When resuscitating critical patients, we sometimes take patients from their homes, through the Emergency Department, CT scan, cath lab and ICU within a few hours. Therefore you can imagine that critical patients do not care about domains of different departments, but should rely on a seamlessly connected process of the prehospital and inhospital phase. The chain of survival in cardiac arrest is a good example of this process. In order to improve emergency care within this chain, it is essential for hospitals to work together with the ambulance services (emergency medical services, EMS). Here are 10 ways to improve collaboration between hospitals and EMS;
1. Share education
Learning from each other is a great way to improve quality of care. My experience is that EMS personnel is eager to learn what the diagnostic and therapeutic processes the patients they present will be going through. Likewise, hospital staff will understand their patients better when they know what happened in the prehospital phase. There are different education activities in which these goals can be met. At the Academic Medical Center (AMC) in Amsterdam where I work, the regional trauma network (SpoedZorgNet AMC) organizes a theme-evening twice a year, which is an evening filling symposium with a central theme. Speakers will present different viewpoints on that theme, in which all phases of emergency care are discussed. Most of the time around 250-300 people attend these evenings, many of these from ambulance services
2. Case discussions
Next to education on a broader theme, case discussions can give great insight in the chain of acute care of a specific case. This gives the opportunity to discuss the specific elements, like the decisions that were made. Often, these decisions are made in a time-critical setting and it is good to reflect on the arguments at that time. Sometimes, an other decision would possibly be better for the patient, but often the decisions were right and that also can be very learnfull for people who attend the case discussion. For example, we have multitrauma case discussions in which 2 multi-trauma cases are discussed. Everyone is invited: dispatch center, ambulance service, ED, anesthesia, ICU, surgery, etc. Most of the time, the people who treated that patient are all there, including the ambulance crew. We try to start from the beginning, with the voice recording of the call to the dispatch center, prehospital phase, to the ED and subsequent period of hospital stay. Sometimes we even get to see pictures of the patient in the current phase of the out-patient follow-up. Patients almost always give consent for these meetings and pictures because they realize how important it is that we learn from their case.
In both pre- and inhospital emergency care, much is still unknown. We need good quality research to increase our knowledge on how to improve the care for our patients. Most of the times, there is more research activity in hospitals compared to ambulance services. But the challenges faced in the prehospital setting have to be studied too, and this can help to improve treatment in the hospital as well. Enough arguments to get together and exchange thoughts on research questions and start collaborating. In my experience, ambulance crews are highly motivated to cooperate when they know the results have possible advantage for the care they give. As a consequence, it can be very rewarding for researchers to conduct a study when people are really willing to participate and implement improvements based on the results, to give better care of patients in an emergency.
If you want to improve the care for patients in the emergency setting, you need to realize this probably has consequences for the rest of the chain. Collaborating in innovation can strongly amplify the impact on emergency care. For example, a digital system in which hospitals can show how busy their emergency department is, can help ambulances make the decision to which hospital they should go to. And also: having a virtual prehospital waiting room, through which you have insight on how many patients you will receive will help emergency departments arrange all what is needed to receive these patients. This is just one example, there is so much more to think of in regard to innovation. But do it together.
5. Contact persons
Knowing each other helps cooperation. Having a contact person with regular meetings can facilitate constructive dialogues on how to improve the care of our patients. And I don’t mean persons on a management level only, but also on the operational level for the practical stuff. Furthermore, it can be helpful for an EMS medical director to have a contact person (consultant) in the various departments to arrange specific questions regarding certain groups of patients (for example STEMI or stroke patients).
6. Invite the EMS Medical Director
There are frequent meetings in the hospital which are interesting for the EMS Medical Director. Both from a medical and organizational point of view. You can think of a symposium, case discussion or clinical governance day. Involving the Medical Director, or other senior medical staff in EMS, will broaden the discussion and increase mutual understanding. Or even better: invite him/her as speaker!
If you want to improve something, you have to measure it first. Only than you can determine if certain improvement projects are successful. So think of a few important aspects of emergency care which you can measure. Make sure that these quality indicators are clinically significant. Then arrange an audit to see where you stand and what possible improvements can be made. I think these audits are most likely to be successful when health care providers themselves are in the lead: both in the design of the audit and the audit itself. This will also increase the chance that the recommendations following the audit are implemented and create a culture of excellence. There are different audit toolkits available, like the Urgent and emergency care clinical audit toolkit.
8. Exchange personnel
What could be more effective for collaboration than actually working in both organizations? I don’t know all the stuff that has to do with contracts and human resources, and there are some disadvantages as well, but regarding the subject of this blog: improving collaboration between EMS and hospital, it is worth considering. You may already know some examples of people who both work in the prehospital setting and in the hospital. It is often these people who see opportunities to optimize the process from pre- to inhospital. And these people know who to talk to get things done. Above all, knowledge on the prehospital phase can be spread during grand rounds and skills which are needed frequently inhospital but infrequent in the prehospital setting (like airway management) can help EMS personnel who also work inhospital stay competent in these skills.
If exchanging personnel is not possible, it is easier to organize some observer shifts. Have paramedics over to join you for some observer shifts in the emergency department. And have the trauma surgeon tag along on ‘the bus’ for an evening shift with the paramedics. It will increase understanding in the others expertise and setting and prevent unfriendly remarks at the hand-over. At the AMC, we have student ambulance nurses over for a three-day rotation with us as emergency anesthesiologists, on call for trauma and resus. In the meanwhile, we practice airway management in the sim lab and we spend time in the OR for both airway management and all kinds of other interesting stuff (physiology, sedation, IV access, shock, etc.).
Not all, but some equipment can be the same in the hospital and the ambulance service. For example: using the same supraglottic airway device in prehospital care and in the hospital, will lead to familiarity with the device when the patients arrives in the emergency department. Or regarding mechanical chest compression devices, it is practical to have one in the ED to rotate with the ambulance who is bringing in an OHCA patient on a mechanical compression device. But this spare device in the ED can of course also be used for an arrest in the ED. So when deciding which equipment to buy, it can be smart to ask the other what opinion they have and be on the same page.
As you can see, there are many ways to improve collaboration between your ambulance service and hospital. See for yourself which of these ways can help in your local setting. And realize it is all about the patient. This should be our motivation to work together as a team. And perhaps this is tip 11: Don’t curse on each other. It is easy for everyone to make unfriendly remarks when having coffee and the other party not present. But this does not add to the culture of collaboration and excellent preforming systems. Same counts for the situation when EMS and hospital people meet or work together: be professional. We all work hard to get the job done. And when you feel there is room for improvement, discuss that later, with respect for each other. I strongly believe, when you invest in the first 10 ways on improving collaboration, there will be no need for tip 11.
On the picture, you see me with Micha Smit. An ambulance driver who now studies medicine and helped me a lot with my PhD research on ventilation during advanced life support for out-of-hospital cardiac arrest. It is great to work together, because we both have experience in prehospital and inhospital emergency care. The research we are doing now, increases the collaboration of our ambulance service and hospital. I am convinced that this will have a positive impact on patient outcomes in the near future.
Our patients need us to collaborate. So be a team!
Such an excellent blog post Hans! These are key elements to producing a high performing health care system. Thanks for putting this out there
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Thanks Dave! Hope you can implement some of it. Let me know if I can help you in any way. All the best, Hans
You’ve energized me to start working again on a formal “visiting clinician” model where we bring Physicians, Mobile Intensive Care Paramedics, and Emergency Medical Technicians into the State Emergency Medical Service Office to see the work we are doing.
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Great to hear Scot! Sounds like a good plan. If you want more info on the ways I described, let me know. I can give you more info on my local situation. Hans
You got that right! Beautiful web site. I look forward to reading your blog posts. Keep up the good work…
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