Annual EMSC Grantee Meeting

State Partnership Representatives

Jumpstarting Your Performance Measure Activities

Part II: Measures 67 and 68

June 20 – 22, 2006

JENNIFER: Discussed today, when you're reporting your progress on this measure in one of the data collection forums, if you don't meet this measure, there will be a scale provided where you can say, okay, well I only have one of the six priorities mandated or two of the six. So you'll have an opportunity to explain to the program where you are and that you are making some type of progress even though you haven't mandated all six.

UNKNOWN SPEAKER: Back to the requirements of (inaudible) priorities. Am I to assume that it doesn't necessarily have to be an EMS rule or statute? For example, in Florida, the administration, they govern the hospitals. So if they have a rule or statute that requires them to have these specific things, we need the measures?

DIANA: Absolutely.

JENNIFER: I think in the measures as EMS or hospital, healthcare, statutes, regulations.

UNKNOWN SPEAKER: It might be places for other people to look. And trauma has different statutes as well in our states.

DIANA: All right. We have covered all of the performance measures in the last two days, and hopefully we've provided some clarification at this time and point. But I am sure that many of you went home last evening and thought about what had been shared yesterday, and I guess the question is, are there ‑‑ even though we didn't discuss a specific measure today, did you have things pop into your little brains and wake you up in the middle of the night that we need to be aware of as far as challenges so that we can try and help see? Because if you've got this challenge somebody may as well.

Yes, Bob.

UNKNOWN SPEAKER: I still have kind of heartburn with on‑line direction with no definition with the states being able to determine that. So when EMSC, at the national group tries to collect that data, it's all over the board. Nevada could say that we say on‑line direction is when the janitor (inaudible) and I think when you set the performance measure, when you say on line direction it should be a definition that says on‑line direction means that a person, a physician or a nurse who had specific pediatric training is the one that's going to be able to provide that. Then in Nevada I can say no, we don't need that. But we can try to. But if there's no goal to go to, then, I mean I think the Feds should have been the one to set the definition for what on‑line direction is. We have regulations that say every hospital has to be able to provide on‑line direction have radio communication with every ambulance. And the ambulances have to to be able to use that.

But for us to sit down in my advisory committee or whatever and say okay we're going to determine that anybody that's in an ER that answers a radio meets the qualifications for on‑line medical direction for pediatrics, I think you guys need to have a definition. Otherwise you're collecting apples and oranges and everything else like we talked about this morning. It's all over the board about what on‑line direction is.

So I would just hope that you could come up with a definitive definition so that that's something for us to go for. Maybe we don't need it right now. And I know in my rural offices we can't meet that requirement. But boy that gives me something to say we need to do something about training our rural physicians, ER physicians in pediatric‑specific emergency care. But otherwise I don't think you're going to accomplish anything by saying whether you had it or you don't if you don't give us a definition.

UNKNOWN SPEAKER: What's a reasonable definition to have that would not penalize a bunch of states that ‑‑

UNKNOWN SPEAKER: I don't think it's a penalizing. I think it's you meet it or you don't.

UNKNOWN SPEAKER: I guess the challenge for us at the national level is knowing that the states are so different in the resources that they have for medical direction. We felt that the state medical director or your medical director group needed to be involved in identifying what was appropriate medical direction, on‑line medical direction for pediatric patients. It doesn't have to be at every hospital.

It may be that you'll have a central toll free number at a call center at a large regional hospital who will answer those special pediatric calls.

We're not telling you have to do it in any one format. It doesn't have to be at every hospital. But there needs to be access to on‑line medical direction wherever you go. For example, I think I was speaking with the folks in Alaska, and they're thinking that all those calls are going to come into Anchorage to one of the two key ICUs.

So you need to define where your resources are for that pediatric special on‑line medical direction that this child is severely ill or injured and needs care beyond what is in my written protocols. And what is the access point for that. And we're trying to let your state be creative in identifying the resources that's going to provide high quality on‑line medical direction.

So I would go back to your medical directors and have them think through, you know, what is going to satisfy them in terms of making sure that children get high quality on‑line medical, get the care from that perspective that's beyond what you have for your written protocols.

UNKNOWN SPEAKER: Just now you gave a little more. You said hi quality on‑line. Now, that at least then gives me something to shoot for. Not just on‑line direction. On‑line direction can be anybody that answers that radio. I'm saying if you'll tell me what you mean by on‑line direction, then we can define it, just like you did with the continuing education. We're not going to tell you for the paramedic, what program they just have to have something. You guys determine that. But I think you at least have to tell us what, at what level you want that direction or what do you expect it to be, maybe not what you want it to be, what you expect it to be.

So high quality is more than you had before.

UNKNOWN SPEAKER: Okay, but I think it's something, when the child's condition exceeds what they have directions for in their written protocols, who do they go to to be able to manage that child during transport. And you decide in the state who can provide those resources for you and work with your medical directors and determine it. It doesn't have to be at every hospital. You decide. Maybe there's a toll‑free number that they call. It doesn't have to be toll free but there's one number, you know, that they can call for each region, or maybe one place in the state.

DIANA: But I think what Bob is saying we need to expand on the on‑line direction and provide some guidance that the state needs to look at what their resources are, where their pediatric resources specifically. Because I agree, many services get their on‑line direction from the physician who is moon lighting at the community hospital who's got a degree in dermatology and, yes, we need doctors to take care of skin disorders, but they may not have pediatric resuscitation.

UNKNOWN SPEAKER: Right. Okay. We can go back and clarify that better for you. But our goal is to improve the quality of care that children receive.

UNKNOWN SPEAKER: If you leave it up you'll be all over the board what you think, what I determine is on‑line medical direction, is somebody that answers that radio, and you would hope that I would say that it needs to be somebody that was trained. And I would like to have kind of like Minnesota, something that says that those physicians, in order to qualify for that on‑line direction, need to have at a minimum one of these programs.

UNKNOWN SPEAKER: And I don't think we can set that guideline for you, but we can probably clarify and then you work with your medical directors and they define what the qualifications are.

DIANA: Perhaps we can even come up with some recommendations that be considered, and that would give you more guidance and ammunition to go with your committee.

Okay, any other suggestions, clarifications? Yes?

UNKNOWN SPEAKER: You had mentioned that it might be possible to come out and visit ‑‑ and I'll say this: Our EMS committee has (inaudible) do whatever it takes. Volunteer. They do what they do. Meet quarterly. They're great. They (inaudible) staff (inaudible) very excited about what they do. But just now in this past year have they actually begun to talk to each other within any of the subcommittees.

So in August they'll be having their next quarterly meeting and there's finally scheduled pediatric committee and EMS directors where measures 66‑A and 66‑B have the, are the biggest contentious pieces of this particular area.

Now, my state, my area just recently got this grant. Used to reside in another portion. So they have a relationship and ideas about how they've been doing this in the past and moving to the forefront. But we do know this next meeting is going to be slightly contentious because there are very strong ideas in this (inaudible) and the pediatric folks. And they're exceedingly vocal.

We know it will probably take us a year to get, you know, to get to some sort of compromise. But my question is: If we see that, yes, that ‑‑ because they've already been discussing this. My state has had this grant for at least two rounds of three years. And they've been working on the same performance measures. Similar. They're working on on‑line, off‑line. Working on pediatric continuing education, that portion of it.

So they've been working on it for in excess of six years to try to get these kinds of things going in the rules, and they're just beginning to now get some of these things passed. My question is: If we see this is still coming to an impasse, is it possible that you could come in as facilitators to help as a neutral voice to discuss this piece between them to help us find neutral ground.

UNKNOWN SPEAKER: Yes.

UNKNOWN SPEAKER: Thank you.

(Laughter)

UNKNOWN SPEAKER: You need to send us a request and then we need to talk with (inaudible) to get approval to travel. But, yes, it can be worked out. For any of you, if there's particular help, we will do what we can by phone, but if it's something that really needs someone to be on site, please feel free to ask and we will do our best to facilitate having someone come and participate in a meeting or help you to problem solve.

UNKNOWN SPEAKER: The changes that you just outlined as far as the requirements for that last measure, where things are not mandated. Is that what's reflected in that final document we got, or is this something new?

JENNIFER: It's in the FAQ document that was on the list serve. So the implementation manual, the final ‑‑ I know we keep using the word final but it's never final. It's not in there, no.

DIANA: The thing you need to be aware, even the FAQs will be updated. That was a draft, and we've already got all kinds of things that we know we need to go back to address, because of your wonderful comments and discussion. So they will be updated, and we'll try and make sure they come out in a different color font or version number, something. So you know where to look for those. Okay?

Cindy? I beg your pardon?

UNKNOWN SPEAKER: Where was it posted?

UNKNOWN SPEAKER: Where will they be posted?

DIANA: They get sent out on the EMS list serve that you get on a regular basis. They'll be sent to you directly but we can probably post them on websites as well.

JENNIFER: I have a central website, so I think we can definitely do that.

DIANA: Cindy.

UNKNOWN SPEAKER: The final document, does that have to go through government (inaudible) approval. Because I understand you're going to put them in frequently asked questions and slides and definitions; but some of our committee members who are focused on their one issue, to give them a printout of what 66A, B, whatever it is or 66C and tell them to look at frequently asked question 24, 26, 27 and 29, some of our surgeons don't pay enough attention to do that, to be quite honest. But if you have it go through government printing, government approval to change those sheets, I understand that it will take a long time.

But at some point a final number 3 would be helpful so that scoring I gave them, all those scoring sheets, and we spent two hours in March going through every single one, every advisory committee had ten minutes to self‑rank what they thought our state was then there was this long discussion. They wanted on that one sheet of paper ultimately. And I don't know what the time line for federal approval is for that.

UNKNOWN SPEAKER: Changing a PDF is easy but not if you have to have a federal document.

JENNIFER: I know we updated the detail sheets, Jane. I know Dan uses that.

UNKNOWN SPEAKER: The sheets are going to be on the new website as soon as we get it turned on. But I can't give you a clear date when that's going to happen. But I mean that will ‑‑ the new changes we've already gotten and converted to HTML code will be on the website.

DIANA: Any other comments, challenges? Going one, going two. Okay. My understanding is that we were scheduled to be in here until 3:00. So you've got, and then we were going to break. So we can sit here and discuss anything else you'd like to discuss or you can all get up and go for a walk.