The National EMS Quality Alliance (NEMSQA) has had the privilege of working with the American College of Surgeons (ACS) to identify and specify performance measures to align with and support implementation of the updated Field Triage Guideline (FTG). This work was conducted by a Technical Expert Panel (TEP) consisting of the NEMSQA Measure Development Committee, chaired by Dr. Jeff Jarvis, as well as subject matter experts in trauma care and EMS, including representatives from the ACS Guideline TEP and NEMSIS. As the research and evidence phase was completed by the ACS Guideline TEP, NEMSQA conducted the identification and specification of measures.
Summary Table of the Measures
Implementation Technical Documentation
The NEMSQA Field Triage Guideline Measure Development TEP began the process of measure identification and prioritization by defining what needed to be accomplished both in terms of the Field Triage Guideline and the efforts of the TEP itself.
- Goal of the Field Triage Guideline: The big picture goal of the guideline very simply is: “Getting the Right patient to the Right place at the Right time” and “When you have a choice, did you make the right choice?”
- Goal of the Measure Development Technical Expert Panel: Translating the Field Triage Guideline into measures.
Over the course of discussion, several themes related to measure development emerged.
- System of Care Centric: Measures should be focused on the system of care and the integration of the EMS component into the system in order for the trauma center to be ready to receive the patients.
- Evidence-Based: The measures must recognize and align with existing evidence.
- Working in the Present and Planning for the Future: In planning for measure development, there is a need to create the best measures from what is available and plan for future measures by identifying data elements that should be available to support the best measures. There will be limitations in what can be measured due to current constructs (i.e. specific data relating to the receiving facility), however, NEMSQA can make recommendations to improve next stage measures.
- Technical Considerations: The TEP will need to plan for NEMSIS v3.4 and v3.5 in developing measures. Changes on v3.5 were closed prior to the initiation of the Field Triage Guideline update. There is already a change logged for the revisions to the Field Triage Guidelines criteria and several options for how to implement changes.
The TEP identified four primary questions that NEMSQA sought to answer through the developed measures:
- Did EMS take the right patient to the right place?
- If the patient really needed it (red category), did EMS get the patient to a Level I or Level II trauma center?
- Did the hospital receive a notification prior to patient arrival?
- Is the system set up for successful transport for trauma patients?
Ultimately three measures were identified to move to specification phase. Two of these measures are EMS performance measures based upon the NEMSIS data standard and can be implemented at the EMS agency level to support improved care of patients treated by EMS and improved system of care performance. The last measure has two parts. The first part is similar to the other measures – it is based on the NEMSIS data standard and can be implemented at the EMS agency or state level. The second part of the measure provides EMS agencies and states guidance on how to create descriptive-type reports using GPS coordinates and the Haversine formula to calculate distance between EMS response scene and trauma centers.
Trauma-04: Trauma Patients Transported to the Trauma Center
Trauma-04 was an existing NEMSQA measure originally designed using CDC Guidelines for Field Triage of Injured Patients, 2011. This measure identifies the proportion of patients meeting trauma triage criteria who are transported to a trauma center. During discussion, it was noted that trauma centers are not always available or accessible, and it was therefore decided to keep the existing NEMSQA structure of transport to any trauma center rather transported to a specific level trauma center. The specifications for the NEMSQA Measure were respecified to align with the new triage criteria based upon the NEMSIS data standard. This measure can be used at the EMS agency level to ensure that patients meeting triage criteria are taken to the appropriate facility.
F.A.I.R. Trauma-14 Trauma Call Rate
Trauma-14 was a measure developed by NEMSQA for the Florida Department of Health as a part of the FAIR project. Like Trauma-04, this measure was respecified to align with the new triage criteria based upon the NEMSIS data standard. This measure connects the system of care and can be used at the EMS agency level to ensure that the receiving facility is notified in advance of patient arrival that a patient meeting triage criteria is enroute.
ACS-01a Trauma Patients Transported to Highest Level of Trauma Center
ACS-01a is a new measure and is part 1 of a 2-part measure. Overall, ACS-01 is a structure measure designed to measure access to trauma center care. Part A measures the proportion of patients meeting red criteria (high risk for severe injury) that are transported to a Level I or Level II trauma center. Understanding that availability of a Level I or Level II trauma center may prevent EMS from transporting these patients to a Level I or II trauma center, part B of the measure provides insight on distance to the appropriate facility. This measure is based upon the NEMSIS data standard and can be implemented at the EMS agency level.
ACS-01b Distance to Nearest Trauma Center
Given concerns about limited access to trauma centers in certain communities, the TEP thought it would be helpful for communities to evaluate the system of care and access to trauma centers. Part B of this measure provides a histogram of distance from location of injury to nearest Level I or Level II trauma center for EMS transports originating from a 911 request for patients who met ACS red field triage criteria who were not transported to a Level I or Level II trauma center. This measure can be implemented at a state or EMS system level to understand the availability of trauma resources in an area.
Each measure is broken down into parts, or elements, required for calculation. For the purposes of quality measurement, the numerator is defined as the processes or outcomes expected for each encounter defined in the denominator. The measure numerator essentially defines the action that satisfies the conditions of the measure. The denominator refers to the encounters being evaluated for performance. The encounters included in the denominator share a common set of specified characteristics. In some measures, denominator exclusions are used, which specify encounters or patients that should be removed from the denominator before determining if numerator criteria are met. Denominator exclusions are used when the clinical processes or outcomes expected in the numerator do not apply to the subset of patients/encounters. The summary table of measures provides a general overview of the measures and includes measure ID, measure title, measure description, descriptions of initial patient population, denominator, numerator, exclusions, and exceptions, domain, and scoring information. The summary table provides quick, at-a-glance information for each measure.
