Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

EMS Garage on Press Ganey – Should We Reward High Scores

Continuing from EMS Garage on Wait Times, the discussion of Monday night on the EMS Garage with Buck Feris titled The Prodigal: EMS Garage Episode 132.

Anne Robinson took the position that Press Ganey scores are useful in evaluating quality. Somebody suggested that a debate between a nurse and me is not the place to be, but there is no reason to assume that there is any benefit, or handicap, in being a nurse in this debate. Am I supposed to disagree more strongly just because the person I do not agree with is a nurse?

What are Press Ganey scores?

Press Ganey scores are evaluations of the care received in the emergency department by the patients who have been seen in the ED (Emergency Department) and discharged from the emergency department.

Patients admitted to the hospital and patients transferred to other hospitals do not receive Press Ganey emergency department satisfaction surveys. While some questions about the emergency department may be included on inpatient surveys, the answers to those questions count toward the inpatient satisfaction scores, not the emergency department satisfaction scores.[1]

In other words, the Press Ganey scores of patients admitted through the ED will not affect the ED’s Press Ganey scores, but the Press Ganey scores patients who never needed to be seen in the ED will.

Press Ganey is just a way for those who abuse the ED to make ED treatment more to their liking.

If the main reason for EDs to exist is supposed to be for the patients with life threatening emergencies, why is Press Ganey evaluate the satisfaction of those who should not be in the ED?

What does a Press Ganey score have to do with improved outcomes?

Absolutely nothing.

AP Photo/Julio Cortez
The wait time at the Bayonne Medical Center’s emergency room is seen on a billboard on Tuesday, April 12, 2011 at Journal Square in Jersey City, N.J.[2]

How are wait times any better at determining the quality of care delivered?

Outside of cardiac arrest, how are EMS response times any better at determining the quality of EMS delivered?

We do a great job of measuring the wrong things.

In EMS, we like to focus on better looking vital signs at the time of patient transfer, although this often leads us to give treatments that endanger the survival of the patient. We are EMS. We just care about the documentation.

We need to change our focus to assessing outcomes, rather than making the paperwork pretty for the QA/QI/CYA departments and their myopic obsession with vital signs trends, policy compliance, and other things that cannot be shown to improve outcomes. We need to start doing what is in the best interests of the patient, not what the lawyers claim is in the best interests of the organization.

Therefore, maybe we should be rewarding those with the worst Press Ganey scores.

These may be the doctors and EDs that the abusive patients don’t like.

Why don’t we find out what the outcomes are for the patients treated by those with the worst Press Ganey scores?

What will we find?

Unfortunately, Press Ganey scores are often based on sample sizes that are too small be anything other than random number generators, but rewarding low Press Ganey scores is definitely something to consider.


[1] 2+2=7? Seven things you may not know about Press Ganey Statistics
by William Sullivan, DO, JD & Joe DeLucia, DO
September 22, 2010
Emergency Physicians Monthly

[2] N.J. Hospital Debuts Wait-Time Billboards
Posted: Friday, April 15, 2011
Updated: April 15th, 2011 03:45 PM CDT
EMS World


EMS Garage on Wait Times

Last night on the EMS Garage there was the return of a voice that has been absent for a while – Buck Feris, so the podcast is titled The Prodigal: EMS Garage Episode 132.

Some of the topics discussed were ones that I feel are important. First – The use of wait times, or Press Ganey satisfaction scores to claim that we are assessing quality.

Wait times do not tell us anything. What does an 8 minute wait time mean?

AP Photo/Julio Cortez
The wait time at the Bayonne Medical Center’s emergency room is seen on a billboard on Tuesday, April 12, 2011 at Journal Square in Jersey City, N.J.[1]

According to the article, this is what the posted wait time means –

the average time it takes from entering the door at the ER to seeing a medical provider.[1]

They do not define medical provider. Could that mean someone from security or registration, who may be required to have some medical training (CPR, First Aid, . . . ) and therefore someone considered to be a medical provider – at least as far as not violating truth in advertising laws?

Is the medical provider a triage nurse, who provides a triage assessment of the patient and then decides that the patient can wait a few hours to be brought to the back and placed in a bed, where other medical providers will further assess and treat the patient.

What about a patient with chest pain?

Is registration or security going to recognize someone who looks bad and call someone to assess this patient ahead of every other patient waiting to be assessed?

What the wait time does not tell us is what the wait time means.

We need to educate people about the use of emergency departments and about the use of 911. In stead, we try to dumb everything down to satisfy the What if . . . ? people – the people who are trying to prevent all of us from thinking.

Last week on EMS Office Hours, I was not one of the guests, but the discussion was about what we are doing to educate the public about EMS for EMS Week. Go listen to that discussion, too.

“With these billboards, we have reaffirmed our promise to provide our patients and the residents of Hudson County with quality care without having to wait in an emergency room for hours,” said Daniel Kane, President and CEO of Bayonne Medical Center, in a prepared statement. “Were dedicated to providing our patients the best possible care close to home.”[1]

This is not even close to true.

Should anyone with a minor complaint be encouraged to go to the emergency department because Daniel Kane, President and CEO of Bayonne Medical Center says they won’t have to wait for hours?

If I have a minor complaint, there is no good reason I should not expect to wait for hours. One of the reasons for the long wait times is that there are too many people there with minor complaints.

Daniel Kane, President and CEO of Bayonne Medical Center appears to be encouraging longer wait times.

Bayonne Medical Center says it is the first hospital in the tri-state area to publicly post its emergency room wait-times, highlighting improvements since it was saved from bankruptcy in 2008.[1]

How do we know that similarly misguided sales pitches were not the cause of the reported near-bankruptcy?

How do we know that publicizing their documented wait time has anything to do with the appearance of not currently facing bankruptcy?

Since we do not know what the wait time means, how can anyone claim that a change in the documentation of wait time means any kind of improvement?

Where is the research to show that shorter documented wait time, using the same methodology, leads to better outcomes?

Some more on this later in EMS Garage on Press Ganey – Should We Reward High Scores?


[1] N.J. Hospital Debuts Wait-Time Billboards
Posted: Friday, April 15, 2011
Updated: April 15th, 2011 03:45 PM CDT
EMS World


Podcasting, rather than doing taxes

I am on a couple of podcasts this week.

At EMS Garage we were discussing money, conflicts of interest, and reimbursement. Three in One: EMS Garage Episode 130 with Chris Montera, Dr. “Anonymous” Mike Sevilla, Kyle David Bates, Scott Kier, Russell Stine, and James Warmuth.

Last night I was on EMS Office Hours with Jim Hoffman, Mark Albert of EMSMedRx, and Numan Ejaz, the creator of the PAGNY (Paramedic Association of Greater New York). PAGNY is trying to improve EMS in NY. They are not the only organization doing this, but they are focused on what is best for the patient. Focusing on the patient is what is most important in improving EMS. ABC’s Of An EMS Association – PAGNY Highlight.


School House Rock – EMS Garage Episode 121

The most recent EMS Garage covers university/college EMS organizations. School House Rock: EMS Garage Episode 121.

I have heard many criticisms of university/college EMS, but I have worked closely with VEMS (Villanova EMS) and found that the criticisms are no more than the typical inter-agency trash talking that is common in police, fire, and EMS. My experiences with this university-based transport EMS agency has been very positive.

If you are going to be going to a school that has EMS, then listening to the podcast may help you to decide if university/college EMS is something for you.

The NCEMS (National Collegiate Emergency Medical Services Foundation) can provide a lot of information about what is available.

The 2011 NCEMSF Annual Conference is February 25 – 27 in Philadelphia, PA.

Regular Registration
January 16, 2011 through February 19, 2011
Personal Member: $75, Non-member: $90

Late Registration (and on-site)
February 20, 2011 through February 27, 2011
Personal Member or Non-member: $100

Conference registration fees do not include travel, parking, lodging and some meals. Contact the conference host facility for room reservations at the special conference rate.

The details of the schedule have not yet been posted other than for the keynote speech.

Major John P. Pryor, MD Memorial Lecture – Edward T. Dickinson, III, MD, FACRP, NREMT-P, Associate Professor of Emergency Medicine and Director of EMS Field Operation at the Hospital of the University of Pennsylvania will deliver the keynote.

Dr. Dickinson is worth listening to. He knows his stuff and explains it in a clear and entertaining fashion.

If you have any interest in collegiate EMS, this is a great chance to learn more as is listening to the EMS Garage podcast.

The 18th Annual NCEMSF Conference will be hosted at the Loews Philadelphia Hotel.

Parking information can be found on the transportation page.

For directions to the hotel use your GPS device or favorite mapping Web site (Google Maps, Yahoo Maps) to route to:
1200 Market Street Philadelphia, Pennsylvania, 19107


Podcasting on the 2010 AHA Guidelines

Also posted over at Paramedicine 101. Go check out the rest of the excellent material there.

There are three podcasts discussing the new AHA (American Heart Association) guidelines. I am not on any of them, but I strongly encourage you to listen to all three of these. Each focuses on different changes, so there is minimal repetition from listening to all three.

No One Ever Died of Cardiac Arrest: EMS Garage Episode 108

The audio is a bit rough, but the discussion is excellent. If you want to know what is important, all of these podcasts contribute important information to our understanding of the new AHA (American Heart Association) guidelines.

Emergency Cardiovascular Care 2010 Update Interview

A great interview by Jamie Davis Tom Bouthillet and with Dr. Monica Kleinman, a representative of the AHA.

EMCrit Podcast 34 – 2010 ACLS Guidelines

The shortest podcast, and the first 3 minutes are a discussion of questions related to the previous podcast on stroke.

This is supplemented by a detailed summary of the new guidelines created by Dr. Weingart. If you want one document to read to cover all of the new AHA guidelines, this one is very well done.

Updated 02/08/11 to reflect the new blog address for EMCrit. http://emcrit.org/ The old links did not redirect appropriately.


EMS Liability What You Should Know: EMS Garage Episode 106

Listen to EMS Liability What You Should Know: EMS Garage Episode 106. Steve Wirth of Page, Wolfberg & Wirth, LLC talks about the recent appeals court reversal in the case in Missouri of the chest pain refusal not being covered by immunity.

There is a lot of good information.

Do you know what your state’s rules are?

Do you know what your employer’s rules are?

Do you know what an informed consent is?

Do you know what an informed refusal is?

EMS Liability What You Should Know: EMS Garage Episode 106

Also on the show were –

Chris Montera

Kyle David Bates

Jamie Davis

Scott Kier

James Warmuth

and me.

I also wrote about this in –

EMS case law? AMA Refusals, Death, and Documentation – Life Under the Lights


Chest Pain Refusals.


Kenneth Stokes – Your life is important, unless you work in EMS

Apparently, City Councilman Kenneth Stokes does not believe that people who work in EMS are people.

“Human life is too important to take it for granted, and when a person is shot, there’s no such thing as a simple gunshot wound. All gunshot wounds are serious,” he said. “Anytime that a person needs to be taken to the hospital, a second can be the difference between life and death. And it’s important that we treat life in such a manner that everyone knows it’s irreplaceable.”[1]

Irreplaceable – unless you work in EMS.

Is City Councilman Kenneth Stokes the Dumbest Person of the Week?

Can Lindsay Lohan compete with his bottomless stupidity?

National EMS Authority CEO and President Steve Williamson of Tulsa, Okla., said he had read Stokes’ comments. He said Stokes is overlooking one fact:

“It incensed me that he would put so little importance on the safety of the caregiver,” he said. “You don’t want to exacerbate the problem by having more victims because the scene wasn’t safe. It’s almost beyond common sense that you would send people who are unprotected into that type of environment.”

Williamson recited a business mantra: “A dead medic can’t help anyone.”[1]

City Councilman Kenneth Stokes would probably be complaining that being dead is no reason for the medic to not treat the patient. Lazy, good-for-nothing medic!

Stokes, however, said if another ambulance company cannot be found, the city of Jackson should consider running its emergency medical services through the Fire Department. He said emergency medical providers need to be willing to take the same risks as police and fire department employees.[1]

Now it makes sense.

All this talk about saving lives was just a smoke screen for City Councilman Kenneth Stokes to get some support from the IAFF (International Association of Fire Fighters – the fire fighters’ union).

As much as the IAFF thinks that their continuing expansion as a union depends on taking over EMS, they will not tolerate having their union members serving as targets for the local gangbangers to shoot at until the police arrive.

While many Jackson firefighters are medical first responders, and some are EMTs, department spokesman R.D. Simpson said firefighters do not enter an unsecured scene.

“We do have a policy, and it is that no JFD personnel will enter a known hostile situation without law enforcement personnel on the scene and without the scene being stabilized,” Simpson said.[1]

The IAFF will not treat voting members like that.

Even City Councilman Kenneth Stokes will not go into a shooting scene until after police have secured the scene.

(AMR spokesman Jim) Pollard says he has studied the times and found they got the call at 10:15:04, were on scene at 10:22:24, and had patient contact at 10:22:29 or seven minutes twenty-five seconds after getting the call.[2]

The highlighting is mine.

Meanwhile, the actual contract with AMR is handled through the county.

Hinds County supervisors said the county remains satisfied with AMR’s policies and performance and that no change is eminent.[1]

City Councilman Kenneth Stokes claims that it took 23 minutes for police to arrive at a shooting scene in the city, even though dispatch records show EMS on scene in 7 minutes?

City Councilman Kenneth Stokes is a liar.

Picture credit[3]

But is City Councilman Kenneth Stokes the dumbest person of the week?

Elsewhere in EMS Blogging on the dumbest person of the week City Councilman Kenneth Stokes:

Dear Kenneth Stokes…

The Assault of Sensibility By The Dullard Kenneth Stokes

BYOT: EMS Garage Episode 105

CALCULATED RISK AND LETTERS IN THE FILES – I wear my seatbelt in an ambulance, regardless of who is driving. I wear my seatbelt in a car, regardless of who is driving. I do not wear a seatbelt on a motorcycle. 😉

Kenneth Stokes and AMR: A Political Cartoon + A Video

Kenneth Stokes is an idiot

Jackson, MS City Councilman Kenneth Stokes …



[1] Paramedics back policy on perilous situations – Councilman’s criticism of ambulance service rebuked
The Clarion-Ledger
Therese Apel

[2] Stokes criticizes AMR
Posted: Sep 21, 2010 12:59 PM EDT
Updated: Sep 21, 2010 7:50 PM EDT
By Bert Case – bio | email

[3] Kenneth Stokes, the Clarion-Ledger, and signs made by 3rd graders
Ipse Blogit
June 7, 2010


EMS Garage Rant – Prehospital Pain Management

On BYOT: EMS Garage Episode 105 we discussed 2 things that I wanted to rant about – here is some of the second rant.

The second topic was prehospital pain management. I think that Chris Montera saw my post A Prehospital Pain Management Discussion at the NAEMSP Site and wanted to discuss it. There is a lot of excellent material at the NAEMSP discussion site.

There are a lot of ideas discussed on the podcast.

Listen to it.

Why are there so many doctors discouraging appropriate patient care?

What can we do to convince them that prehospital pain management is safe, effective, and necessary?

This is not directed at Chris, since he is aggressive with pain management. He was only repeating one of the arguments against aggressive prehospital pain management – actually, it is an argument against all prehospital pain management.

I scared Chris a little bit with my response, when he repeated what some people claim about pain – Pain never killed anyone!

If anyone wishes to provide some evidence, please do so.

If there is no evidence to support this claim, then prove it. Let me deliver some extreme pain to you, just for a while. I won’t break anything or burn anything, but I will see if I can cause enough pain to kill you.

If Pain never killed anyone!, it won’t kill you either.

What have you got to lose?

You will have experienced some memorable pain. You may have nightmares and other PTSD (Post Traumatic Stress Disorder) symptoms, but since you have already made it clear that you don’t take pain seriously, why should you mind?

We’ll strap you to a chair, so that you don’t injure yourself by thrashing around. Safety first. We’ll hook you up to a monitor to see just how much stress your body is experiencing. We’ll even get a medical director, who believes in Mother-May-I protocols, to supervise. What could be safer – if you are right?

Pain is not dangerous, this is completely safe – Right?

If pain does not need to be treated, then there is no medical problem created by just causing a bit of pain – OK – a lot of pain. Or is pain dangerous?

Pain never killed anyone!

I dare you to prove to me.

Put up or shut up.

I can be reached at the email below or in the comments.