P REDICTED U TILIZATION OF E MERGENCY M EDICAL S ERVICES T ELEMEDICINE IN D ECREASING A MBULANCE T RANSPORTS

Objective. To determine predicted utilization, decrease in ambulance transports, and target population for emergency medical services (EMS) if telemedicine capabilities were available to the medic units in the field. Methods. A retrospective chart review of 345 consecutive ambulance transports to four hospitals (Level I urban trauma center, urban tertiary care center, children's hospital, and suburban community hospital) was performed by a panel of three board-certified emergency medicine physicians experienced and credentialed in emergency telemedicine. They independently reviewed the emergency department (ED) and EMS records and were asked to determine whether patients required ambulance transport for evaluation or whether disposition could be made following paramedic and emergency physician assessment via telemedicine. A five-point Likert scale was used to grade feasibility of telemedicine disposition (definitely yes, probably yes, maybe, probably no, definitely no). Other variables analyzed included age, sex, race, chief complaint, phone, private medical doctor, and call location by patient zip code, call site, and receiving hospital. Results. In 14.7% of cases (6% definitely yes and 8.7% probably yes), disposition could be made without transport using telemedicine. The age range for eliminating transport was 2 weeks through 92 years, with mean age of 26.6 years. Under the age of 50 years, 46 out of 238 patients (19.3%) could have possibly been managed by telemedicine. Conclusion. Use of EMS telemedicine could result in an approximately 15% decrease in ambulance transports when it alone is added to the prehospital care provider's armamentarium. Emphasis for implementation should be placed on younger patients and an identified subset of chief complaints conducive to management using telemedicine.     

U TILIZATION AND I MPACT OF A MBULANCE D IVERSION AT THE C OMMUNITY L EVEL

Objective. To evaluate the utilization and impact of ambulance diversion in the metropolitan area of Syracuse, New York. Methods. This was a retrospective review of the ambulance diversion system operated by the hospitals of Syracuse, New York. This system allows each emergency department to divert incoming ambulances during periods of extreme overcrowding. Data collected included numbers of hours on ambulance diversion by hospital, numbers of hours when all four hospitals were on diversion simultaneously, and numbers of ambulances received while the hospitals were on and off diversion. Results. For three of the five years evaluated, ambulance diversion hours were most numerous during the period between January and March. For the most recent year studied (2000), ambulance diversion hours did not decline after the first quarter. During periods of diversion, hospital emergency departments received 30%–50% fewer ambulances than they did while open. Conclusion. This study demonstrated that, in Syracuse, New York, ambulance diversion was once a seasonal phenomenon, but is increasingly occurring throughout the year because of staff and resource limitations. It also demonstrated that ambulance diversion can be employed to reduce numbers of incoming transports.     

Ambulance Diversion and Emergency Department Offload Delay: Resource Document for the National Association of EMS Physicians Position Statement

Abstract

The emergency medical services (EMS) system is a component of a larger health care safety net and a key component of an integrated emergency health care system. EMS systems, and their patients, are significantly impacted by emergency department (ED) crowding. While protocols designed to limit ambulance diversion may be effective at limiting time on divert status, without correcting overall hospital throughput these protocols may have a negative effect on ED crowding and the EMS system. Ambulance offload delay, the time it takes to transfer a patient to an ED stretcher and for the ED staff to assume the responsibility of the care of the patient, may have more impact on ambulance turnaround time than ambulance diversion. EMS administrators and medical directors should work with hospital administrators, ED staff, and ED administrators to improve the overall efficiency of the system, focusing on the time it takes to get ambulances back into service, and therefore must monitor and address both ambulance diversions and ambulance offload delay. This paper is the resource document for the National Association of EMS Physicians position statement on ambulance diversion and ED offload time.     

H OSPITAL F OLLOW - UP OF P ATIENTS C ATEGORIZED AS N OT N EEDING AN A MBULANCE U SING A S ET OF E MERGENCY M EDICAL T ECHNICIAN P ROTOCOLS

Objective. Using hospital outcomes, this study evaluated emergency medical technicians' (EMTs') ability to safely apply protocols to assign transport options. Methods. Protocols were developed that categorized patients as: 1) needs ambulance; 2) may go to emergency department (ED) by alternative means; 3) contact primary care provider (PCP); or 4) treat and release. After education on application of the protocols, EMTs categorized patients at the scene prior to transport but did not change current practice. Hospital charts were reviewed to determine outcome of patients whom EMTs categorized as not needing an ambulance. Category 2 patients were assumed to need the ambulance if they were admitted to a monitored bed or intensive care unit. Category 3 and 4 patients were assumed to need the ED if they were admitted. Results. The EMTs categorized 1,300 study patients: 1,023 (79%) ambulance transport, 200 (15%) alternative means, 63 (5%) contact PCP, and 14 (1%) treat and release. Hospital data were obtained for 140 (51%) patients categorized as not needing ambulance transport. Thirteen of 140 (9%) patients who transporting EMTs determined did not need the ambulance were considered to be undertriaged: five in category 2, six in category 3, and one in category 4. Six of 13 (46%) undertriaged patients had dementia or a psychiatric disorder as one of their presenting complaints. Conclusion. These protocols led to a 9% undertriage rate. Patients with psychiatric complaints and dementia were at high risk for undertriage.     

Utilization and impact of ambulance diversion at the community level

Objective. To evaluate the utilization and impact of ambulance diversion in the metropolitan area of Syracuse, New York. Methods. This was a retrospective review of the ambulance diversion system operated by the hospitals of Syracuse, New York. This system allows each emergency department to divert incoming ambulances during periods of extreme overcrowding. Data collected included numbers of hours on ambulance diversion by hospital, numbers of hours when all four hospitals were on diversion simultaneously, and numbers of ambulances received while the hospitals were on and off diversion. Results. For three of the five years evaluated, ambulance diversion hours were most numerous during the period between January and March. For the most recent year studied (2000), ambulance diversion hours did not decline after the first quarter. During periods of diversion, hospital emergency departments received 30%-50% fewer ambulances than they did while open. Conclusion. This study demonstrated that, in Syracuse, New York, ambulance diversion was once a seasonal phenomenon, but is increasingly occurring throughout the year because of staff and resource limitations. It also demonstrated that ambulance diversion can be employed to reduce numbers of incoming transports. PREHOSPITAL EMERGENCY CARE 2002;6:191-198     

Road user perceptions of appropriateness of ambulance lights and sirens use in developing countries

IntroductionAmbulance lights and sirens use has traditionally been an important strategy to shorten ambulance travel times. This study explored road users’ perceptions toward the importance and risks of lights and sirens use by ambulances in Jordan.MethodsA cross-sectional survey was used on a sample of 1700 adult road users in Northern Jordan. The questionnaire included 19 items addressing demographics, driving-related characteristics, and perception statements toward lights and sirens use. Continuous variables were summarized as means and standard deviation and categorical variables were reported as frequencies and percentages. Chi-square test was used to assess differences between categorical variable.ResultsA total of 1634 participants completed the questionnaire. The mean age was 32.4 (SD ± 11.4) years, and 65.4% were males. Most participants agreed on the importance of using lights and sirens for emergency medical services to function effectively (96.5%), and penalizing those who do not yield to emergency ambulances (90.2%). However, around half of the participants perceive that lights and sirens could be over-used by ambulance personnel (48.1%), provoke distraction (48.7%) and create stress (50.3%) for road users. These negative perceptions were reported more often among males, taxi/bus drivers, and novice drivers.ConclusionsAlthough the majority of road users, in our region, acknowledge the importance of ambulance lights and sirens use, about half of them perceive that ambulance lights and sirens put them under stress, distraction, and unacceptable risk. Policy-related and educational interventions might be necessary to monitor the use of ambulance lights and sirens and reduce negative road users’ perceptions.     

The Impact of Ambulance Diversion on EMS Resource Availability

Objective. Ambulance diversion has been proposed as a solution to emergency department overcrowding andwaiting room deaths. For ethical andlegal reasons, it remains highly controversial. The impact on EMS resources is not known. This study seeks to determine how diversion impacts the availability of ambulance resources, specifically transport time, hospital turnaround, andtotal out-of-service time. Methods. All emergency ambulance responses in 2002 while one of the city's hospitals was on diversion were collected, including those responses during the hour of the diversion and30 minutes before andafter. The time intervals for these responses were time anddate matched to 2001, if no hospital was on diversion. Total out-of-service time (911 to availability for another call), time from departure from scene to arrival at hospital (transport interval), andtime from arrival at hospital to availability for another call (turnaround time) were compared by using a t-test. Results. The 1,563 instances of diversion were included, with 1,403 controls. Interim analysis allowed calculation of a sample size of 1,049 in each group to show a 2-minute difference in turnaround time and330 calls in each for a 5-minute difference in total out-of-service time (0.25 SD). Transport, hospital turnaround, andtotal out-of-service times were not different between diversion andcontrol time periods. This relies on the accuracy of the status button system andmay not generalize to systems with different geography, diversion policy, number of hospitals, or handling of interfacility transfers. Conclusion. The availability of EMS resources is maintained during times of ambulance diversion. Diversion avoids potential delays associated with sending ambulances to overwhelmed emergency departments.     

The fast emergency vehicle pre-emption system improved the outcomes of out-of-hospital cardiac arrest

PurposesAmbulance response time is a major factor associated with survival in out-of-hospital cardiac arrests (OHCAs); the fast emergency vehicle pre-emption system (FAST?) aids response time by controlling traffic signals. This eight-year observational study investigated whether FAST? implementation reduced response times and improved OHCA outcomes.MethodsData was prospectively collected from 1161 OHCAs that were not witnessed by emergency medical technicians from April 1, 2003, to March 31, 2011. The study took place in Kanazawa city, where ambulances without FAST? (non–FAST?-equipped) were being progressively replaced by new FAST?-equipped ambulances. OHCA data, including the response times recorded in seconds, were collected and compared between the FAST?-equipped and non–FAST?-equipped ambulances. OHCA outcomes were subsequently compared in the subgroup of OHCAs managed by emergency medical technicians without tracheal intubation or epinephrine administration. The primary end-point of this study was one-year (1-Y) survival.ResultsThe median response time significantly differed between the FAST?-equipped and non–FAST?-equipped groups at 327 and 381 s, respectively. The 1-Y survival rates were 7.0% in the FAST?-equipped group and 2.8% in the non–FAST?-equipped group. Logistic regression analysis revealed that the dispatch of a FAST?-equipped ambulance was an independent factor for 1-Y survival (adjusted odds ratio = 3.077, 95% confidence interval = 1.180-9.350).ConclusionsThe FAST? implementation significantly reduced ambulance response times and improved OHCA outcomes in Kanazawa city.     

T EMPORAL T RENDS IN A MBULANCE D IVERSION IN A M ID-SIZED M ETROPOLITAN A REA

Objectives. To evaluate the amount of ambulance diversion in an emergency medical services (EMS) system and to investigate potential predictive factors. Methods. Ambulance diversion status of hospitals in the four-county metropolitan Portland, Oregon, area has been recorded for approximately 15 years. These data are used by EMS transporting agencies to determine appropriate hospital destination for their patients. The authors calculated the total yearly hospital ambulance diversion time for “Total Ambulance Divert (TAD)” and “Critical Care Divert (CCD)” for the time period between January 1, 1996, and December 31, 1999. Yearly EMS 9-1-1-generated patient transport volume, hospital emergency department (ED) census volume, total population, amount of health maintenance organization (HMO) penetration, and number of licensed and available hospital beds were calculated for each yearly interval. Kendall's tau-b correlation was used to determine significant secular trends. Potential predictive factors for the amount of ambulance diversion were tested using Pearson's correlation. Results. Total TAD increased 122.5% (p = 0.04), total CCD increased 64.4% (p = 0.50), total EMS transport volume increased 16.1% (p = 0.04), total ED census increased 9.4% (p = 0.04), total licensed beds decreased 5.7% (p = 0.17), total available beds decreased 15.8% (p = 0.17), HMO penetration increased 4.7% (p = 0.04), and total population increased 9.7% (p = 0.04) over the four-year study period. CCD and TAD were not significantly related to each other (p = 0.50). The only significant factor associated with the increase in TAD was number of available beds (p = 0.03). There were no significant factors associated with CCD. Conclusion. TAD increased significantly over time and was associated only with the decrease in available hospital beds.     

Emt knowledge of ambulance traffic laws

Objective. The safe operation of ambulances using warning lights and siren requires both the public and emergency medical technician (EMT) drivers to understand and obey relevant traffic laws. However, EMTs may be unfamiliar with these laws. The purpose of this study was to evaluate EMTs' knowledge of traffic laws related to the operation of ambulances with warning lights and sirens. Methods. North Carolina EMTs participating in a statewide EMS conference October 6–8, 1995, completed a five-question survey. Knowledge of ambulance speed limits, yielding at intersections, yielding in roadways, and following distances was assessed using a multiple-choice format. Demographic data pertaining to EMT age, years of experience, paid vs volunteer status, driver's education courses, and past accident involvement were also obtained. Proportions were compared using chi-square analysis, alpha = 0.05. Results. Two-hundred ninety-three of 308 (95%) EMTs attending the conference completed questionnaires. The median number of correct responses to the five knowledge questions was 1 (range 0–4). Thirty-three percent of the EMTs knew that other vehicles are required by law to yield while either approaching or being overtaken by an ambulance with warning lights and sirens; 2% knew that due regard for safety is the only requirement of an ambulance approaching a red light at an intersection; 14% knew that the minimum following distance behind an ambulance is one city block; and 28% knew that there is no speed limit on ambulances with warning lights and sirens. Respondents were more likely to score above the median if they had taken one or more emergency driver's education courses or had nine years or more of EMS experience. Conclusion. In this sample, EMT knowledge of basic traffic laws pertaining to ambulance operation is poor. Emergency driver's education courses and increased experience appear to be related to increased knowledge scores. Increased training for EMTs about traffic laws may improve the safe operation of ambulances.     

Tourniquets: A Review of Current Use with Proposals for Expanded Prehospital Use

Objective. To perform an initial screening study of methicillin-resistant Staphylococcus aureus (MRSA) contamination in an ambulance fleet. Methods. This was a cross-sectional study of MRSA contamination in an ambulance fleet operating in the western United States in June 2006. Five specific areas within each of 21 ambulances (n = 105) were tested for MRSA contamination using dacron swabs moistened with a 0.85% sterile saline solution. These samples were then plated onto a screening media of mannitol salt agar containing 6.5% NaCl and4 mcg/mL oxacillin. Results. Thirteen samples isolated from 10 of the 21 ambulances (47.6%) in the sample group tested positive for MRSA. Conclusions. The results of this preliminary study suggest that ambulances operating in the emergency medical services (EMS) system may have a significant degree of MRSA contamination andmay represent an important reservoir in the transmission of potentially serious infections to patients.     

P REHOSPITAL E MERGENCY C ARE , 6 TH E DITION

Abstract

Background. Traumatic brain injury (TBI) represents a serious subset of injuries among persons in the United States, and prehospital care of these injuries can mitigate both the morbidity and the mortality in patients who suffer from these injuries. Guidelines for triage of injured patients have been set forth by the American College of Surgeons Committee on Trauma (ACS-COT) in cooperation with the Centers for Disease Control and Prevention (CDC). These guidelines include physiologic criteria, such as the Glasgow Coma Scale (GCS) score, systolic blood pressure, and respiratory rate, which should be used in determining triage of an injured patient. Objectives. This study examined the numbers of visits at level I and II trauma centers by patients with a diagnosed TBI to determine the prevalence of those meeting physiologic criteria from the ACS-COT/CDC guidelines and to determine the extent of mortality among this patient population. Methods. The data for this study were taken from the 2007 National Trauma Data Bank (NTDB) National Sample Program (NSP). This data set is a nationally representative sample of visits to level I and II trauma centers across the United States and is funded by the American College of Surgeons. Estimates of demographic characteristics, physiologic measures, and death were made for this study population using both chi-square analyses and adjusted logistic regression modeling. Results. The analyses demonstrated that although many people who sustain a TBI and were taken to a level I or II trauma center did not meet the physiologic criteria, those who did meet the physiologic criteria had significantly higher odds of death than those who did not meet the criteria. After controlling for age, gender, race, Injury Severity Score (ISS), and length of stay in the hospital, persons who had a GCS score ≤13 were 17 times more likely to die than TBI patients who had a higher GCS score (odds ratio [OR] 17.4; 95% confidence interval [CI] 10.7–28.3). Other physiologic criteria also demonstrated significant odds of death. Conclusions. These findings support the validity of the ACS-COT/CDC physiologic criteria in this population and stress the importance of prehospital triage of patients with TBI in the hopes of reducing both the morbidity and the mortality resulting from this injury.     

PARTICIPANT DIRECTORY

Objective. To determine the effect of pre-emptive ambulance distribution based on the implementation of a real-time, Internet-accessible emergency department (ED) workload schematic andprehospital Australasian Triage Scale (ATS) allocations on ambulance diversion in Western Australia. Methods. Comparison of July–December 2002 andJuly–December 2003 metropolitan Perth ED cubicle occupancy, ambulance diversion, ambulance distribution, andambulance unloading delays at four inner andfour outer metropolitan EDs. Results. Ambulance diversion fell from 1,788 hours in 2002 to 1,138 hours in 2003 (p < 0.001) despite an increase in mean weekly ED cubicle occupancy from 31 patients (95% confidence internal [CI] 29–33) in 2002 to 39 patients in 2003 (95% CI 36–43, p < 0.001). Inner metropolitan ED ambulance attendances fell 2.7% from 27,475 in 2002 to 26,743 in 2003, andouter metropolitan correspondingly rose from 5,877 to 6,628 ambulance attendances (p < 0.001). Unloading delays were similar in 2002 (219, 0.66%) and2003 (223, 0.67%, p = 0.84); however, median duration of unloading delays increased from 38 minutes (interquartile range [IQR] 18–68) in 2002 to 50 minutes (IQR 25–108) in 2003 (p < 0.001). Conclusions. The implementation of pre-emptive ambulance distribution using Internet-accessible ED information andprehospital ATS allocations was associated with reduced ambulance diversion, probably consequent upon the redistribution of ambulances from inner to outer metropolitan EDs. The rise in ED cubicle occupancy between the study periods suggests that this approach to reducing ambulance diversion should be viewed only as complementary to direct efforts to reduce ambulance diversion by improving hospital inpatient flow andthe balance between acute andelective hospital inpatient accommodation.     

Efficacy of the presence of an emergency physician in prehospital major trauma care: A nationwide cohort study in Japan

PurposeThe beneficial effect of the presence of an emergency physician in prehospital major trauma care is controversial. The aim in this study is to assess whether an emergency physician on scene can improve survival outcome of critical trauma patients.MethodsThis retrospective cohort study was conducted by using nationwide trauma registry data between 2004 and 2013 in Japan. Severe trauma patients (injury severity score (ISS) ≥ 16) who were transported directly to the hospital from the injury site were included in our analysis. Patients who were predicted to be untreatable (abbreviated injury score (AIS) = 6 and/or cardiopulmonary arrest at least one time before hospital arrival) were excluded. Participants were divided into either a physician or paramedics group based on the prehospital practitioner. The primary outcome was survival rate at discharge. Multivariable logistic regression analysis was performed to compare the outcome with adjustment for age, gender, ISS, cause of injury, and pre-hospital vital signs.ResultsA total of 30,283 patients were eligible for the selection criteria (physician: 1222, paramedics: 29,061). Overall, 172 patients (14.1%) died in the physician group compared to 3508 patients (12.1%) in the paramedics group. Patients in the physician group had higher ISSs than those in the paramedics group. In multivariable logistic regression, the physician group had an odds ratio (OR) of 1.16 (95% confidence interval (CI) = 0.97 to 1.40, p = 0.11) for in-hospital survival.ConclusionsOur results failed to show a difference in survival at discharge between non-physician-staffed ambulances and physician-staffed ambulances.     

大型公共活动的急救医疗转运保障——2010年上海世博会急救医疗转运情况汇总分析

目的：汇总分析2010年上海世博会期间急救医疗转运的实际成效及出现的相关问题,以期提高今后大型公共活动急救医疗转运保障能力。方法：采集了上海市医疗急救中心记录的全部8533份世博急救转运随车病案,对运力、转运病患特点、转运时效性、随车救援措施、救援车辆能耗等情况进行了回顾和相应的分析。结果：世博期间,急救转运月平均出车（1238.86±194.23）车次,转运患者（1 192±188.90）人次,有效转运率为90.92%,常规配备的救护车可基本满足日常急救转运需求。转运患者中以创伤患者（37.55%）最为常见,其中又以女性患者居多（62.51%）。园区内转运半径及转运时效性优于全市平均水平,但救援车辆油耗量高于相关要求,且随车急救措施、救护能力及信息记录系统有待进一步完善。另外随车救援实施率仅为34.98%。结论：创伤是上海世博会期间最常见的需转运的疾病类型,世博会期间的医疗运力和时效性基本满足实际需要,但仍可通过改善布局、完善法规、促进民众意识、优化流程、改良设施配备来进一步的提高转运效率,以符合此类大型活动的需求。     

E MERGENCY R ESPONSE T EAM : H URRICANE G EORGES IN K EY W EST

Hurricane Georges (category 2) struck Key West, Florida, on September 25, 1998. Lower Florida Keys Hospital, which serves Key West and the Lower Keys, had previously been evacuated of inpatients and staff. An emergency response team composed of three emergency medicine (EM) physicians and four EM nurses was sent at the request of the state to maintain emergency department (ED) operations at the hospital. Eighty-six patients presented to the ED during the 72-hour period. Medical problems accounted for the majority of visits (52.3%), with minor trauma next (41.9%). Initially, patients requiring hospitalization were evacuated, but as the storm neared, this was stopped. Six patients required hospitalization at Lower Florida Keys Hospital during the period that evacuations were unavailable. Four deaths occurred during the 24-hour period. Complicating factors included environmental conditions, limited laboratory and radiologic studies, limited medication stocks, and closure of local pharmacies before and after the hurricane. More than 300 nursing home patients were housed at the nearby jail shelter. Knowledge of such high-risk groups that remain in the vicinity is crucial to planning a response plan.