Measuring quality in the prehospital care of chest pain patients.
BACKGROUND
Rates of compliance with evidence-based treatment guidelines are commonly used to evaluate hospital quality of care. This method of quality assessment has not been widely extended to the prehospital environment. Previous studies have shown that the prehospital care of chest pain patients is often incomplete.


OBJECTIVE
To determine how well paramedics in an urban public hospital system deliver high-quality, comprehensive care for patients with nontraumatic chest pain.


METHODS
Patients with a primary complaint of nontraumatic chest pain for two quarters of 2006 were identified, records were randomly sampled, and a retrospective audit was performed. Seven individual quality indexes were identified by the medical director of the Denver Health Paramedic Division. A composite metric (bundle score) was also created to assess the completeness of care. This bundle score was considered unmet if any single variable was not present.


RESULTS
Five hundred eighty-six patient care reports were evaluated. Overall, 92% of the patients received oxygen, 62% received aspirin, 97% had lung sounds assessed, 99% had vital signs assessed, 84% had an intravenous (IV) line established, 92% had an electrocardiogram (ECG) obtained, and 73% were assessed for cardiac risk factors. The composite score was met for only 39% of patients. Significant differences across age groups were found in assessing cardiac risk factors, obtaining ECGs, and administering aspirin, and in the composite measure. In all of these metrics, the prehospital care rendered to the younger patients was associated with a lower rate of provider compliance than that delivered to the older patients.


CONCLUSIONS
There was generally good compliance with each individual metric, yet compliance with the comprehensive metric was poor. This manner of quality assessment, utilizing a bundle score, can be successfully applied to the prehospital arena, although future work is needed to establish criteria for measuring optimal quality of care.
Colwell
Christopher
C
Denver Health Paramedic Division, Denver Health and Hospitals, Denver, Colorado 80204, USA. christopher.colwell@dhha.org
Mehler
Philip
P
Harper
Justin
J
Cassell
Lisa
L
Vazquez
John
J
Sabel
Allison
A
D000328:Adult; D022561:Advanced Cardiac Life Support; D000368:Aged; D000369:Aged, 80 and over; D002637:Chest Pain / Q000175:diagnosis* / Q000188:drug therapy; D003120:Colorado; D004632:Emergency Medical Services / Q000592:standards / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D019984:Quality Indicators, Health Care; D011787:Quality of Health Care / Q000592:standards / Q000706:statistics & numerical data*; D012189:Retrospective Studies