Timely Topics in EMS CQI: The ACS patient

When most people consider how best to CQI cardiac/ACS patients, most consider the monitoring and reporting of STEMI recognition, STEMI point of entry, and the timely administration of ASA as their criteria for measurement. While these are common and certainly appropriate metrics to consider when attempting to determine if your EMS agency’s ACS patient population is being properly served, the prudent CQI coordinator should consider other potential opportunities for improvement in this population.

The Data Source

Let’s begin by considering your data source. It is a well-established fact that the data derived from most EMS agency’s ePCR programs is inaccurate. Errors on the part of field providers in entering the data can be frequent and significant. There may be missing, incomplete, or erroneous entries. Additionally, providers may mischaracterize their findings resulting in the misclassification of important data. In other instances, the data may be inaccurate simply because the provider got it wrong.

Let’s say you are working on a CQI project that involves the identification of STEMI patients. Simple enough right? Simply generate a report of all the chest pain patients and then look to see if STEMIs were identified properly by the crew. While you may pick up all the patients who complained of chest pain, you may miss all the chest pain equivalents that did not get recognized. What about that 85-year-old woman complaining of nausea? Does your report include those patients who may be having a cardiac event? Maybe not, especially if your providers did not even consider the possibility of ACS as a possible cause. Starting your CQI project with misleading data can be a waste of time and effort and may have you chasing ghosts in your effort to make positive change.

Critical Miss Categories

Even if the patient is complaining of chest pain, providers can sometimes be led astray based on incomplete assessments or anchoring bias. If the patient tells them they get this pain from time to time and it is simply their GERD, a provider may take that at face value and not perform an ACS assessment or workup. We frequently hear from providers that the pain was not likely to be cardiac based on faulty information and a lack of thorough assessments. Knowledge gaps may also present a problem. We often hear from medics that the patient’s pain increased or decreased on palpation, motion, or inspiration. These are inaccurate predictors of the likelihood for cardiac etiologies and should not be relied upon as the basis for ruling a patient in for potential ACS.

Another common “assessment” criteria ALS providers use is the Nitroglycerin “challenge”. In this scenario, if the provider feels the chest pain is not likely cardiac, but they want to “cover their bases”, the medic will sometimes administer Nitro to the patient and if the patient does not experience relief from the 1 time does of NTG, they are declared noncardiac by the medic and further attempts at pain control are not performed. Responsiveness to NTG, especially when given as a single does, is not an accurate predictor of ACS versus a non ACS event and should not be relied upon to determine if the patient warrants further ACS workup.

In performing CQI on these patients, these sorts of activities need to be identified and feedback provided to the providers on why these activities have limited value, if any, in determining whom to work up. There are a wide variety of issues with ACS patients that can pop up during a CQI review. Below is a common list of issues identified that every EMS CQI professional should be on the lookout for.

• The provider didn’t work up the patient as they did not think the patient was cardiac. Usually, faulty assessment is used as noted above. This can also be a function of the providers level of experience with determining how best to differentiate between cardiac and non-cardiac presentations.
• The Nitro challenge. Again, as noted above some medics believe this is predictive and a reliable method for determining cardiac vs non-cardiac etiologies.
• Provider not sure, so they opted not to provide an ACS workup. Providers sometimes do not consider other factors such as patient age, risk factors for ACS, family and patient history, or cardiac equivalents in making a decision.
• Provider gave the patient Aspirin (just in case it is cardiac) but not NTG as they felt there is doubt as to whether the patient is or is not cardiac. We see this one often and it drives many medical directors crazy. The advice from most medical directors is, in for a penny/in for a pound. If you are concerned enough that this may be cardiac, give the full workup and let the hospital determine if it is or is not.
• Lack of serial 12 leads
• Lack of blood pressures after med administration
• Time to ASA, NTG and Fentanyl administration. Time to ASA is particularly important to note during a CQI review.
• Lack of moving on to Fentanyl after NTG does not fully resolve the issue (often because providers do not want to deal with the issues of opening and using the narc box.)
• Only partially treating the pain. Another issue we see is providers treating the patient’s 8/10 pain to the point of 1/10 but not going all the way to pain free. They are satisfied with the improvement in the pain level and do not continue with treatments. Most medical directors want field providers to get the patient to pain free and not just “lessen” the pain. In fact, many protocols now specify that the patient should be treated until pain free.
• Not calling medical control for high-risk refusal of patient with ACS symptoms. On occasion ACS patients want to refuse transport. This is a bad idea if it can be avoided. The patient has the right to refuse care even with a legitimate medical condition, but field providers should be encouraged to call on-line medical control before cutting the patient loose.

While this is not an exhaustive list of common ACS errors, it provides a framework for CQI coordinators to consider when auditing PCR forms and creating educational content and improvement plans.

For more discussion on the treatment of ACS patients, listen to our podcast: Timely Topics in EMS CQI: The ACS Patient. It can be found on our website www.girardassoc.com.

The G&A Way podcast can also be found wherever you get your podcast from.

You can also contact Paul Girard at, paul.girard@girardassoc.com.