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QI Project Improves Prehospital Protocol Compliance

Monday, March 12, 2018 - 12:45

As a pediatric emergency medicine (PEM) physician, Manish Shah knows that a seizure or a severe allergic reaction can be deadly for children if they are not treated quickly and appropriately. With a grant from the U.S. Department of Health and Human Services, Health Resources and Services Administration’s Emergency Medical Services for Children program, he led the creation of guidelines for treating children during ambulance transport.

That was just the first step, though. He had to find a way to help paramedics understand and implement those new guidelines. 

“As part of the project, we created nine different guidelines,” says Dr. Shah, Prehospital/State Partnership Lead, National EMS for Children Innovation and Improvement Center; Associate Professor, Department of Pediatrics, Section of Emergency Medicine, Baylor College of Medicine; and Attending Physician, Emergency Center, Texas Children’s Hospital. 

“But when it came time to update existing protocols or implement them as new protocols, we were faced with the challenge of training the providers in our local EMS system in Houston.”

-Dr. Shah


An Intervention of Education is Born

Thus, the quality improvement project, Improving Prehospital Protocol Adherence through a Multifaceted Educational Intervention, was born. The project is an example of applying quality improvement methods ― part of maintaining certification ― that can lead to significantly improved care for children.

Dr. Shah and PEM fellow Megan Marino, MD developed a curriculum to conduct five in-person training sessions for the 400 paramedics in the Houston Fire Department. Each session was three and a half hours. 

“When we designed the curriculum, we made it case-based, so we would provide a case scenario and then ask some questions related to the case about how they should manage it,” Dr. Shah says.

They also offered hands-on learning stations, and Dr. Marino created pocket field guides with pediatric dosing information, as well as information about when to use epinephrine for anaphylaxis and how to determine when to use a lower or higher dose epinephrine auto-injector. 

Drs. Shah and Marino used rapid cycle improvement to enhance their curriculum: “After each training day, we would get feedback from the paramedics and tweak what was needed before the following day,” Dr. Marino says.

After training paramedics over a two-week period, Dr. Marino launched a social media campaign.

“I showed the visuals that I had used in the training, such as a figure showing how to manage an airway and the progression for pediatric airway management. I would use a little picture, as well as a one-line blurb, just as a reminder,” she said.

She did this every other day during a nine-month period to reinforce the concepts used in training. She and Dr. Shah then looked at what paramedics did before and after the training and protocol implementation. The results showed improvement in how the paramedics treat anaphylaxis and seizures.


Education, Engagement Pays Off

“We saw that they really are treating more anaphylaxis patients with epinephrine, which was one of the things that we looked at in the study,” Dr. Marino says. “As far as the patients with seizures, the protocol changed to have paramedics either give intranasal or intramuscular midazolam as the initial dose instead of [intravenous (IV)] midazolam because it’s difficult to start an IV in a bouncing ambulance with a seizing patient. And we saw a really significant shift.”

Prior to the change in the protocol and training, only 29 percent of the patients were getting their midazolam intranasally or intramuscularly.

“After the training and through the follow-up that Meg used on social media, and with the use of reference cards that we distributed, we saw an increase to 74 percent,” Dr. Shah says.

Before the training, only 17 percent of children who were transferred by paramedics received intramuscular epinephrine for anaphylaxis, rising to 67 percent after the training.

“All these protocol changes that we made were based on some sort of evidence, and to see that shift in how the paramedics were using the medication was really satisfying.”

-Dr. Shah

“We could make a change in evidence-based practice through that protocol modification because of the training we did. Both seizures and anaphylaxis are lifethreatening conditions, and a delay in treatment, or giving treatment in a sub-optimal manner, has a negative impact on the health of children. So we’re really pleased with the findings that making a system-wide change like this — using the education that Meg developed and that we implemented in the system — has that sort of an impact on two very lifethreatening conditions for kids.”

The ABP recognized this quality improvement work with MOC Part 4 credit.

Dr. Marino completed her fellowship in 2017 and now is Director of Pediatric Prehospital Education, Pediatric Emergency Medicine, at Ochsner Health System in New Orleans. 

“I feel more motivated to continue this kind of work in New Orleans because I see what a difference it makes,” Dr. Marino says. “Good education really does translate into improved patient care in the prehospital setting.”