Risk-adjusted CPR Rates as a Measure of Quality During Interfacility Transports

Abstract

Introduction Over the past decade, the health care industry has witnessed an unparalleled reporting of hospital-specific comparative outcomes. Clearly, there has been a growing consensus among a broad array of agencies and institutions around the importance of reporting quality measures, including those that measure clinical outcomes. Previous research suggests that there is substantial variability in care between hospitals, particularly in trauma centres. In 2006, the American College of Surgeons (ACS) Committee on Trauma launched the Trauma Quality Improvement Program (TQIP) to study the variability in outcomes between trauma centers to improve the quality of trauma care in North America. The primary goal of TQIP is to improve the quality of trauma care through outcomes-based, risk-adjusted benchmarking of trauma centers and feedback reports. However, differences in patient selection (selection bias), case mix, data quality, geography, and other factors inherent to different injured populations likely contribute in part to observed differences in outcome. Risk-adjustment is a methodology used to ensure that “like” patients are being compared, so that differences in outcome can be attributed solely to differences in the processes and quality of care provided. Transport services are beginning to use performance metrics to analyze for variations between ambulance and transport services in order to improve quality of care during transport. The “Ground Air Medical qUality Transport Quality Improvement” (GAMUT) Collaborative collects transport data in a large database to use as a free resource for transport teams to track, report, and analyze their performance on transport-specific quality metrics by comparing it to other program's. Because of the nature of transport, most of the metrics are process metrics or intermediate outcomes. Arguably, the only transport-related definitive outcome that GAMUT reports is rate of cardiac arrest during transport (Rate of CPR performed during transport). However, this rate is reported as an unadjusted rate: there is no risk-adjustment. We propose a simple methodology to allow for risk-adjustment of CPR rate during transport. Methods Ornge is the sole provider of Air Ambulance and Critical Care Transport Services to the province of Ontario, Canada. The province has a land mass of over 1 million square kilometers, and has a population of almost 14 million people. Ornge operates a fleet of Pilatus Next Generation PC-12 airplanes, Leonardo AW-139 helicopters, and Crestline Commander land ambulances, staffed with Critical Care and Advanced Care Paramedics. For low acuity patients requiring a lower level of care, Ornge uses a Standing Agreement to Chart Air Ambulance services from contract carriers, staffed by primary care paramedics. For interfacility transfer patients, we propose to compare CPR rates year over year for Ornge (2013-2017). SA transports will not be included, as they represent a very low-risk group. Risk adjustment will be done by adjusting for mechanical ventilation (yes/no), use of infusion(s) of vasopressors (yes/no), mechanical ventilation and pressors (yes/no), or none. Rates will be standardized to the distribution of cases during the reference year of 2013-14, and reported per thousand hours. Results Discussion Comparing variability in outcomes is helpful in improving quality of care. High performing centres can share their best practices to improve quality of care throughout the system. Risk adjustment is a methodology used to ensure that “apples” are being compared to “apples”, and that case selection is not affecting the analysis. Transport agencies are now reporting CPR rates during transports as an outcome measure, as part of their quality improvement programs. These rates are unadjusted, and are difficult to compare across groups. Air ambulances transport many different types of patients, such that standard risk adjustment methods may not be directly applicable. Risk adjustment for trauma patients is completely different than for post STEMI patients. As well, transport agencies only care for patients during a very short period of time. We presented a methodology of risk-adjustment for CPR rates during interfacility transports that have correlational validity with our changes in our quality processes over time.