2.8 Invasive Prehospital Procedure Documentation Rate

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Description of Indicator

Relationship to Quality Medical care should be effective 
Type of Indicator Prehospital process and outcome, System level
Proposed Data Source EMS Records
Definition Documentation of high-risk low-volume prehospital procedures* attempted, performed successfully and associated complications per 100 EMS contacts with injured patients
Numerator All EMS records for patients 18 years and older with a) documentation of the following invasive procedures attempted prior to arrival in hospital, b) documentation of procedures successfully performed and c) documentation of any procedure dependent complications*: Intubation, Cricothyroidotomy, Needle decompression thoracostomy, Defibrillation
Denominator All EMS contacts for injured patients age 18 years and older
Benchmark Not specified at present
Risk Adjustment Not specified at present 

* For each of the four procedures, three measures will be calculated: i) number of documented attempted procedures per 100 patients, ii) number of documented successful procedures per 100 patients and iii) number of documented complications per 100 patients.

This indicator is intended to monitor the rate of high-risk low-volume invasive prehospital procedures attempted, successfully performed and associated complications.

Panel Review
Panelists emphasized that the indicator is not designed to encourage the performance of invasive procedures, but rather charting compliance of procedures when performed. The indicator should reflect the decision-making that paramedics do, and have the capacity to be interrogated. Panelists noted that the ability of EMS organizations to provide high quality advanced life support procedures for severely injured patients will likely be associated with robust patient care records and corresponding quality improvement program.
In addition panelists noted that the types of EMS providers should be documented in order to allow for international comparison. Panelists also discussed the need to ensure consistent definitions for procedure success and complications. Panelists noted that similar indicators could be developed for other healthcare workers.

Trauma Center Review
The trauma centers emphasized the importance of this indicator because accurate and complete documentation of invasive procedures is necessary for ongoing patient management, assessment of quality of care, and, in some cases, research purposes. In order for the indicator to be effective, it would be essential to ensure there is documentation of all attempted procedures, time of procedures and success rates. The trauma centers had concerns that data collection is often difficult because of missing or incomplete medical records and it would be time consuming if the system does not have an electronic EMS medical record. The trauma centers questioned the value of this indicator for rural areas where prehospital providers may have more limited training to perform invasive procedures and may not be exposed to sufficiently large patient volumes to maintain these skills.

Review of Literature & Evidence
Face Validity: In one study, 100% of Delphi panel participants ranked documenting indications for select prehospital interventions as very important13.
Construct Validity: One study showed inconclusive association between the quality indicator and mortality13.
Reliability: No studies identified.
Risk Adjustment: No studies identified.
Utilization: Emergency medical service documentation guidelines are used as an indicator by a small number of trauma centers: USA 13% (25/200), Canada 0% (0/35), Australasia 0% (0/12).

Rosengart et al. developed the indicator using a Delphi panel of trauma experts13.


13. Rosengart MR, Nathens AB, Schiff MA. The identification of criteria to evaluate prehospital trauma care using the Delphi technique. J Trauma. 2007;62(3):708-713.