Developing a Prehospital/Paramedic CPI for Spinal Cord Injury - Essay Example

Developing a Prehospital/Paramedic CPI for Spinal Cord Injury Table of Contents I. Introduction II. Clinical Performance Indicators for Paramedic/Ambulance Services III. Developing a Prehospital/Paramedic CPI for Spinal Cord Injury IV. Appendix: Prehospital/Paramedic CPI for Spinal Cord Injury (12 years old and above) References I. Introduction This paper details a new clinical performance indicator for spinal cord injury for ambulance and paramedic services in particular, leveraging the recent literature on paramedic and ambulance clinical performance indicator or CPI development, processes, and issues, as well as the literature on spinal cord injury. The aim is the development of a CPI for spinal cord injury that will form as a foundation for standardizing procedures and protocols for dealing with emergency situations involving the condition, and with an eye towards improving care and patient outcomes through the provision of standards that can form the basis of metrics for measuring improvements to the services over time. The literature notes that CPIs improve ambulance and paramedic services in particular, and healthcare delivery in general, by providing structure, guidance, metrics, and standards for the delivery of different kinds of care services. In the paramedic sector for instance, CPIs improve on traditional performance metrics that have limited themselves to times of response, while providing no basis for the evaluation of things like adequacy of care, patient outcomes, and standardization of procedures as well as adequacy of materials and processes to successfully deal with different kinds of emergencies. The profession has come to recognize the importance of CPIs, to the extent that there have been concerted efforts to come up with national CPIs for a host of key services and conditions in paramedic and ambulance services and care, including cardiac arrest, asthma, different forms of stroke, hypoglycemia, and myocardial infractions of the acute kind. Looking around, there are a large number of other emergency and life-threatening conditions that can benefit from the drafting of CPIs for paramedics to use and standardize on, such as back injuries in accidents. A CPI for back injuries in general and for spinal cord injury in particular would help shore up the quality of services provided for such cases in emergency settings, and improve outcomes for patients and for paramedic services delivery in particular (SIriwardena et al. 2010; Mainz 2003; McColl et al. 2000). II. Clinical Performance Indicators for Paramedic/Ambulance Services The value of clinical performance indicators or CPIs lie in their ability to shore up services quality as well as to provide metrics for measuring quality of services and other relevant indicators in healthcare, with the goal of improving care and patient outcomes in the long term. They form a kind of foundation and a structure, as well as a repository for best practices. The key uses are in the appropriate assessment and improvement of healthcare services in general, and in recent years, there have been attempts to extend the use of CPIs in settings prior to hospital admission, such as in ambulance and paramedic settings, where critical care sometimes can make all the difference between life and death and poor and great patient and recovery outcomes. What a CPI is fundamentally is a tool for assessment for various protocols in healthcare, and in paramedic settings, they can be used as tools for the assessment of the delivery of emergency ambulance services, among others. The assessment is made in the context of being able to monitor and to assess key functions in management, governance, and support, that all have a bearing on the care outcomes of patients. Here quality in healthcare is measured in terms of how well health services are able to achieve the targeted health outcomes for patients, making use of the best available medical practices and knowledge. As a tool for assessment therefore, the value of the CPI for any procedure or condition lies in the excellence of its crafting, and taking off from the definition of quality in healthcare, a useful CPI has to leverage the best available and most current medical knowledge as can be had from best practices and in the academic and medical literature. This is to make sure that the CPI provides the best guidelines, and incorporates the metrics and factors that have the most impact on the quality of healthcare provided for that particular condition or paramedic situation (SIriwardena et al. 2010). That said, the observation is that historically, performance indicators for ambulance and paramedic services have been confined to the measurement of response times, which is inadequate especially in the context of the many life and death situations tied to paramedic services, and especially in light of the critical nature of the services. Such myopic focus on response times to the neglect of other indicators that can dramatically improve services and patient outcomes are hypothesized to have contributed historically to poor patient outcomes, low morale, and stress, owing to the lags, inconsistencies and gaps in the delivery of critical care, and the incurring of other costs of opportunity. On the other hand, the literature does not provide much straightforward advice on how to go about drafting CPIs for paramedic and general prehospital services, and therefore there has been a dearth of clinical effectiveness measures that have undergone national validation and use. This is an issue, moreover, given that the literature notes that when it comes to research in paramedic and general prehospital healthcare, it is precisely the development of new CPIs to upgrade the traditional measures of performance tied solely to response times that needs the most attention(SIriwardena et al. 2010). Taking a step back, inadequacy defines the work that has been done in crafting CPIs for paramedic and ambulance services. What CPIs are available out there need to be validated nationally for meaning and relevance, and usefulness, but such validation exercises are difficult to undertake, and so the whole discipline suffers. The literature provides guidelines for assessing the quality of CPIs that are crafted in this space. Among them are that the CPIs have to be realistic, and they must lend themselves to measurement. The CPIs moreover, have to be able to adequately cover the most relevant and pressing concerns and needs of both the patients and the healthcare professionals delivering the services, in this instance paramedics and ambulance support staff. This is to be able to provide a benchmark for how paramedics team perform relative to standards and peers. This is to reduce variances in the nature and quality of the delivered services within paramedic teams, and among different teams of paramedics in different healthcare organizations around the country. The CPIs moreover have to provide a kind of framework or structure, or be used as forming part of a bigger framework for improving the quality of clinical work in general. The CPI and the framework has to be able to leverage the principles and techniques tied to modern process and and services improvements, together with the tools for such. The CPIs have to be able to provide healthcare services and interventions that are marked by effectiveness, timeliness, efficiency, equity, safety, and a focus on patients, among others. Critical to the crafting and evaluation of CPIs is in its being able to empower paramedics and healthcare personnel to provide improved care, as well as to be able to effect improvements in the quality of care through the CPIs (SIriwardena et al. 2010). The literature further notes that CPIs normally are established from metrics for certain target populations that have been defined, or else they are for key incidents that have high criticality, as is the case for many conditions and situations in paramedic settings. The CPIs can be employed to provide metrics for healthcare outcomes, as well as for processes as well as structures. Process measures respond sensitively to healthcare quality, although the observation is that certain process metrics that have been proven in practice to provide a significant impact on the outcome of care or an intervention, can be regarded as having a higher value as forming part of the CPI in comparison to simple process measures. For instance, the provision of certain key interventions, such as the administration of aspirin in emergency heart cases, when measured in a CPI, can have a more profound impact on the outcome of care for such patients, as opposed to simply measuring a non-impactful process, such as the recording in AMI of the patient’s electrocardiograph. These things surface in best practices and when sifting through the evidence, with the implication that CPIs that are evidence-based and that cull the wisdom of actual practice have a potentially larger impact and greater applicability than those that are based purely on theory. CPIs when properly crafted therefore can help in the overall improvement of care delivery in paramedics and ambulance work, in terms of being able to provide modes of assessment and inputs to processes tied to the improvement of healthcare quality. The idea is to make use likewise of the most modern guidelines for crafting the CPI, that incorporates all of the insights from experiences of what has worked in previous exercises, utilizing both processes knowledge in this area as well as domain knowledge in the various medical disciplines as appropriate to craft the most useful and relevant CPIs for the purpose (SIriwardena et al. 2010; Mainz 2003b; Bird et al. 2003). III. Developing a Prehospital/Paramedic CPI for Spinal Cord Injury A thorough grounding in the latest medical knowledge relating to spinal cord injuries and the proper way to treat and handle patients with potential spinal cord injuries in paramedic and prehospital settings is essential to crafting a useful CPI for such injuries in such settings. Starting with the end in mind, for instance, there is value in being able to understand what the final desired outcomes for patients with spinal cord injuries are, and what clinicians are measuring when it comes to assessing the outcomes of hospital interventions to deal with spinal cord injuries (Alexander et al. 2009). At the same time, recent literature exists that integrates the best available medical knowledge and research relating to actually managing care and interventions for patients with potential spinal cord injuries in paramedic and prehospital situations dating to 2011. This very useful piece of literature scans both the academic and medical literature as well as the guidelines based on evidence to come up with a review and an assessment of where the discipline is when it comes to providing emergency and paramedic care to patients who may have spinal cord injuries prior to being admitted to the hospital. Again the idea is to have a thorough grounding on where western medicine is in general in terms of its knowledge and understanding of what works and what does not work in these paramedic settings, with the goal of being able to craft a CPI for spinal cord injuries that integrates the best insights from evidence and from the literature, and with an eye towards being able to maximize the prospects of recovery for such patients and to provide a way to benchmark and improve, as well as standardize, the administration of emergency interventions and care for patients with spinal cord injuries in emergency ambulance and paramedic settings (Ahn et al. 2011). The literature provides an outstanding perspective on best practices and knowledge in the handling and treatment of patients with potential spinal cord injuries in paramedic settings, because of the way that perspective comes from a panel of experts in medicine and surgery specializing in spinal cord injuries, and the way the panel scanned the best medical literature and evidence-based practice guidelines to come up with answers to key questions, the answers to which can reasonably form the foundation of a CPI for aspects of spinal cord injuries management of paramedic care. Those questions relate to one, the optimality of type and time duration of paramedic immobilization of the spine for patients with acute spinal cord injuries; two, in the paramedic setting, in the course of the manipulation of the airway, the most ideal methodology for immobilizing the spine; three, the effect/impact on patient outcomes for spinal cord injuries, of the time of transport of the patient by the paramedic/ambulance team from the place of injury all the way to the hospital and to the point of being given care; and four, the role of paramedics and ambulance care providers in clearing and immobilizing the patient’s cervical spine. What is noteworthy about this meta analysis of the evidence-based guidelines as well as the academic and medical literature on the subject is that it does not stop at that analysis, but rather moves forward with the drafting of guidelines for each of the four questions or topics tied to providing care for such patients in paramedic settings, making use of the Delphi methodology in the conduct of the review of the available guidelines based on evidence, and which relates to the topics/questions. Those recommendations form the foundation of points addressing the four questions/topics/issues raised above (Ahn et al. 2011). Those recommendations are listed here, and can form the basis of a CPI for handling and administering care to patients with potential spinal cord injuries in paramedic/ambulance/prehospital settings. They include the following: the use of a cervical collar to achieve patient immobilization prior to hospitalization, together with a spinal board and the immobilization of the head; the use of boards that are padded or that are made up of bean bags that are inflatable to ease pressure; making the transfer of patients off the spine boards in the soonest possible time a priority, including the transfer off of spine boards while on queue to be transferred from one medical facility to the facility where the patient gets “definitive care”; the provision of cervical spine tractions that are in-line and manual for the management of airways for patients in need of intubation in the paramedic setting; the recommendation to the delivery of the patient to the facility of definitive care within 24 hours from the occurrence of the injury; appropriate training for ambulance/paramedic personnel in qualifying and clearing victims of spinal cord injuries; appropriate training for paramedic personnel in the immobilization of patients who are suspects for sustaining spinal cord injuries at the point of rescue (Ahn 2011). Meanwhile, for the purposes of crafting the CPI for spinal cord injury for parademic and prehospital settings, there is also value in looking at the relevant measures and indicators that clinicians have cited as important in evaluating the treatment outcomes for patients with spinal cord injuries in the hospital. This latter set of indicators have value in providing perspective to the CPI for paramedics, in terms of understanding the kind of care that must be in place at the point of the prehospital interventions in order to maximize the chances of optimal recovery. The parameters of recovery can provide a perspective on the nature of care for such patients, as described by panels of experts for the discipline. This latter piece of literature is important for culling inputs and insights from a wide number of experts spanning the public and private stakeholders in spinal cord injuries and related disciplines in the healthcare field, including scientists from academia, private firms representatives, and practitioners in government. Again these indicators are to provide perspective, and are useful as such in the provision of a big picture of final desired outcomes, even if they don’t directly impact the content of the CPI for spinal cord injuries in prehospital settings. Without going into details, the indicators relate to neuroimaging; sensory and motor functioning; potential in physical function; functions of the upper extremities; ambulation; autonomic functions in the general sense; functions of the rectum and colon; functions of the lower urinary tract; pain levels; spasticity; levels of depression; life quality; and social participation (Alexander et al. 2009). Integrating, the two vital pieces of literature are important for integrating the best academic and medical literature, the best evidence-based guidelines, and the collective inputs of panels of experts in the field relating to spinal cord injuries to come up with recommendations for guidelines in assessment and in interventions and care for such patients in both prehospital/paramedic and hospital settings. As such they provide a rich ground for the development of a useful and high quality CPI that can be used for assessment and for the improvement in the quality of care and the care processes in the prehospital and paramedic environment/setting. The prehospital recommendations relate to the actual crafting of the CPI for the purpose, while the post-treatment outcome indicators as described above provide an overall perspective on what the ultimate goals of care are at the hospital setting. The focus of the CPI crafting exercise here is on the prehospital and paramedic recommendations that have been listed above (Alexander et al. 2009; Ahn et al. 2011). Focusing on the prehospital recommendations in Ahn et al. (2011). one can note that each of those recommendations can form an aspect of a high quality CPI for spinal cord injuries for paramedics and ambulance care providers. Therefore those will form the basis of the CPI for this exercise. Detailed answers to the four questions or issues/topics enumerated above tied to this meta analysis paper provide further details for the CPI in this exercise. For instance, in response to question/issue number one, with regard to the best type and the optimal time duration of immobilization for the spine for patients with suspected spinal cord injuries, the response from a survey of the literature and the evidence-based guidelines is that the use of a cervical collar and board together with the immobilization of the head with the use of wedges of foam or towels achieved the greatest stability of immobilization in the biomechanical sense. The inclusion of the board with the collar provided better immobilization in comparison to the sole use of the collar. Not enough data is available for the assessment of the best type of collar, and likewise no clinical guidelines are available with regard to the efficacy of the use of straps to secure the spine at the thoraco-lumbar area from movement. The use of board cushioning moreover, had additive protective effects on the patient, easing the pressure on the patient’s sacrum and the occiput while not compromising the effectiveness of the immobilization interventions. The padding also helped secure patient comfort in cases of prolonged use of the boards. These and other details of the responses to the four issues/questions enumerated above form the foundation of the proposed CPI for patients with spinal cord injuries in prehospital and paramedic settings . The final CPI is detailed in the appendix. The caveat here is that as the literature notes, not enough data is available to make recommendations for patients with spinal cord injuries below the age of 12, so the CPI is only for patients who are 12 years old and up (Ahn et al. 2011). IV. Appendix: Prehospital/Paramedic CPI for Spinal Cord Injury (12 years old and above) Immobilization >Use of all three: head immobilization, spinal board, and cervical collar >Use of padded boards to ease pressure on patient body. boards can either be padded, or made of inflatable bean bags >Use of appropriate cervical collar to achieve maximum patient body stability on board >Use of foam wedges or towels to achieve head immobilization >Movement of patient off of the boards at the soonest possible time; movement off from the board even in between hospitals to final facility where patient gets definitive care Airway management > For patients requiring intubation: manual cervical spine traction that is in-line to manage the airway > Airway management modes that allow for in-line stabilization of the spine do not worsen status of neurology post-management of the airway, and can be used Transport Times from Point of Rescue to Point of Definitive Care Provision > Transport time is 24 hours or less Paramedic/Ambulance Care Provider Training > Training provided for detecting/assessing possible occurrence of spinal cord injuries at points of rescue > Training provided in immobilization of patients with potential spinal cord injuries at points of rescue CPI inputs source: Anh et. al 2011 References Ahn, H. (2011). Pre-Hospital Care Management of a Potential Spinal Cord Injured Patient: A Systematic Review of the Literature and Evidence-Based Guidelines. J Neurotrauma 28 (8). [online]. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3143405/ [accessed 12/12/2015]. Alexander, M. et al. (2009). Outcome Measures in Spinal Cord Injury. Spinal Cord. 47 (8). [online]. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2722687/ [accessed 12/12/2015]. Bird, S. (2005). Performance indicators: good, bad and ugly. J. R. Statist. Soc A 168. [online]. Available at: http://www.bristol.ac.uk/media-library/sites/cmm/migrated/documents/performance-indicators-report-jrssa.pdf [accessed 12/12/2015]. Mainz, J. (2003). Defining and classifying clinical indicators for quality improvement. International Journal for Quality in Health Care. [online]. Available at: http://intqhc.oxfordjournals.org/content/15/6/523 [accessed 12/12/2015]. Mainz, J. (2003b). Developing evidence-based clinical indicators: a state of the art methods primer. International Journal for Quality in Health Care 15. [online]. Available at: http://www.veginfor.org/master/indc/Developing_clinical_indicators.pdf [accessed 12/12/2015]. McColl, A. et al. (2000). Clinical governance in primary care groups: the feasibility of deriving evidence-based performance indicators. Quality in Health Care 9. [online]. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1743509/pdf/v009p00090.pdf [accessed 12/12/2015]. Siriwardena, A. et al. (2010). Development and pilot of clinical performance indicators for English ambulance services. Emerj Med J 27. [online]. Available at: http://eprints.lincoln.ac.uk/2361/1/Siriwardena_Development_of_ambulance_CPIs.pdf [accessed 12/12/2015]. Read More