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The COVID-19 pandemic caused uncertainty for EMS providers and created confusion on how to best deliver care for patients. At the height of the pandemic when COVID-19 cases skyrocketed, Orange County Fire Authority (OCFA) noticed challenges in the transport decisions of hypoxic patients and started to receive feedback from hospital emergency departments.

Before a patient or the system of care took a turn for the worst, OCFA turned to data to drive quality improvement within the agency during a time of EMS and hospital staffing shortages, high patient volume and increased patient offload times.

OCFA EMS Staff Captain Paramedic Brandon Grinstead—an individual with a passion for EMS and a knack for data—used information documented in ImageTrend Elite, the electronic patient care report (ePCR) system used by OCFA to document patient encounters, to lead the change. Extracting data from Elite with the built-in ImageTrend Report Writer, Grinstead analyzed current data points including vital signs, hospital outcomes, disposition and volume data to compare them to pre-pandemic levels. He noticed discrepancies in hypoxic patients being transported with BLS vs. ALS protocols and an increase in patients declining ALS transports.

“We realized a challenge and understood that hypoxic patients could decline rapidly without essential care or could require advanced treatment once they’ve arrived at the emergency department, such as intubation,” Grinstead said. “When you look at the possible causes, it could be a combination of things—call fatigue, not fully understanding or recognizing a patient is hypoxic and strain on the entire EMS and health care system.” 

Orange County Fire Authority Wins Hooley Award for evidence-based protocol change.

Weekly OCFA hypoxia transports Oct. 2020–April 2021.

To implement a change throughout the agency, Grinstead—along with the agency medical director and team of continuous quality improvement (CQI) registered nurses—developed a mutually agreeable definition of hypoxia and guidelines for the transport of hypoxic patients, which was not previously defined by the county system or agency. Using the new definition and guidelines put in place, OFCA configured a CQI category in Elite’s CQI Module to implement a data-driven standard to improve the delivery of patient care with minimum impact to operations. The CQI Module uses CQI questions focused on overall patient care and hypoxia to bring details to the situation.

Capturing this enhanced data allows daily hypoxia reports to be populated in Report Writer and shared with OCFA nurse educators. The nurse educators utilize a tailor-made approach to review ePCRs related to hypoxia and provide crew feedback via CQI Notes to drive the new standard of care. In addition, OFCA also implemented a training called Just In Time to deliver information on the best practices for caring for patients with hypoxia and to reinforce providers’ ability to recognize and make the necessary transport decisions.

Orange County Fire Authority Wins Hooley Award for evidence-based protocol change.

OCFA hypoxia transports (total volume vs. disposition) January 2020–April 2021.

“We now review 100% of the ePCRs for hypoxic patients and provide feedback to providers on nearly every call to make sure we’re improving wherever we can,” stated Grinstead. “It’s one thing to implement a change but it’s a whole other thing to make it stick, and we’re proud of the effort and commitment of our providers to rise to a new standard.”

With continuous utilization of the CQI Module and capitalization of Elite’s reporting capabilities, OCFA has been able to maintain this change to improve patient care since the initiative’s inception one year ago. Through this initiative, OCFA found ALS transports increased for hypoxic patients with BLS transports on the decline, and in a two-month period, OCFA went from 52% compliance to 96% with hypoxia transport decisions.

Orange County Fire Authority Wins Hooley Award for evidence-based protocol change.

OCFA EMS hypoxic patients vs. Orange County COVID hospitalizations Oct. 2020–Jan. 2022.

Grinstead and OCFA were recipients of a 2022 Hooley Award in the Innovation category. The Hooley Awards recognize innovators and thought leaders, honoring their involvement, creativity and passion, and were founded to acknowledge their contributions in innovation and excellence. The Hooley Awards finalists were celebrated and the winners were announced during the 14th annual ImageTrend Connect Conference.

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