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Continuing Quality Improvement

LTS REGIONAL CQI PROGRAM

 

Please note that the LTS Regional CQI Committee meets
concurrently with the LTS EMS Advisory Board.

 

2021 Meeting Dates:



January 21, 2021 (Lycoming County)

March 18, 2021 (Zoom)

June 17, 2021 (Zoom)

October 21, 2021 (Zoom)

 

 

LTS REGIONAL EMS COUNCIL

 CONTINUING QUALITY IMPROVEMENT PROGRAM

 GOAL:

To review and collectively evaluate structure, process and outcome of clinical and operational protocols or aspect of care in Lycoming, Tioga and Sullivan Counties as promulgated by Act 37 and the Pennsylvania Department of Health Division of EMS Systems as related to Quality Assurance.

STRUCTURE:

Each EMS service will secure representation on a county CQI committee for Lycoming, Tioga, and Sullivan Counties.  The Regional CQI Committee will be comprised collectively of the county CQI committees in cooperation with Regional EMS Council staff.

Each county CQI committee and the regional CQI committee will be guided by a chairman to address pertinent issues within the EMS community.

Each county committee and the Regional CQI Committee will meet on a quarterly basis.

QUARTERS shall be defined as:

BEGINNING

ENDING

FORM/REPORTS DUE

JANUARY 1

MARCH 31

APRIL 15

APRIL 1

JUNE 30

JULY 15

JULY 1

SEPTEMBER 30

OCTOBER 15

OCTOBER 1

DECEMBER 31

JANUARY 15

Each EMS service CQI representative will be responsible to submit a written report outlining results of their service evaluation.  Reports will be submitted on preprinted forms distributed by the regional council and will include the following data:

  •   NAME OF SERVICE
  •   GOALS AND OBJECTIVES OF THE PROTOCOLS
  •   AFFILIATE NUMBER
  •   SERVICE FINDINGS
  •   NAME OF BLS PROTOCOL YOU ARE EVALUATING
  •   PLAN OF CORRECTIVE ACTION (IF NECESSARY)
  •   QUARTER START AND END DATES
  •   SERVICE EVALUATION OF THE ACTION TAKEN
  •   NUMBER OF PATIENT CARE REPORTS REVIEWED
  •   OUTCOME DATA
  •   NUMBER OF PATIENT CARE REPORTS IN COMPLIANCE WITH THE PROTOCOLS
  •  REPORT # OF NON-RESPONSES ("SCRATCHES") & JUSTIFICATION

Upon receipt of quarterly service reports, the LTS Regional EMS Council will compile data received and report back to CQI committees with data findings.  Reports will not identify individual service names and data.


Examples of Important Tripsheet Review Criteria

1.     Prompt and safe response to correct address when dispatched.

2.     Equipment working properly and unit completely restocked.

3.     Proper initial patient assessment performed.

4.     Quarterly, the Regional CQI committee will advise EMS Agencies of their recommendations for topics to be evaluated.  In addition, the Regional Field Coordinator will provide the evaluation criteria at the beginning of each quarter.  If no calls during the quarter fall under the recommended topics, Agencies may elect to choose an alternate review criteria based on the PA EMS Protocols:

 BLS Protocols:  Department of Health 2019 Protocols - BLS (also attached below)

 ALS Protocols:  Department of Health 2020 Protocols - ALS (also attached below)

5.     Communications with medical commanders available and used when indicated.

6.     Assessment and treatment is performed in expedient manner consistent with urgency of situation.

7.     Medical commanders follow approved treatment protocols or regional aspects of care.

8.     Receiving physician is given adequate and timely information on pre-hospital assessment/treatment.

9.     Management of high-risk situations (DOA, CPR, and multiple traumas) is routinely reviewed for efficiency of care.

10.    Patients are assessed en route and changed in patient’s condition are communicated and/or documented appropriately.

11.    Complete and accurate documentation and patient data is recorded on Tripsheet for each call.

 

Click HERE to download the CQI Quarterly Reporting Form.

 

Currently, the 2021 Aspects of Care recommended for evaluation are:

ALS Cardiac Arrest

BLS Cardiac Arrest

Patient Refusals

Patient Assisted Medications

Spinal Immobilization


Other Aspects of Care to be Considered:

AED Usage

Patient Assisted Medications

Patient Refusals

Spinal Immobilization

Seizures

Altered Level of Consciousness

Breathing Difficulty

Non-Traumatic Chest Pain

 

ALS ONLY:  Etomidate Usage (100% Chart Review)

 

*For services that are recognized Epi-Pen Services in the Commonwealth, CQI is required for Epi Administration as well.

 

RETURN TO LTS EMS COUNCIL HOMEPAGE

 

For more information contact:
 
Name:  William Miller
Title:  Regional EMS Field Coordinator
Office:  LTS EMS COUNCIL
Email:  wmiller@lyco.org
Voice:  570-433-4461
Fax:  570-433-4435

LastUpdated

Last Updated: 4/26/2021 12:04 PM
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