WIXLIB

Do Response TimesReally Matter?Matt Zavadsky, MS-HSA, EMTDirector of Public AffairsMedStar Mobile Healthcare, Ft. Worth, TXAdjunct FacultyUniversity of Central FloridaCollege of Health and Public Affairs

What we’re gonna do Figure out how we got “here” Review the science of clinical impact ofresponse times Focus on improving response times that matter Figure out how to ‘un-get’ here!

Disclaimer Response time discussions volatileCheck your weaponsSet your Phasers on ‘stun’Local community discussion!!Help them ‘look forward’ and ‘see beyond’

A Word About Texas

Where did this “Need forSpeed” come from

Cardiac Resuscitation in the CommunityImportance of Rapid Provision and Implications for ProgramPlanning Mickey S. Eisenberg, MD, PhD; Lawrence Bergner, MD, MPH; Alfred Hallstrom, PhD“If CPR was initiated within four minutes and if definitive care was provided within eightminutes, 43% of patients survived. If either time was exceeded, the chances of survival felldramatically.The time to initiation of CPR and definitive care are factors directly influenced by emergencymedical service program decisions.A realistic option to improve time to initiation of CPR is widespread citizen CPR training. Apossible option to improve the time to definitive care is the training of emergency medicaltechnicians in defibrillation.”

1979!!

What Matters? EMS has a history of “feel good”innovationsoWith little to no scientific basis Good thing we can change! MAST pants Water bumpers

Measuring What Matters Patient outcomes ooEMS is healthcareNeed to look at patient outcomes Risk vs. BenefitoIs faster really “better”? 74% of crashes occur while driving “HOT”

Consequences of Speed

Consequences of Speed

CAEMS StudyFractile,Average,BothHOTDavenport, IABoth7:59Fort Wayne, INFractile8:30Fort Worth, TXBoth9:0015:00Kansas City, MOFractile9:0020:00Little Rock, ARFractile8:5912:59Mecklenburg County, NCFractile10:5920:00Nova Scotia, CanadaFractile8:5914:59Pinellas County, FLFractile10:0020:00Reno, NVFractile8:2929:59Both8:5959:59Tulsa, OKFractile8:5912:59Oklahoma City, OKFractile8:5912:59LocationRichmond, VACOLD

The Current Science Paramedic Response Time: Does it affect patientsurvivaloo9,559 ‘unselected’ patientsUrban setting, DenverCONCLUSIONS:A paramedic response time within 8 minutes was not associated with improvedsurvival to hospital discharge after controlling for several important confounders,including level of illness severity. However, a survival benefit was identified when theresponse time was within 4 minutes for patients with intermediate or high risk ofmortality. Adherence to the 8-minute response time guideline in most patients whoaccess out-of-hospital emergency services is not supported by these results.Acad Emerg Med. 2005 Jul;12(7):594-600

The Current Science Lack of association between pre-hospital responsetimes and patient outcomesooo373 study patients 10:59Compared to 373 10:59 patientsUrban community – 750,000 - CharlotteCONCLUSIONS:Compared with patients who wait 10:59 minutes or less for ALS response,Priority 1 patients who wait longer than 10:59 minutes could experiencebetween a 6% increase and a 4% decrease in mortality, and do not have anincrease in critical procedures performed in the field. Our data are mostconsistent with the inference that neither the mortality nor the frequency ofcritical procedural interventions varies substantially based on this pre-specifiedALS RT.Prehosp Emerg Care. 2009 Oct-Dec;13(4):444-50

The Current Science Optimal defibrillation response intervalsfor maximum out-of-hospital cardiacarrest survival ratesoooPart of the OPALS Study9,273 treated cardiac arrest patients1991 - 1997

Study objective: Many centers optimize their (EMS) systems to achieve a targetdefibrillation response interval of “call received by dispatch” to “arrival at scene byresponder with defibrillator” in 8 minutes or less for at least 90% of cardiac arrestcases. The objective of this study was to analyze survival as a function of time totest the evidence for this standard.Results: Overall survival 4.2% (392 out of 9,273 cases worked). There was a steepdecrease in the first 5 minutes of the survival curve, beyond which the slopegradually leveled off. 9 minutes (4.6%; 18 lives) 8 minutes (5.9%; 0 lives) 7 minutes (7.5%; 23 lives) 6 minutes (9.5%; 51 lives) 5 minutes (12.0%; 86 lives)Conclusion: The 8-minute target established in many communities is not supportedby our data as the optimal EMS defibrillation response interval for cardiac arrest.EMS system leaders should consider the effect of decreasing the 90th percentiledefibrillation response interval to less than 8 minutes.Ann of Emerg Med Volume 42, Issue 2 , Pages 242-250, August 2003

The Current Science Response time effectiveness: comparison ofresponse time and survival in an urbanemergency medical services systemooooooCarolinas Medical System – 2002Urban county (620,000)10:59 RT standard for P1 calls5,424 transports studied71 did not surviveOf those:Acad Emerg Med. 2002 Apr;9(4):288-95.

Results:No significant difference in median RTs between survivors (6.4 min) andnon-survivors (6.8 min) was noted (p 0.10). “However, mortality riskwas 1.58% for patients whose RT exceeded 5 minutes, and 0.51% forthose whose RT was under 5 minutes (p 0.002). The mortality riskcurve was generally flat over RT intervals exceeding 5 minutes.Conclusion:In this observational study, emergency calls where RTs were less than 5minutes were associated with improved survival when compared withcalls where RTs exceeded 5 minutes. While variables other than timemay be associated with this improved survival, there is little evidence inthese data to suggest that changing this system's response timespecifications to times less than current, but greater than 5 minutes,would have any beneficial effect on survival.Acad Emerg Med. 2002 Apr;9(4):288-95.

The Current Science Eight minutes or less: does the ambulanceresponse time guideline impact trauma patientoutcomeoooEvaluate effect of exceeding the 8 min RT guideline onpatient survival for victims of traumatic injury treatedby an urban paramedic ambulance EMS system andtransported to a single Level I trauma center – Denver3,490 patients evaluatedPatients were grouped according to ambulance RT: or 8 min (n 2450) or 8 min (n 1040)J Emerg Med. 2002 Jul;23(1):43-8.

Results:After controlling for other significant predictors, there was nodifference in survival after traumatic injury when the 8 minambulance RT criteria was exceeded (mortality odds ratio 0.81,95% CI 0.43-1.52). There was also no significant difference insurvival when patients were stratified by injury severity scoregroup.Conclusion:Exceeding the ambulance industry response time criterion of 8min does not affect patient survival after traumatic injury.J Emerg Med. 2002 Jul;23(1):43-8.

What do the Eagles Think?EVIDENCE-BASED PERFORMANCE MEASURES FOR EMERGENCY MEDICALSERVICES SYSTEMS: A MODEL FOR EXPANDED EMS BENCHMARKINGA STATEMENT DEVELOPED BY THE 2007 CONSORTIUMU.S. METROPOLITAN MUNICIPALITIES’ EMS MEDICAL DIRECTORS“In many jurisdictions, response-time intervals for advanced life support unitsand resuscitation rates for victims of cardiac arrest are the primary measures ofEMS system performance.”“The association of the former with patient outcomes is not supported explicitlyby the medical literature, while the latter focuses on a very small proportion ofthe EMS patient population and thus does not represent a sufficiently broadselection of patients.”PREHOSPITAL EMERGENCY CARE 2008;12:141–151

“Over-emphasis upon response-time interval metrics may lead tounintended, but harmful, consequences (e.g., emergency vehiclecrashes) and an undeserved confidence in quality and performance ”“ much of the clinical research utilized to establish an acceptable“advanced life support (ALS) response time interval” was conducted in aperiod when only paramedics could operate a defibrillator, and thecompression component of basic cardiopulmonary resuscitation (CPR)received much less emphasis.”“Now that basic life support (BLS) providers and lay rescuers can providerapid automated defibrillation as well as basic CPR, the relativeimportance of the ALS response-time interval has been challenged, bothfor cardiac arrest as well as for other clinical conditions.”PREHOSPITAL EMERGENCY CARE 2008;12:141–151

“Many communities are still not measuring the intervals for themost important predictive elements for optimal outcome: timeelapsed until initiation of basic chest compressions and timeelapsed until defibrillation attempts.”PREHOSPITAL EMERGENCY CARE 2008;12:141–151

So What!? What is the ‘cost’ of insanityKeep doing the same thing and expecting adifferent outcomeo “It’s what the community wants ”oReally?

Well, maybe somecommunities overfocus on speed?

Time / Quality Tradeoff How do we reduce ALS response times?ooAdd more paramedics!Not a problem, right?

Back to the Eagles “As more paramedics are added to a particular system, however, thefrequency with which each individual paramedic has theopportunity to assess and manage critically ill or injured patients inthe primary or “lead” paramedic role may decrease.Pragmatically, considering that ALS cases constitute a small minorityof all EMS 9-1-1 responses, adding more paramedics into the systemmay actually reduce an individual paramedic’s exposure to criticaldecision-making and clinical skill competencies.”PREHOSPITAL EMERGENCY CARE 2008;12:141–151

Back to the Science The effect of paramedic experience onsurvival from cardiac arrestoExamine the relationship between the years ofexperience of paramedics and survival fromout-of-hospital cardiac arrest. Seattle – 2009oAll witnessed, out-of-hospital VF cardiacarrests (n 699) that occurred betweenJanuary 1, 2002, and December 31, 2006.Prehosp Emerg Care. 2009 Jul-Sep;13(3):341-4

RESULTS:“We found that every additional year of experience of the medic in chargeof implementing procedures such as intravenous line insertions,intubations, and provision of medications was associated with a 2%increase in the likelihood of survival of the patient (95% CI: 1.00-1.04). Thenumber of years of experience of the paramedic who did not performprocedures but instead was in charge of treatment decisions was notsignificantly associated with survival (odds ratio [OR] 1.01, 95% CI: 0.991.03). When we combined both paramedics' years of experience, we saw a1% increase in the odds of survival for every additional year of experience(95% CI: 1.00-1.03).”CONCLUSIONS:This study suggests that the amount of experience of the paramedic whoperformed procedures on cardiac arrest patients was associated withincreased rates of survival. However, we did not find an associationbetween survival from VF and the number of years of experience of theparamedic who made treatment decisions.Prehosp Emerg Care. 2009 Jul-Sep;13(3):341-4

Does the number of paramedics affectclinical benchmark thresholds?METHODS:This was a retrospective review of annual experience profilesfor paramedics working during 2001-2005 using the MCEMSpatient care record (PCR) database.The number of patient contacts, role as team leader/reportwriter, adult and pediatric endotracheal intubations, adultand pediatric intravenous (IV) access initiations, medicationadministration, and 12-lead electrocardiogram (ECG)acquisitions were analyzed. t-tests and descriptive statisticswere performed for comparison with the 1997 study.Prehosp Emerg Care. 2008 Jul-Sep;12(3):302-6