QI can be heartbreaking

NomadicMedic

NomadicMedic

I know a guy who knows a guy.
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I just did a review on a cardiac arrest chart that was so mismanaged that I may have to request the doc pull the medic's privileges.

I'm just disgusted.
 
It isn’t personal. Best advice I’d heard given to my wife regarding her role as a nurse manager: Collect & Disconnect.
 
NomadicMedic said:
I just did a review on a cardiac arrest chart that was so mismanaged that I may have to request the doc pull the medic's privileges.

I'm just disgusted.
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Was it the care or the way it was documented that was the worst?

TAing for 200 level college courses was heartbreaking for me, without the lie/death of a code. I found it hard to imagine why someone would pay good money to go to school and put in literally 0 effort.
 
It was both. The documentation was bad, and when I reviewed the actions from code review, the care was just as dismal.
 
NomadicMedic said:
It was both. The documentation was bad, and when I reviewed the actions from code review, the care was just as dismal.
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As a partner of mine used to say... Some people are just meant to dig ditches...
 
@chriscemt, that was my question as well; was the documentation poor, or the care that was documented poor. Since it was both, that's very disturbing.

Did you ask the medic what happened? Meaning, did he or she not understand the protocol for cardiac arrest for your agency? did he or she not grasp the medicine? did he or she simply have a brainfart on what drugs to give? was there something unusual or confusing about the patient presentation? was it a scene management issue, where the medic didn't delegate properly, or did the first responding fire captain on the engine trample over the medic which was why it didn't go well?

While I think everyone agrees that some people aren't cut out to be paramedics, the question that needs to occur is how can this be prevented from happening in the future, and can this particular medic be retrained correctly so this issue doesn't happen again in the future.
 
I’m not going to get into the specifics of it here.

This is probably going to end this guys employment with us.
 
It’s all about the patient. Period.
 
I have reviewed a few charts that are borderline criminal. Some providers just get by under the radar for far too long and I think some places tolerate mediocrity too much.
 
VFlutter said:
I have reviewed a few charts that are borderline criminal. Some providers just get by under the radar for far too long and I think some places tolerate mediocrity too much.
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Are you familiar with Just Culture? Do you guys use it?

If your statement is true, then your QI process is deficient. That is a system issue.
 
Dang. To be fireable vs re-training, I'm guessing this isnt their first run in with QA/QI? Obviously you cant give call details, but any generalities on what went wrong (wrong meds, shocking wrong rythms?)
 
The frustrating thing is how long a lot of this falls through the cracks or gets ignored.

I got a transfer once that was so bad that the HEMS crew basically arrested a floor stable kid with completely unnecessary interventions, fortunately we were able to recover them and they didn't have any long term deficits. We documented our concerns immediately and our CMO ended up addressing them with that company, I don't think anything ever came of it. Better is that the crew then falsified their chart, and in a way that still didn't make sense.

There are many issues that are systemic. I sit on several committies that look at EMS, nursing, and medical practice both in our hospital, throughout the system, and to a limited extent externally. There are also some clinicians who are just bad apples, they are rare but definitely out there.
 
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We recently had a young guy in arrest transported to us where the medic gave amiodarone for an asystolic rhythm, among other issues. Just reading that chart was mind-boggling.
 
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MonkeyArrow said:
We recently had a young guy in arrest transported to us where the medic gave amiodarone for an asystolic rhythm, among other issues. Just reading that chart was mind-boggling.
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I was never the QI guy at my old service, but did not make any friends when Id respond with my coworkers as a firefighter. Witnessed a few botched RSIs that I took to the team leader. Nothing ever came of them, but God forbid I give nitro without an IV.
 
GMCmedic said:
I was never the QI guy at my old service, but did not make any friends when Id respond with my coworkers as a firefighter. Witnessed a few botched RSIs that I took to the team leader. Nothing ever came of them, but God forbid I give nitro without an IV.
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I’ve found that nothing happening after a poor clinical performance seems to be the norm at more services than not. I had a group chat with a few of my QI friends and we’re all in the same boat.

How aggressive should we be with QI and when does poor performance become a termination offense rather than just remediation. And does anyone think a remediation plan will actually work? (Most of us say no)
 
NomadicMedic said:
How aggressive should we be with QI and when does poor performance become a termination offense rather than just remediation. And does anyone think a remediation plan will actually work? (Most of us say no)
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1. You can have an aggressive QI program while tailoring the style and content of feedback to individuals. That's just being realistic about modern sensibilities.
2. I'm guessing your ability to terminate employees is largely subject to local rules. We used a three-strikes-and-you're-out policy for intermediate offenses -- i.e., not life-threatening but risk-enhancing. Major offenses occasionally resulted in immediate termination. Remediation for minor offenses usually went on indefinitely. The definition of major, minor, and intermediate certainly isn't universal.
3. In my experience, remediation does work with some people for some offenses. I wouldn't rule it out before trying.
 
NomadicMedic said:
How aggressive should we be with QI and when does poor performance become a termination offense rather than just remediation. And does anyone think a remediation plan will actually work? (Most of us say no)
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I think the other thing that has to be looked at is whether a remediation process will actually assist in improving clinical judgement. Every place I've ever worked if you blow up call type X, you get remediated on call type X. Nevermind that call Xs might be few and far between, dammit we re-trained them to not make that mistake again. And yet on call Y, poor judgement is shown. It seems like a nearly impossible task to remediate clinical judgement. If the provider cannot make good, critical decisions, can they continue to work as a paramedic?
 
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