Peninsulas EMS Council has a strong focus on improving the EMS provided within our region.  We accomplish this focus through several activities and programs:

Regional Performance Improvement Plan - Through the efforts of the PEMS Performance Improvement (PI) Committee and the Performance Improvement Coordinator, PEMS produces a regional plan each three years to guide the process of improving EMS in areas other than trauma.  This plan is reviewed annually and revised when necessary.

 Click here to download the PEMS Regional Performance Improvement Plan (General EMS).

Regional QA/QI and Performance Improvement guidance - PEMS provides education and advice to regional agencies with regard to establishing internal QA/QI and performance improvement plans and programs.  The templates used in production of these plans and programs fully meet the requirements of 12VAC5-31, Virginia EMS Regulations.

    Click here to download the General EMS Quality Management Template .

Statistical Reviews and Reports - PEMS provides reports to authorized agencies and organizations who do not have their own capability to do so, providing statistical information regarding provision of EMS in the PEMS region.  

Medical Incident Review (MIR) - PEMS provides a system whereby any member of an agency, the healthcare system or the general public can make known their concerns regarding specific patient care incidents.  Each of these incidents is investigated and referred to the agency having authority for accomplishment of corrective action where necessary.  Information obtained through this process is handled with all due regard for HIPAA/PHI considerations.  Sanitized and aggregate results of MIRs are reviewed by the PI Committee to determine whether flaws in systemic processes contributed to the circumstances requiring the review.

Click here to submit a Medical Incident Review or   download a form here and send to our secure fax at 804-302-6073.

Regional coordination - The PEMS PI Coordinator communicates regularly with PI counterparts in our sister Councils to determine where we can coordinate to reduce duplication of effort in performance improvement activities throughout Virginia.

dark blue horiz line290x10

PEMS Performance Improvement (PI) Committee

The PEMS Performance Improvement Committee consists of representatives across the entire spectrum of emergency medical services in our region. The committee meets quarterly to plan and review data on special projects and MIRs (Medical Incident Reports). Our goal is to ensure that our region meets or exceeds the EMS standards of care established by our Protocols, Policies & Procedures as well as the Commonwealth of Virginia.

The PI Committee serves the data and information needs of the Trauma Triage, STEMI, and Stroke Task Forces as well as the Medical Advisory Committee and other PEMS committees and stakeholders.  The PI Committee also supports the needs of our hospital partners in accomplishing their accreditation goals for their various specialty teams.

Performance improvement is a never-ending process in which all healthcare workers are encouraged to work together, without fear of repercussion, to develop and enhance the system in which they work. Based on EMS community collaboration and a shared commitment to excellence, performance improvement reveals potential areas for improvement of the EMS system, identifies training opportunities, highlights outstanding clinical performance, audits compliance with treatment protocols, and reviews specific illnesses or injuries and their associated treatments. These efforts contribute to the continued success of our emergency medical services through a systematic process of review, analysis, and systemic improvement.

Each quarter the PI Committee focuses on a specific project. Reports from these studies are reported through PI Committee meeting minutes and reports and are available here.

dark blue horiz line290x10

When Everything Goes Right

Debbie Thomas

While attending the bi-monthly EMS Collaborative meeting at Sentara Williamsburg Regional Medical Center recently, attendees were notified about a Stroke case in which everything came together perfectly and produced optimal outcome for the patient.

Great things often happen at every hospital and for every agency in the PEMS region. Sometimes we hear about it, sometimes we don’t. As the Clinical Programs Coordinator for PEMS, I facilitate meetings for our Stroke Task Force and I know first-hand the great stuff we are doing region-wide. I am sharing this report because it demonstrates best practices in Stroke care across the spectrum.

In this particular area of the PEMS region, direct transport to a Comprehensive Stroke Center for patients with RACE scores of 5 or greater would extend transport time by more than 15 minutes, so agencies routinely transport to the closest Primary Certified Stroke Center.

Even though an agency here isn’t going to bypass based on the RACE score, SWRMC stresses it is still important for them to perform the RACE evaluation, issue a Stroke pre-alert and report the score enroute to the hospital. Doing so enables the hospital to prepare and initiate their plan for management of the patient which may include transfer to a Comprehensive center.

Here’s the story:

  • 82 year old male traveling from PA to Florida with family
  • Family states the patient had no complaints and seemed normal.  He got up from the table, took a few steps and collapsed to the floor; awake but unresponsive at approximately 1515 hours.  Family immediately suspected a stroke and called 911.
  • James City County Fire Department dispatched a medic unit at 15:21 hours.
  • Patient had a RACE score 7 with right-side paralysis and aphasia (inability to speak).
  • Blood glucose checked - 107
  • Blood drawn and IV established.
  • JCCFD medic marked enroute to SWRMC at 15:41 and called in the "stroke alert" to SWRMC at 15:42.
  • JCCFD marked arriving at SWRMC 15:48 (33 minutes after stroke onset)
  • SWRMC documents an EMS door time of 15:53.
  • Patient is seen briefly by Dr. Boesler and taken directly to CT by EMS (Having EMS transport directly to CT eliminates time otherwise spent transferring the patient to an ED bed only to transfer again in CT.)  Every minute counts!
  • Patient's weight was recorded at 16:00.  Accurate patient weight is essential for correct dosage of tPA.
  • CT started at 16:02 – 9 minutes after arrival.  (The CT scan is required to diagnose a hemorrhage, which would be a contraindication for tPA.)
  • Neurology evaluation in CT 16:07 – Patient had an NIHSS (National Institute of Health Stroke Score) of 21, which is quite high.  Nuerology orded alteplase and a CT-Angiogram.  (The CT-Angiogram uses an injection of iodine contrast medium along with the CT to evaluate the condition of blood vessels.  In this case, within the brain. 
  • Alteplase (a medication used to dissolve blood clots) was started in CT 16:15

22 minutes from Door to Needle - Excellent!

1 hour from Stroke Onset - Amazing!

  • Patient exhibits marked improvement in movement to right upper and lower extremities within 30 minutes of alteplase administration.
  • NIHSS changed from 21 to 6 within 24 hours
  • Discharged to Inpatient Physical Rehabilitation on day 4.
  • Discharged to home on day 15.
    • Able to ambulate with walker
    • Able to do most Activities of Daily Living with little assistance
  • The patient has shared his story here:


dark blue horiz line290x10


Our various EMS committees and workgroups, along with our regional stakeholders, agencies and providers, work very hard to improve our regional EMS system.  This page provides a forum for getting information from all of these folks back to the providers regarding notable performances by our providers, changes to standards of care and areas we need to continue to work on.

If you have an article you would like to submit, please submit it here with your phone and email contact information.

dark blue horiz line290x10

Main Menu

Back To Top