Emergency medical services advanced life support response times: lots of heat, little light.
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Emergency Medical Services↗
Biomedical subjects
David C Cone
Publications and source records attributed to David C Cone.
Quality in clinical practice.
This paper reports the proceedings of the discussion panel assigned to look at clinical aspects of quality in emergency medicine. One of the seven stated objectives of the Academic Emergency Medicine consensus conference on quality in emergency medicine was to educate emergency physicians regarding quality measures and quality improvement as essential aspects of the practice of emergency medicine. Another topic of interest was a discussion of the value of information technology in facilitating quality care in the clinical practice of emergency medicine. It is important to note that this is not intended to be a comprehensive review of this extensive topic, but instead is designed to report the discussion that occurred at this session of the consensus conference.
Emergency Medicine↗
Whither the fourth link?
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Cardiopulmonary Resuscitation↗
Developing research criteria to define medical necessity in emergency medical services.
"The Neely Conference: Developing Research Criteria to Define Medical Necessity in EMS" convened emergency medical services (EMS) physicians, researchers, administrators, providers, and federal agency representatives to begin the development of a set of uniform triage criteria and outcome measures that could be used to study and evaluate medical necessity among EMS patients. These standardized criteria might be used in research studies examining EMS dispatch and response (e.g., dispatch triage protocols, alternative response configurations), and EMS treatment and transport (e.g., field triage protocols, alternative care destinations). The conference process included review and analysis of the literature, expert judgment, and consensus building. There was general agreement on the following: 1. Any dispatch triage or field triage system that is developed must be designed to offer patients alternatives to EMS, not to refuse care to patients. 2. It is theoretically possible to develop a set of clinical criteria for need. Some groups of patients will clearly need a traditional EMS response and other groups will not, but this has yet to be defined. 3. In addition to clinical criteria, certain social and other nonclinical criteria such as pain or potential abuse may be used to justify a response. 4. Communication barriers, patient age, special needs, and other conditions complicate patient assessment but should not exclude patients from consideration for alternate triage or transport. 5. These research questions are important, and standard sets of outcome measures are needed so that different studies and innovative programs can be compared.
Adult↗
Criteria currently used to evaluate dispatch triage systems: where do they leave us?
Some emergency medical services (EMS) systems are interested in considering the possibility of triaging some patients who call an emergency dispatch center to alternatives to the traditional emergency response, but concerns exist about the safety of that triage. In January 2003, the Neely Conference was held in association with the National Association of EMS Physicians annual meeting in Panama City, Florida. The Neely Conference began the process of developing criteria to be used in research studies evaluating dispatch and field triage systems. Various outcome measures have been used, including expert opinion, patient interviews, specific patient complaints, field findings and interventions, and emergency department or hospital outcomes. This commentary reviews the methods used in the current literature to evaluate dispatch triage systems.
Emergency Medical Service Communication Systems↗
Field triage systems: methodologies from the literature.
The primary goal of the Neely Conference project is to work toward defining a set of research criteria for medical necessity in emergency medical services (EMS). This paper reviews the extant literature on triage and nontransport decisions made in the field by EMS personnel, with emphasis on the methodologies that have been used to date. Two types of medical necessity standards are considered. First, there are triage criteria for determining whether a given patient requires EMS transport to the hospital, or whether an alternative might be appropriate. These triage criteria might be incorporated into protocols that field personnel could apply on scene to determine the best disposition for a given patient. Second, there are the outcome measures against which the decisions made by the field personnel are judged. In some cases, the outcome measure is the judgment of a reviewing emergency physician or nurse, while in others specific outcome measures are used to judge the performance of the criteria and the decision making of the field providers. While review of the literature shows that no "standard" set of triage criteria have been generated or validated in determining medical necessity in EMS, there are certain themes that emerge from the literature, and these themes can likely form the basis of a consensus on elements of a medical necessity criteria that need to be validated and refined. These may include (for triage criteria) vital signs, chief complaints, and physical exam findings, and (for outcome measures) hospital admission, critical events, death, and diagnosis.
Emergency Medical Services↗
Defining research criteria to characterize medical necessity in emergency medical services: a consensus among experts at the Neely Conference.
OBJECTIVE: Researchers interested in ensuring appropriate use of emergency medical services (EMS) resources have attempted to define safe and effective protocols for triage either at the time of dispatch or after on-scene evaluation. Published work in this area is difficult to evaluate because protocols and outcome criteria vary from study to study. The goal of the Neely Conference was to bring together EMS experts to define a set of criteria to be used in research studies evaluating dispatch triage and field triage systems. METHODS: Thirty-one experts in EMS systems and research attended a day-long workshop to assess the current literature regarding dispatch triage and field triage, and make recommendations to standardize methods used to evaluate future triage protocols. Participants were surveyed during the workshop; consensus analysis techniques were used to determine if a formal consensus was reached. A Bayesian posterior probability of 0.99 was required to consider responses a "consensus." RESULTS: Participants considered current evidence regarding the usefulness of EMS triage criteria to be "weak." However, respondents agreed on a set of research criteria that could define the need for an EMS response and/or EMS transport. Field triage criteria were considered more plausible than dispatch criteria. Valid outcome criteria for assessing the effectiveness of triage protocols included ED assessment and the need for immediate surgery. Hospital admission, final diagnosis, and expert opinion were not considered adequate outcome measures. CONCLUSION: EMS experts agreed on a standard set of triage criteria and outcome measures for evaluating triage protocols supporting alternative forms of transport and care.
Ambulances↗
Automated external defibrillator training and skill retention at a ski patrol.
OBJECTIVES: To determine whether members of a ski patrol, most of whom have no off-season medical responsibilities, can successfully complete an automated external defibrillator (AED) training program prior to the ski season, and retain AED skills at the end of the season and at the beginning of the following season. METHODS: A prospective educational study was conducted with 61 ski patrol personnel: 51 (84%) had no other medical training, 44 (72%) had no off-season medical duties, and 57 (93%) had no prior exposure to AEDs. Prior to the ski season (December 1, 1998), all members were trained and tested using the standard American Heart Association (AHA) AED training package and a Life-Pak 500 AED and AED Trainer donated by the Medtronic Physio-Control Corporation. Both after the ski season (April 1, 1999) and prior to the following season (October 30, 1999), with no refresher training, participants were retested with the same written and practical exams. Cochrane's linear trend test was used to compare scores on the practical and written tests over time. RESULTS: For the three testing sessions, practical test pass rates were 95%, 92%, and 97%, and written test pass rates were 100%, 98%, and 98%. There was no change in individuals' scores on either the written test (p = 0.914) or the practical test (p = 0.413) over time. CONCLUSIONS: A heterogeneous group of ski patrollers can successfully complete an AED training course, with good skill retention both after the ski season and at the beginning of the following season.
Adult↗
Subcutaneous epinephrine for out-of-hospital treatment of anaphylaxis. National Association of EMS Physicians Standards and Clinical Practice Committee.
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Anaphylaxis↗
A time-motion study of ambulance-to-emergency department radio communications.
OBJECTIVE: A prospective time-motion study of radio communication between inbound ambulances and emergency department (ED) triage personnel was conducted to assess hospital triage staff time utilized, and how often radio reports result in actions taken in the ED to prepare for patient arrival. The study hypothesis was that reports for "priority 2" (P2, nonemergent) patients rarely provide information that is acted upon in the ED prior to the patient's arrival. METHODS: The study was conducted at an academic adult ED receiving 22,000 ambulances per year. An observer in the ED monitored and timed (to the second) all radio reports as well as the activities of triage nurses and arriving emergency medical services (EMS) personnel. RESULTS: A convenience sample of 437 reports was collected: 83 priority 1 (P1, emergent) and 354 P2. Average report times (minutes:seconds) with ranges were 0:53 (0:07-1:57) for P1, and 0:44 (0:04-3:50) for P2. Only 16% of the P2 reports resulted in any preparatory action, and 55% of these were requests to have hospital police officers available to receive intoxicated patients, as per local protocol. An in-person report was given in the ED for 61% of the P2 cases, and in 48% of these, the in-person report was longer than the radio report. CONCLUSIONS: In the system studied, P2 reports rarely provide information that is acted on prior to the patient's arrival. The time spent giving a radio report is frequently duplicated in the ED. Radio reports for low-priority patients may not be an efficient or productive use of providers' or nurses' time.
Academic Medical Centers↗
Advancing disaster epidemiology and response: developing a national disaster-victim database.
BACKGROUND: The need to further disaster preparedness has resulted in a call for more comprehensive disaster research. Past disaster research has, for the most part, been limited by the inability to obtain complete medical data from victims of disasters. A national disaster-victim database (NDVD) can be developed that will facilitate collection and aggregation of disaster-victim medical data from health care facilities. Three aspects of the NDVD are discussed: DATA REQUIREMENTS: Medical records of disaster victims must be standardized before being uploaded from various databases into the NDVD. Existing data dictionaries provide formats in which data elements can become standardized. Once standardized, data sets from different facilities can be pooled and subjected to analyses. Database System. The three tiers of the NDVD system are: 1) medical data are collected at the point of care, 2) medical data are entered into databases and converted into a specific format, and 3) formatted data sets are uploaded to the NDVD. In order for this system to be viable, it must not add burden to health care workers; rather, it must benefit them and their facilities. REAL-TIME COLLECTION OF MEDICAL DATA: Capturing data on victims of a disaster, during a disaster, is ideal. This would allow for more victim data to be studied as well as for more accurate data to be collected. Technologic advancement has encouraged a real-time data-collection model in St. Louis that can act as a model for NDVD implementation.
Databases as Topic↗
Can a simple reminder letter improve numbering of single-family residences?
OBJECTIVE: To determine if a single mailing from the local volunteer fire department can increase the number of homes with proper, visible address numbering. Proper numbering is essential in rapidly locating a house during an emergency response. METHODS: The study was conducted at a suburban/rural fire department providing EMS and fire suppression services to a 22 square mile area with residential mailboxes located at the street. During a hazard identification pre-plan tour, each house was examined and assigned a classification: (A) No number visible on the house or mailbox (improper); (B) Number on only one side of the mailbox (improper); (C) Number on both sides or the end of the mailbox, or visible on the house (proper). The homeowners of all residences with improper numbering (A or B) were sent a one-page letter, discussing the need for proper numbering. The tour was repeated six weeks later to determine whether deficiencies had been corrected. It was prospectively determined that a 25% improvement was sought. RESULTS: During the pre-plan tour, 73 houses were classified as type A, 454 as type B, and 1706 as type C. At the re-visit, 135 (26%) of the type A and B homes had been properly numbered. Correction of deficiencies was better at type A homes (37, or 51%) than at type B homes (98, or 22%) (p < 0.001 by Chi-square). CONCLUSION: For houses with improper numbering, a single mailing from the fire department can be effective in encouraging residents to post proper numbers.
Connecticut↗
Noninvasive fireground assessment of carboxyhemoglobin levels in firefighters.
OBJECTIVES: Carboxyhemoglobin (COHb) levels can be estimated by chemical analysis of exhaled alveolar breath. Such noninvasive measurement could be used on the fireground to screen both firefighters (FFs) and victims. The purpose of this study was to assess the feasibility of using a hand-held carbon monoxide (CO) monitoring device to screen for CO toxicity in FFs under field conditions. METHODS: Informed consent was obtained from all participants. Using a hand-held breath CO detection device, COHb readings were collected at baseline, and then as FFs exited burning buildings after performing interior fire attack and overhaul with self-contained breathing apparatus (SCBA) during live-fire training. Ambient CO levels were occasionally measured in interior areas where the FFs were working to assess the degree of CO exposure. RESULTS: Baseline COHb readings of 64 FFs ranged from 0% to 3% (mean 1%, median 1%). One hundred eighty-four COHb readings were collected during training exercises. The mean and median COHb levels were 1%. The maximum value in a FF wearing SCBA was 3%; values of 14%, 5%, and 4% were measured in instructors who were not properly wearing SCBA. Ambient CO readings during fire attack ranged from 75 to 1,290 ppm, and the ambient CO reading for overhaul ranged from 0 to 130 ppm. When the device was used for interior CO monitoring, washout time limited its utility for COHb monitoring in FFs. CONCLUSIONS: A hand-held CO monitoring device adapted for estimation of COHb levels by exhaled breath analysis can feasibly be deployed on the fireground to assess CO exposure in FFs.
Adult↗
The safety of a field termination-of-resuscitation protocol.
BACKGROUND: A 1999 National Association of EMS Physicians position paper recommends that termination of resuscitation (TOR) be considered if the adult nontraumatic out-of-hospital cardiac arrest (OOHCA) patient receives cardiopulmonary resuscitation, definitive airway management, intravenous access, and at least 20 minutes of resuscitative efforts, yet remains in asystole or pulseless electrical activity with no return of spontaneous circulation (ROSC) in the field. OBJECTIVE: To test the safety of this protocol, with survival to discharge as the primary endpoint. The study hypothesis was that the protocol is 100% specific: no patient who would be eligible for TOR survived to discharge. METHODS: Utstein template data were collected prospectively for all OOHCA patients received at two academic emergency departments between August 1999 and January 2003, and retrospective OOHCA data were collected at one of the hospitals covering the interval October 1993 to June 2002. Each case was examined to determine whether the patient would have been eligible for TOR, and whether he or she survived. RESULTS: Three hundred sixty-six prospective and 135 retrospective cases were included. Twelve patients survived to discharge, but none were eligible for TOR, as all had ROSC in the field (specificity 100%, sensitivity 58%). Of the 63 patients who survived to admission, four were eligible for TOR (specificity 94%, sensitivity 64%). None of these four survived to discharge, and not regained consciousness prior to death. CONCLUSIONS: The proposed protocol appears to be safe, with 100% specificity for lack of survival to discharge in this sample. A small number of patients eligible for TOR did survive to admission, but none survived to discharge.
Adult↗
EMS physician certification: just one piece of the puzzle.
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Certification↗
A novel inexpensive IV catheterization training model for paramedic students.
INTRODUCTION: Teaching paramedic students venipuncture and intravenous catheterization has traditionally relied on bulky, expensive phlebotomy models. A gelatin intravenous model (GIM) costing less than 50 cents is currently being used in the training of medical students and interns. The study objective was to evaluate paramedic students' perceptions of the GIM as a training tool. METHODS: GIMs are created using gelatin, psyllium, Penrose drains, food coloring, salt, and water. Penrose drains are filled with artificial blood composed of salt water and food coloring. The drains are placed in an aluminum pan with a base of hardening gelatin, with half-inch drains at the bottom of the pan and quarter-inch drains higher up in layers of mixed psyllium and gelatin to simulate deep and superficial veins respectively. A convenience, volunteer sample of 14 paramedic students who previously trained with traditional phlebotomy models each made two to five attempts at intravenous insertion using the GIM. Perceptions of the GIM were measured using a Likert scale (1, worst rating; 5, best rating). Means are reported. RESULTS: Study subjects rated ease of use at 4.17, realism at 4.07, and effectiveness in learning intravenous insertion at 4.28. GIM as a more effective teaching tool than the conventional rubber arm yielded a rating of 4.14. CONCLUSIONS: This study is limited by a small sample size, and further studies evaluating the GIMs construct and content validity are needed. Despite these limitations, given the GIMs simplicity and value, paramedic instructors may wish to consider implementation of this device in their training programs.
Adult↗
Is there a role for first responders in EMS responses to medical facilities?
OBJECTIVE: Emergency medical dispatch (EMD) protocols should match response resources with patient needs. We tested a protocol sending only a commercial ambulance, without fire department first responders (FR), to all non-cardiac-arrest EMS calls at a physician-staffed HMO facility. Study objectives were to determine how often FR provided patient care at such facilities and whether EMD implementation could conserve FR resources without compromising patient care. METHODS: All EMS dispatches to this facility in the 4 months before implementation of the EMD protocol and 4 months after implementation were identified through dispatch records, and all FR and ambulance patient care reports were reviewed. In the "after" phase, all cases needing ALS transport were reviewed to examine whether there would have been benefit to FR dispatch. RESULTS: Of 242 dispatches in the "before" phase, BLS FR responded to 156 (64%), and ALS FR to 117 (48%). BLS FR provided patient care in 2 cases, and ALS FR in 17. Of 227 dispatches in the "after" phase, BLS FR responded to 10 (4%), and ALS FR to 10 (4%); all but one were protocol violations. BLS FR provided care in one case, and ALS FR in three. Review of the 93 "after" cases requiring ALS transport found none where FR presence would have been beneficial. CONCLUSIONS: First responders rarely provided patient care when responding to EMS calls at a physician-staffed medical facility. Implementation of an EMD protocol can safely reduce the number of FR responses to unscheduled ambulance calls at such a facility.
Advanced Cardiac Life Support↗