Patient Care Reports and NEMSIS

By Karen Owens

How many times have you questioned the need to fill in all of the “required” fields on every prehospital care report (PCR)? Indeed, much of the provider’s frustration after an emergency medical services (EMS) run likely stems from completing the PCR. Did you get the patient data you needed? Did your narrative provide enough information to justify the treatments provided? If your department bills for service, did you collect a signature and all the necessary insurance information? Although it may seem that much of the information collected on every PCR is pointless and overly time consuming, the data collected from PCRs are actually used in a variety of ways that reach well beyond continuation of patient care.

Background

The 1973 Emergency Medical Services Systems Act recognizes 15 components essential to an EMS system.¹ Included in these 15 components were coordinated patient record keeping, review, and evaluation; recognizing the importance of data collection; and a review to improve EMS. Although the need was recognized, there was no standardized data set developed as part of the Act.

Aided by a 1991 American Heart Association recommendation for uniform data reporting for out-of-hospital cardiac arrests, the National Highway Traffic Safety Administration (NHTSA) in 1994 defined 81 data elements important in the EMS information system. (1) These elements, 49 of which were considered essential, provided EMS agencies with the ability to benchmark their activities as well as provided a standard definition for each element.

The “EMS Agenda for the Future,” written in 1996, further developed the required data elements and further specified the collection of data. Among the five recommendations was one aimed at the development and adoption of “a uniform set of data elements and definitions to facilitate multisystem evaluations and collaborative research” and the ability to “collaborate with other health care providers and community resources to develop integrated information systems.” (1)

As states implemented their data collection systems, there was a recognized deficiency in the uniformity of data collection and use, leading to the development of the National EMS Information System [NEMSIS (www.nasemso.org)], the NEMSIS data set was assembled in 2001 using the NHTSA prehospital data set. Now in its third version (NEMSIS V3), the data set has evolved to better integrate with PCR software vendors and products as well as other public health, medical, and epidemiological data sets maintained by local, state, and federal partners.

Table 1 shows an overview of the NEMSIS components. Keep in mind that although the NEMSIS standard has a minimum data set, states and local agencies can collect additional information, but they must – at a minimum – collect the data elements defined in the NEMSIS.

Data by the Numbers

In October 2003, NASEMSO developed a Memorandum of Understanding recognizing the need for EMS data collection at the national level and asking each state to support and promote EMS data collection initiatives. Over time, every state signed an agreement to participate and submit data to NEMSIS. With the national data standard in place since 2002, you would think that compliance would be at almost 100 percent. However, as of 2013, only 23 states submitted at least 95 percent of their EMS data.² Of the 27 remaining states, only 16 are submitting some data while the other 11 are submitting none.³

Unfortunately, incomplete data limit impact that could facilitate improvements to the national EMS system. Without every state participating, the ability to collect and analyze nationwide statistics on issues such as opioid overdose, cardiac arrest, and traumatic injuries is limited. Although efforts to increase state participation are helping, the timeliness of data submission has become an issue. With some states submitting daily, some monthly, and some quarterly (if at all), it becomes difficult at best to ensure that the most up-to-date data are used in research and reviews.

EMS Data in the Field

The importance of data collection can easily be lost in the field. When you have completed your call and transferred care of your patient to the hospital staff, the last thing you want to spend additional time on is completing the PCR. From the beginning of emergency medical technician (EMT) class, the importance of the PCR is emphasized. It ensures continuity of care, demonstrates compliance with standards of care, and justifies actions taken and the care provided. Thus, NEMSIS has increased the importance of accurate PCR data collection.

So how do you use data? The first use of the NEMSIS standard data elements will seem obvious, but it is one that you normally would not consider: patient care decisions. EMT courses encourage EMS providers take – at a minimum – two sets of vitals so they can be compared (i.e., trending). When appropriately documented, these vital signs can provide guidance for future patient treatment decisions.

Consider the scenario of a motor vehicle accident (MVA) with a multisystem trauma patient. On arrival and scene size-up, you begin patient assessment and gather vital signs. After an extended extrication, you place the patient in the ambulance and begin gathering a second set of vitals. If you did not appropriately document the original vital signs for the PCR, how would you know if the patient has improved, gotten worse, or remained stable? Will you remember his blood pressure? His pulse? What about any medications or allergies that you may have learned about?

Additionally, you can pass this patient assessment documentation to the hospital, allowing health care providers at the receiving facility to know what was found in the field and what patient care was provided. Appropriate documentation decreases the potential for medication and other treatment errors. And, because the data elements have common definitions, there is little confusion about what is meant in the documentation. Just like common terminology is important to incident command system functionality, common definitions are important in EMS information systems.

How Data Are Collected

When it comes to data collection, keep in mind that each department determines the data elements it will collect. Often, the data collected at the local level are more extensive than data collected from the prehospital PCRs by the state. From those data, the information collected at the national level for the EMS Information System is even narrower in scope. Each state and locality can choose the elements from the NEMSIS data set. Data input can begin right at the 911 call center if an interface between their computer-aided dispatch (CAD) system and the EMS charting system is available and operating. However, the EMS crew will collect a majority of data during the course of the call. From initial patient contact to finishing the narrative and marking back in service, NEMSIS data points are populated. Department data are then uploaded to the state database. This may be done on a daily, weekly, monthly, quarterly, or even yearly basis and is highly dependent on the PCR software vendor processes and procedures. It is important for EMS chiefs to have a working knowledge of when and how often these transfers are made. Information can be sent from the state database back to agencies and to a state trauma registry and then uploaded to the national database. These data provide a national source of information that you can use in research to improve response and treatment across the country.

Using NEMSIS Data

Most providers are unaware of the benefits of the data uploaded into the NEMSIS database as well as the process for accessing these data. There are two methods for accessing data from the national database. One is to use any number of Web-based tools that allow an individual to run queries to return specific data.⁴ The second is to request the annual research data set, which you can do using instructions found at www.nemsis.org. (4) Data are then used for research aimed at improving emergency medical care. Recent studies that have used NEMSIS data include the following:

• Effectiveness of aspirin administration for acute coronary syndrome patients (2013).
• Disparity of naloxone administration (2014).
• Serious injuries in traffic crashes (2014).
• Fall prevention research (2016).
• Bystander intervention prior to EMS arrival (2016).
• Prehospital response to hazardous materials events (2016).
• Response times for suspected strokes (2016).

Quality Improvement

When it comes to emergency medical care, you can use quality improvement to enhance all aspects of the system. The dispatch and incident data element sets provide statistics to help improve response times; the information collected in the patient data element set such as treatment/medications, procedures, and disposition assist in the modification or improvement of treatment protocols; and the cardiac arrest data can help agencies improve their processes of care for cardiac arrest patients. Although your department can review its own calls, the ability to review nationwide data vastly increases opportunities to benchmark your department against the rest of the world.

Consider this field application: Your operational medical director wants to look at the effectiveness of the supraglottic airway. If your department estimates that 100 calls per year will require use of a supraglottic airway, then the medical director would have only 100 cases to use for his research. However, by using NEMSIS data, the operational medical director could access thousands of calls with similar parameters to help him review the benefits or pitfalls of the airway. Additionally, he can compare your department statistics with statistics from departments similar in composition to determine if inefficiencies occur in all departments or if they are specific to yours.

Community Health Improvement

Does your department serve the community only during emergency events, or does it work with your community on preparedness and prevention activities? You can use statistics gathered from the data collected through NEMSIS to develop prevention programs that assist the community in risk-reduction activities. For example, the state Department of Transportation will use call location data elements to help geocode MVAs and develop a list of high-risk areas for travel. This then allows the department to develop public safety announcements and review road structures and signage to attempt to decrease the MVAs in the hazardous areas.

Consider the increase in opioid overdoses. The ability to collect standard data elements nationwide helped health and human services agencies recognize this increase and develop response plans nationwide to help combat the opioid epidemic. Without NEMSIS data, this pattern recognition would likely have taken considerably longer.

Data collection and number crunching are often regarded as issues involving only those in administrative positions. However, as a field provider, your ability to gather data and collect information from dispatch to marking back in service can greatly influence and improve the delivery of emergency medical care at the local, state, national, and international levels. With the help of additional training and practice as well as improvements in technology, data collection and input will continue to improve and the amount of data uploaded into the national database will not only increase but also improve in accuracy.

References

1. Mears G, J Ornato, and D Dawson (2002 Jan/Mar). Emergency medical services information systems and a future EMS national database. Accessed November 19, 2016 from http://www.nemsis.org/referenceMaterials/documents/PreHospitalECNatEMSDataJournalArticle.pdf.

2. Anonymous (2005). NEMSIS: National EMS information system. Accessed November 20, 2016 from http://nemsis.org/referenceMaterials/documents/NEMSIS%20Fact%20Sheet2.pdf.

3. Goodwin J (2013 May). Delivering on the data. Best Practices in Emergency Services. Accessed November 20, 2016 from http://info.zolldata.com/hs-fs/hub/152170/file-202758586-pdf/docs/delivering_on_the_data__best_practices_in_emergency_services.pdf.

4. Unknown (2012, Winter). Using NEMSIS State-Collected Data; Proving Valuable for Researchers and State, Local and Private Systems Alike; EMS Update. Accessed December 27, 2016 from https://www.ems.gov/pdf/2012/NHTSA_Newsletter_Winter_%202011-2012.pdf.

KAREN OWENS is the emergency operations assistant manager for the Virginia Office of EMS, where she has been employed since 2001. Her duties include oversight of the emergency operations training programs including MCI management, terrorism awareness, and vehicle rescue. Owens has a BA degree in psychology and an MA degree in public safety leadership. She is a Virginia-certified firefighter and had been a Virginia EMT-B instructor since 2002. Owens is the author of Incident Command for EMS (Fire Engineering Books and Videos).

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