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Perspective > Medscape Emergency Medicine > Hot Topics in EM
IS YOUR EMS SYSTEM LEADING THE WAY IN EMERGENCY CARE?
Robert D, Glatter, MD; Paul E. Pepe, MD, MPH; Benjamin (Ben) Weston, MD, MPH
Disclosures
April 10, 2024
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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.
SUGGESTED for you
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.
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Medscape Emergency Medicine © 2024 WebMD, LLC
Any views expressed above are the author's own and do not necessarily reflect
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Cite this: Is Your EMS System Leading the Way in Emergency
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TABLES
AUTHORS AND DISCLOSURES
AUTHORS AND DISCLOSURES
AUTHORS
ROBERT D. GLATTER, MD
Assistant Professor, Emergency Medicine, Department of Emergency Medicine,
Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
Disclosure: Robert D. Glatter, MD, has disclosed no relevant financial
relationships.
PAUL E. PEPE, MD, MPH
Adjunct Professor, Department of Management, Policy and Community Health,
University of Texas Health Sciences Center at Houston, School of Public Health,
Houston, Dallas; Medical Director, Emergency Medical Services and Fire/Rescue
Department, Dallas County 9-1-1 System, Dallas, Texas
Disclosure: Paul E. Pepe, MD, MPH, has disclosed no relevant financial
relationships.
BENJAMIN (BEN) WESTON, MD, MPH
Chief Medical Director, Associate Professor, Milwaukee County EMS, Medical
College of Wisconsin, Milwaukee, Wisconsin
Disclosure: Benjamin (Ben) Weston, MD, MPH, has disclosed the following relevant
financial relationships:
Serve(d) as a director, officer, partner, employee, advisor, consultant, or
trustee for: Milwaukee County
Received academic research grant from: US government entities
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