Audits of documentation quality in emergency medical services - a must have!

Background: In 2020, internal audits showed serious documentation deficits in the emergency protocols of the emergency medical service (EMS) of Tyrol. Only 43.2% were sufficiently completed. Training was implemented to remedy these deficits.Goal: In 2021, further audits aimed to check the effectiveness of the training and, if necessary, to propose continuing improvements.Materials and methods: Based on a standard operating procedure, the emergency protocols from June/July 2020 and 2021, respectively, were analyzed for quality criteria such as completeness, documentation of the clinical situation of the patient, ABCDE/SAMPLE (airway, breathing, circulation, disability, exposure/signs and symptoms, allergies, medications, past pertinent medical history, last oral intake, events leading up to present illness/injury) approach, and vital signs. The education of the emergency medical technicians (EMT) and the type of alert (emergency call 144; home emergency call system) were also considered. The evaluation was executed with descriptive statistics; statistical significances were calculated with ?2 test.Results: In 2020, only 43.2% of the 1376 emergency protocols were completely filled out. In 2021, already 79.4% of the 1284 protocols were complete. In emergencies in 2020 alerted by the home emergency call system, there were significantly fewer (p < 0.001) complete protocols compared to protocols from events caused by emergency calls 144. In 2021, there was no longer a significant difference in documentation quality between the two alert systems (p = 0.384). In terms of training, EMTs are significantly more likely to complete emergency protocols than emergency medical assistants (p < 0.001). The documentation of the clinical picture and ABCDE/SAMPLE approach was significantly better in 2021 than in 2020; only the documentation of the vital signs remained deficient with 41.7%.Conclusion: Although the quality of documentation has significantly improved within 2 years, the aim of 100% complete emergency protocols has not yet been achieved. Comparative data with other EMS would be important.