (for trending)


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It appears in the review queue of the appropriate individual, based on the workflow established by the agency that treated the patient and wrote the ePCR.

is that these calls must be reviewed within 14 days of the incident. The county’s medical director also has the ability to view any calls from the 18 fire departments and EMS service; but typically the first step is for the local agency to handle its own incidents first. .

When a Case is Flagged

Record Review and Addressing Incidents Locally

The County’s Review Policy


Case Study 3: How a Local Fire Department (in a Countywide EMS

System) Uses FirstPass

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Town Fire & Rescue

Town Fire and Rescue is one of the agencies that provides ALS first response to a municipality in Jones County. While the agency does not transport, its paramedics frequently arrive before the ALS transport service’s ambulance and initiate patient care; when the patient requires ALS, Town Fire’s personnel often continue care on the ambulance along with the ambulance team.

Town Fire paramedics complete PCRs using the department’s ePCR software—as soon as they complete and submit the report, it is reviewed by FirstPass using the criteria of the universal protocol and any other protocol that might be appropriate based on the call type and treatment provided.

Serves a Suburban Area

Does not transport, but provides ALS

first response

Has eight stations, each with an

engine company.

Six of the eight engines have ALS

staffing

Town Fire Paramedics

complete ePCRs

ePCRs are immediately reviewed by

FirstPass against the Universal and

other protocols identified by the

county

ABOU

T T

HE A

GENC

Y

EMS Services are provided by a private ALS transport agency and 18 local fire departments that deliver BLS and ALS first response.

Case Study 3: How a Fire Dept. within a County EMS System Uses FirstPass

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Town Fire’s leadership shared details about FirstPass because they didn’t want field providers thinking it was being used to catch providers making mistakes and punish them. Instead they wanted to be clear that the intention was to use FirstPass to improve patient care and the documentation of the care.

The leadership team hoped that making the department’s firefighter-medics aware of the criteria would lead to better care and better reporting—and fewer calls flagged by the system for further review.

Before Town Fire started using FirstPass, department officials sent training bulletins to every member of the department explaining exactly what the system would be looking for in each of the protocols and a rationale for those criteria.


Communicating about FirstPass to Providers

For example, the bulletin explaining the universal protocol stated that two sets of vital signs were required because

“The medical director wants two sets of vital signs, at least 4-5 minutes apart to establish a trend. In fact, saying, writing or typing ‘vital signs stable’ is inaccurate if only one set of vital signs was taken.”

“ Town Fire’s leadership shared details

about FirstPass because they didn’t want field providers to think it was being used to catch providers making mistakes and punish them.

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FAQs: How Town Fire and Rescue Manages Flagged PCRs

What Happens When a Record is Flagged?

If FirstPass does flag an ePCR written by a Town Fire EMS provider, the report appears in the clinical review queue that can be viewed by the EMS Chief as well as any of the three EMS shift lieutenants.

Those lieutenants are responsible for reviewing the flagged reports for their individual shifts—Town Fire has its FirstPass system configured so reports in the clinical review sort by shift, making it easier for the A Shift EMS lieutenant, for example, to

find the A Shift calls.

When the shift EMS lieutenants open a call in FirstPass, they determine why the system flagged the report, and review the entire

record.

How are Report Reviews Managed?

Reviewers in the department received training that provided the following suggestions for approaching a report review in FirstPass:

• Address all flagged calls with a comment addressing that field

• Review the assessment and vitals

• Assure the narrative is appropriate and inclusive for the given type of call

• Assure all signatures are present

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What Happens if No Correction or Action is Needed?

These reviewers focus on deciding whether the case was flagged but does not need any corrections or further action. —for example, a vital sign is missing but the narrative explains why—or if the ePCR has a documentation error or reflects a potential patient care issue.

If the reviewer determines the call satisfies criteria, they choose “review complete-passed” and must choose a reason why the incident is an exception to the rule it was flagged for.

If the reviewer feels a correction needs to be made… the email is augmented when the reviewer logs into the EMS reporting system to returning the ePCR to its author. The provider can make corrections in reports, which are recorded and time-stamped in case there are any concerns later as to when those changes were

made.

Or a conversation can be used to assess the need… Instead of just an email, a conversation with the provider may identify a need for additional training.


What Happens if Action is Needed?

If the reviewers decide action is needed, next steps depend on the nature of the problem.

If it’s a Minor Documentation Error…

Such as neglecting to put the pain score in the vital signs field despite recording one in the narrative or a misspelling—the lieutenant uses the FirstPass system to email a note to the clinician who completed the PCR while also copying his or her supervisor.

The system automatically includes a specific code in the subject line to indicate the email is part of the quality management process so it can easily be redacted if

necessary.

“ The medic will receive the follow-up email, and hopefully that in and of itself will start to make an improvement”

- Town Fire’s EMS Chief

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How Does a Reviewer Know When to Escalate a Report?

The county medical management plan lists certain specific cases that must be referred to the medical director office for review. Those include:

• Protocol violations

• Medication errors or other patient safety concerns

• Significant departure from the standard of care

• Events that meet criteria for immediate or routine notification of the Medical Director

These cases receive a full quality assurance review from the medical director or his designee. At the conclusion of those investigations, the medical director will require the completion of a training verification form or he will convene a medical case review.

What about Case Reviews that Need Immediate Feedback?

The plan delineates specifically what cases require immediate notification of the medical director. In addition, the county uses FirstWatch to provide real-time notification of the OMD any time one of the following is documented: cricothyroidotomy (surgical airway), tourniquet use, needle thoracostomy (chest decompression), a failed airway or a mass casualty incident.

Can the Medical Director Review this Information Also?

The county medical director uses his own database to track any incidents that undergo a quality assurance review. That database includes the resolution of the review, and allows him to include calls that did not come through FirstPass, such as those resulting from a patient or hospital complaint.


What if the EMS Chief or Medical Director Need to Be Involved? The EMS lieutenants can refer calls to the EMS chief for help deciding what further action might

be appropriate.

Also at any time, a reviewer can also send a report to the medical director for review, however, the county’s medical management plan emphasizes root cause analysis, education, and Just Culture.

“ The County’s Medical Management Plan emphasized root cause analysis, education and the use of Just Culture to ensure improvement occurs..

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The Jones County and Town Fire FirstPass workflow

FirstPass Flags an ePCR

Shows up in FirstPass Queue of EMS Chief and Shift EMS Lieutenants

EMS Lieutenant for the shift on which ePCR author works reviews FP: - Looks at and records

comment for all flagged tests

- Reviews assessment and vitals

- Assures narrative is appropriate

- Assures required signatures are present

If EMS Lieutenant determines protocol was violated, can take two options

Email provider

Return ePCR through ePCR system


If EMS Lieutenant determines protocol was succesful, can provide positive feedback

Questions? [email protected]

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FIRSTPASS CASE STUDIES - FirstWatch · improve patient care and the documentation of the care. The...

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