Annual EMSC Grantee Meeting

State Partnership Grant Representatives

Jumpstarting Your Performance Measure Activities

June 20 – 22, 2006

JENNIFER KUO: I just wanted to mention a couple of things. We know that in some states and territories, you ambush inspections or surveys may be conducted every other year in which case it is fine--for example it’s fine to use 2005 data for 2006 or for this year. So, everyone should be smiling, happy.

The other thing is that there is a FAQ document that was distributed on the EMSC list serve. And unfortunately, they were not included in your binders but I think we had some copies floating around, so a lot of the questions people have had thus far, and perhaps some questions you’ll have once you leave here. Hopefully, they’ll be answered in the FAQ document, which we will be continually updating as there are additional questions.

Okay. Performance Measure 66C reads the existence of a statewide, territorial, or regional, standardized system that recognizes hospitals that are able to stabilize and/or manage pediatric medical emergencies and trauma. It’s important to note here that this measure evaluates both pediatric medical emergency facility recognition as well as pediatric trauma facility recognition. And if you look in the implementation manual, we do list some examples of designations and systems for both the pediatric medical emergency facility recognition as well as the trauma. So, you can find that information in your implementation manual.

You’ll also find in the implementation manuals potential data sources for this measure. I know that NEDARC doesn’t have a specific data collection tool for this measure but you can refer to your implementation manual for some suggestions. Also it’s important to note that we are aware that this measure is a longer-term measure and that it will require some states perhaps to institute regulatory changes, and so we are aware of that, which is why the goal for the measure is not until 2011. Any questions or discussion items? I know Mike doesn’t have any data collection tools but if people had any questions, specific questions about this measure?

UNKNOWN SPEAKER: Should we go to the questions that came from them then?

JENNIFER KUO: Sure.

UNKNOWN SPEAKER: Or do you have other slides on this?

JENNIFER KUO: Not this. No. The 66D is next.

UNKNOWN SPEAKER: Well then, why don’t you go ahead and do 66D, and then we’ll come back to the questions--oh, there you go. Laurie has got one.

LAURIE: I have one question about the possible (inaudible) measure. If your state already has regulations for the trauma side but you don’t have it necessarily for the medical side--I mean this is just a yes/no answer, right? So, if we don’t have both, the answer is no.

JENNIFER KUO: Yeah. Unfortunately, for the measure itself is a whole. If you don’t have both, the answer is no. However, in your electronic handbook, there will be a place for you to answer yes or no for the medical emergency side, and yes or no for the trauma. Because that way, once again we’ll be able to track for each of the states, kind of how you are doing because we do want to give states some credit if they do have won or not the other, that’s good for us to know. But unfortunately, at the end of the day, for the measure itself for your state, it would be no. Okay.

So, the last sub-measure for this measure--I know we kind of lie when we say it’s only one measure--is that hospitals have written inter-facility transfer agreements that specify alternate care sites that have the capabilities to meet the clinical needs of critically ill and injured pediatric patients and inter-facility guidelines that specify the following: transportation of individuals, staff and equipment to the alternate care site; the transfer of individual necessities including medications and medical records to and from the alternate care site; individual tracking to and from the alternate care site; and lastly, inter-facility communication between the organization and the alternate care site.

The goal for this measure is that by 2006, 20 percent of hospitals in the state or territory have inter-facility agreements and guidelines. I know that there were a lot of questions from grantees about terms in this measure. There are questions about what we meant by alternate care site. That’s just a fancy term for the receiving facility. There are also questions about the phrase, individual tracking to and from the alternate care site. What we mean by this is that the referral site confirming that the patient has arrived safely at the receiving facility or the alternate care site is the term that we used in the measure. Some grantees had questions as to whether or not this meant that the ambulance had to have a GPS tracking system and the answer is no.

And then there were also questions about the phrase, inter-facility communication between the organization and the alternate care site. Well, this refers just to having a phone or radio access. A lot of cases, there might be a phone conversation between the receiving and referral physicians to make sure that the receiving facility agrees to take the patient. And this is a standard component and a lot of inter-facility transfer agreements. And in the implementation manual, there will be, there are some website links, just some model inter-facility agreements. I think there’s a question back there.

UNKNOWN SPEAKER: Your organization has a referral site or (inaudible)?

JENNIFER KUO: I’m sorry. When we say organization?

UNKNOWN SPEAKER: (Inaudible) referral site I was saying (inaudible)?

JENNIFER KUO: Yes.

UNKNOWN SPEAKER: It seemed to be for the final version of this that we got, this is now two different measures. One is guidance and the other is written (inaudible).

JENNIFER KUO: Yes. Very good question. Yes. Because there are a lot of questions about this measure and because there were concerns that we grouped both agreements and guidelines into the same measure, we have decided for starting next year, so fiscal year 2007, this measure will actually be changed and replaced by two measures that will separate out guidelines and agreements. Unfortunately, but the time we had this discussion aside to make the change, it was too late to put into effect for this fiscal year. We didn’t want to actually go into the details of those two new measures since we want to focus on year one for this session but you will find, if you look in your implementation manual and also in the FAQ document. There will be an explanation of the changes from this year to next year. Yes?

UNKNOWN SPEAKER: Will all of these (inaudible) that we have there in definitions, or they revised (inaudible) put on the final document or they (inaudible)?

JENNIFER KUO: No. There are some, I guess additional like definitions and some changes that are—that we made after the implementation, the final implementation manual you all have. So, the FAQ document will help. I would use it as a supplement to your implementation manual. In addition, the information or the documents that you’ll have in your electronic handbook will reflect any of these kind of new terms or new definitions.

UNKNOWN SPEAKER: We had a draft. We got the initial one. We got the final one. We don’t have any of the new definitions slide like we end up today, is it possible to put it more easily to research on both research websites?

JENNIFER KUO: I think absolutely, yeah. I do apologize. I actually made some changes last night to the slides. So, probably--

UNKNOWN SPEAKER: Find them by next Monday and as we start going around and sending this survey at the hospitals, I do not want to duplicate that. Plus all the FAQs or are they possible to send this (inaudible) to a specific web link with (inaudible) with definitions I’m reading. I think that would be all for all (inaudible).

JENNIFER KUO: We can definitely do that. That shouldn’t be a problem. Just a couple of additional notes and then we’ll turn it over to discussion. I wanted to mention that in your implementation manual, you’ll probably see written throughout the manual that you need to submit supporting documentation along with your continuation application. We have actually changed that requirement. Now, you actually don’t have to submit it unless you’re asked to do so by HRSA. So, it should be another like big smile coming from the audience.

DIANA: But you must have it. In case it’s all been asked.

JENNIFER KUO: Yes.

DIANA: We’re just going to let you keep it.

JENNIFER KUO: Exactly. And then the second additional note here is that there have been some questions as to whether or not tribal EMS services should be included when gathering data for these performance measures and because these tribal EMS services are not included in your grant guidance. States are not required to do that. We also wanted to mention that the Indian Health Services is conducting a survey of tribal EMS services and they’ll be gathering performance measure data for those tribal EMS services in their survey.

JENNIFER KUO: Okay. Well, I’m going to turn it over to--oh yes, sorry Mike. 66D.

MIKE: I’m just going to point out that there’s another template for this measure, and then we’re going to talk about some of the questions that we received if I can get this to work.

So again, in your binder and then on to the website is a survey template for this measure and it follows the same sort of sequence as on the others. This one of course, this survey goes to the hospital not the EMS providers. The definitions are here but we’ll try to get those also--all the definitions on a central website. The basic question is, “Does your hospital medical facility have a written protocol and agreement in place for critically ill or injured pediatric patients that specify a decision-making process regarding patient transfer to another facility?” Yes, no or in process.

And then the second question is if yes, then does it meet these four sub bullets that have been specified by Jennifer. So, this is again pretty straightforward. I’ll just point out that the survey is not meant to be targeted just to emergency departments in the hospital. It’s supposed to be hospital-wide. In other words, if there are any other departments that could be transferring a patient to another facility, that needs to be captured as well. So, you think about who you send it to in the hospital. It may not just be to the emergency department, head nurse or so on. You need to think about a more global, sort of perspective in terms of who you send this to. And there are other data sources that could be useful for you on this such as a trauma registry or a state hospital licensure board or even a state hospital association that could be helpful in getting information that would help you to answer this measure. Okay. I’m going to send it over to Diana.

DIANA: Would you (inaudible)

MIKE: Okay. Your document--or no, your PowerPoint will be right here.

DIANA: There we go.

MIKE: Let’s just start you up. Okay.

DIANA: Okay. What we have here right now are specific questions that--you received a list serve message from us probably about two to three weeks ago, and we specifically asked what kinds of challenges were you going to have in meeting the performance measures or questions that you had specifically. And many of you submitted those questions to us and what we’ve done is we’ve brought them back. Obviously, if this triggers more thoughts from more of you, please feel free to let us know that and we’ll move forward with that.

For measure 66A the questions that in reference to medical direction that were specifically asked were, “Is it a problem if online protocols or guidelines are not specifically addressed in rules or statutes?” The reality of it is we know many of you do not have rules and statutes that specifically address this issue right now and that’s why we’ve given you till 2011 to work on this. But the goal is to have offline protocols and our guidelines addressed in your rules and regs specifically for children.

In some instances one can assume that in rural areas online medical direction will be difficult especially where cell phones and hand-held radios don’t work. Do we have suggestions for that? We again realize that there are some areas where this is going to be extremely difficult. The goal is to continue to have online direction available. That doesn’t mean it has to work all of the time. But the reality of it is you have it available and you have a way of tracking and monitoring in the future to identify where there is problematic areas are that provides you an opportunity to make improvements in your state with online direction in the future. But the goal is certainly to have online medical direction available in across states. Any specific questions in reference to those two? Cindy?

CINDY: When you say regulation, can you interpret that that the regulation states the ruling protocols rather than the protocols of actual verbatim?

DIANA: Absolutely. You cannot have verbatim protocols because as evidence comes up for some of those protocols we know they’re going to change.

CINDY: So, the doctor can incorporate it by a reference. In that phrasing the regulations means yes.

DIANA: Yes. Okay, any other questions? Yes.

UNKNOWN SPEAKER: Are these questions in addition to the document we have in (inaudible).

DIANA: No. These questions we ask the grantees to respond to us via list serve.

UNKNOWN SPEAKER: So, we don’t have.

DIANA: You don’t have these, no. These are just things that the grantees have identified as being specific challenges and what would we recommend as a program and as the NRC and NEDARC.

UNKNOWN SPEAKER: (Inaudible)

DIANA: I think we can incorporate this into FAQs. Yeah, because, the mere fact that you all ask the questions and you want the answers to them, we can certainly do that, that’s a great suggestion. Okay, measure 66B essential pediatric equipment. What if each ambulance does not have its own set of pediatric equipment, but instead, has jump kits brought to the scene? What exactly--is that allowable? Yes, it is allowable, but you need to have it monitored so that you can identify--you only have five jump kits and you have a motor vehicle disaster situation and you’ve got 10 kids in need of it, you’ve got a problem there. Ideally, that’s not what we would like to see but we realized that it exists right now in some states and you all are going to have to work on that and you’re going to have to monitor that.

I think the other piece that we all need to keep in mind is if EMS is responsible for having pediatric equipment on board and the child is brought into a facility and that equipment is not available on the rig, who is actually responsible for that child who has adverse effects? Obviously, the agency is responsible; obviously the provider’s responsible, but also it going to come back to the state. The state set up the guidelines and the state is saying that pediatric equipment needs to be available. And if you don’t have sufficient jump kits available and a child goes without the needed equipment, it has ramifications for everybody, obviously. And I think the quality improvement monitoring pieces, a piece that will eventually go down to as we begin to have data sources that allow us to track when children are void of the appropriate resources, but we just don’t have that right now. Other questions in reference to the jump kits. Nope? Okay.

All right, measure 66C, recognition of facilities capable of treating children, does one envision EDAP designation to be similar to trauma center designation. If in fact you identify and define the qualifications to become an EDAP center then, in fact, and you go out and survey, and yeah, there are similarities, but are EDAP and trauma the same? No, they are not. EDAP, I would see that as a first-tiered trauma goes even as step above that, in most instances. So, if you have a pediatric trauma center, chances are, they would meet the EDAP qualifications or they better or you got a problem with designation criteria.

Is it a problem if this designation process is voluntary and not mandated? Obviously, those of us who love children would like to see that it is mandated in every state, but the reality of it is it’s probably never going to happen across this country at least not in my lifetime, I don’t think. But the hope is that, you can get the voluntary designation process, it’s not as threatening to facilities, and when you talk to some of the states and you can talk to Evelyn Alliance from Illinois. She’s worked for 10 years on a voluntary process and voluntary process will, in fact, work in getting EDAP in play. So, Evelyn, wave your hand for the new people so that they know which states got EDAP up and running. So, she’s the person you want to talk to, if you want to talk about the voluntary process. Obviously, the pros and the cons of the voluntary designation process--Evelyn, do you want to tell them some of the cons are for the voluntary?

EVELYN: Well, obviously,

DIANA: Are there specific pros that you found over the last 10 years with it?

EVELYN: (Inaudible)

DIANA: And if you got questions as to whether voluntary, you can actually get hospitals to participate. Evelyn was very wise when she went out. She chose regions to begin implementation where she knew she could find at least one hospital that would volunteer. So, if you got six hospitals in that same area, if one hospital volunteers and gets it, don’t you think the other five are going to go after it? You better believe it. So, but she started out small with it, so that’s a piece to keep in mind. Other questions in reference to designation for treating kids? Nope? Okay.

66D. Percent of written inter-facility agreements and protocols in place. I’ve heard this from numerous grantees since EMS, where EMSC seems to most often to reside, has no jurisdiction over hospitals in my state. How do I best influence hospitals to have such in place? Anybody want to take a wild guess how to make that happen? Who are some of your partners on your advisory committee? You know? Who are the folks that are going to be able to influence this kind of change? I think our clients assume that hospitals, if you go to a hospital, first of all, they assume they have everything. And then they suddenly realized that they don’t have them, and if you don’t have it, that you’re going to move me to the right place.

The folks that can help you make that happen, do you have a state office that is in charge of hospital licensure? If you have a state office, they need to become your partners in this particular performance measure because what they can do is share with you what their requirements are for hospitals to become licensed. If this is not one of their requirements then I would be highly surprised, then that’s an issue.

The other thing is look at hospitals who are credited by joint commission. That’s another place where this is noted.

What do you do with the patients if you have a child who has burn injuries? What do you with him if you don’t have a burn program? They should have agreements in place and protocols in place. Another place that you can look for as far as partnering is your state hospital association. They certainly want to make sure that patients get the right care and get to the right facilities. But they may not realize that it’s critical that hospitals have inter-facility agreements and inter-facility protocols in place. Any other comments or questions in reference to this one?

UNKNOWN SPEAKER: (Inaudible)

DIANA: Absolutely. And thank you. I didn’t mean to overlook them, but they are absolutely critical and they frequently do not realize either that some places do not make this a requirement, that there be inter-facility agreements and guidelines in place. Okay. Those were the questions that you all submitted about two weeks ago. Jennifer will work with us to make sure they get incorporated into the FAQs. Are there other questions from you all as you’ve listened to us regarding these specific measures? We’re not getting into the other ones right now. These are the ones we are focusing in on this session because if there are, this is your opportunity to ask.

Mike or Jennifer, any further questions from your perspective? Things we need to address? Okay. Dan? The real leader is coming to the front of the room.

DAN: Dan’s going to answer all the questions right here now.

DIANA: That’s great.

DAN: You can just put it down.

DIANA: You okay?

DAN: I just want to say now I appreciate Gerald’s work on the center. There has been a bit daunting but in discussions when we started three years ago with grantees and with professional organizations, we got their input like the EMS positions, ACEP and the state EMS directors and the state EMS officials. We wanted to tie the partnership grants to some things that we could get some data on and to measure, so that we would have the data and say where do we need to go to improve EMS care, improve care for children within the EMS system in this country. And that’s so we’ve really tried now to tie the state partnerships to getting that data and tracking where states are in that process, so we can better know and better inform our colleagues in HHS on the field. Where does the funding need to be directed to improve these efforts, how much--I think one of the next things to figure out is cost analysis.

So, if you know how much funding will it take to make some improvements in these areas that we’ve whittled down to about four within this particular four sub-measures and this one overall measure, so without the data that you all will be collecting, it’s really hard to make the case of how much is needed to improve this within the state so that’s what this is ultimately all about. I mean without the data, it’s hard to know where, not only the EMSC program, but maybe other agencies.

Federal agencies also need to make investments, so I hope that helps to put this in some context. So really, the performance measures are really performance for the EMSC program as a whole, but you’re helping to collect the state, but then you know what is the state of these performance measures within your particular state to give us a better idea of where we need to maybe educate others on where investments need to be made. And we say, “Hey, we have the data that this is where investments need to be made in order to improve the care of children within the EMS system across this country. I hope that helps to see where we’re going with this and why we want to have this information or why grantees and professional organizations that we spoke with felt that these were the areas that would be appropriate to focus on, so.

DIANA: With that said, this particular session is done. Feel free to grab the NEDARC folks, to find the NRC folks for questions, if you should have further. We are free for lunch.