Epidemiology of Pediatric Transports andNon-Transports in an Urban Emergency Medical Services System

Objective. This study was done to describe an urban, Emergency Medical Service (EMS) system's experiences with pediatric patients andthe rate andcharacteristics of non-transports in this setting. Methods. A retrospective analysis of all pediatric patients responded to by the Detroit Fire Department Division of EMS between January 1, 2002 andAugust 30, 2002 was done. Results. There were 5,976 pediatric EMS cases. Children 10 years of age or older accounted for 49.4% of transports, 53.8% of all patients had medical illness, and38.8% of the patients belonged to the non-urgent category. A large percentage of patients were not transported (27.2%), most commonly secondary to parent/caregiver/patient refusals. The median number of minutes on-scene for refusals was longer than for transports (23.5 vs. 17.3, respectively)[difference = 6.2 minutes (95% CI: 5.6–6.9)]. The odds ratios (OR) for refusal was highest for assaults (2.09; 95% CI: 1.66–2.63), difficulty in breathing (1.38; 95% CI: 1.14–1.68), andmotor vehicle accidents (1.19; 95% CI: 1.04–1.37). Conclusions. In this system, the majority of pediatric patients are not severely ill, anda large number are not transported. Non-transports are more likely to be young adolescents, have been involved in assaults, andhave a longer on-scene time.     

Methicillin-resistant Staphylococcus aureus in Ohio EMS Providers: A Statewide Cross-sectional Study

The objective was to determine the nasal carriage prevalence of methicillin-resistant Staphylococcus aureus (MRSA) among emergency medical service (EMS) personnel and the associated risk factors. A cross-sectional study was conducted among Ohio EMS personnel randomly sampled from 84 urban and rural agencies. Surveys assessing demographics, occupational history, health, cohabitation status, and hygiene practice were collected with nasal swabs from those who enrolled. Survey weight adjusted analysis was performed (1) to estimate MRSA nasal carriage prevalence of Ohio EMS providers, and (2) to identify variables associated with MRSA. MRSA was detected in 4.6% (13/280) EMS personnel sampled. After employing a survey-weighted analysis the following risk factors associated with MRSA carriage were identified: those who did not practice frequent hand hygiene after glove use (OR, 10.51; 95% CI, 2.54–43.45; P = 0.0012), living with someone with a recent staphylococcal infection (OR, 9.02; 95% CI, 1.03–78.98; P = 0.0470), and individuals with low frequency of hand washing (< 8 times per shift) (OR, 4.20; 95% CI 1.02–17.27; P = 0.0468). An additional risk factor identified through the logistic regression analysis on the study population was EMS workers with an open wound or skin infection (OR, 6.75; 95% CI, 1.25–36.36; P = 0.0262). However, this was not significant in the survey-weighted analysis. The high prevalence of MRSA in Ohio EMS personnel is both an occupational hazard and patient safety concern. Implementing methods to reinforce CDC guidelines for proper hygiene could decrease MRSA found in the EMS setting. Previous literature suggests that a reduction in MRSA colonization can lead to decreases in transmission and improved health for both patients and personnel.     

Physician Medical Direction andClinical Performance at an Established Emergency Medical Services System

Objective. Few developed emergency medical services (EMS) systems operate without dedicated medical direction. We describe the experience of Hamad Medical Corporation (HMC) EMS, which in 2007 first engaged an EMS medical director to develop andimplement medical direction andquality assurance programs. We report subsequent changes to system performance over time. Methods. Over one year, changes to the service's clinical infrastructure were made: Policies were revised, paramedic scopes of practice were adjusted, evidence-based clinical protocols were developed, andskills maintenance andeducation programs were implemented. Credentialing, physician chart auditing, clinical remediation, andonline medical command/hospital notification systems were introduced. Results. Following these interventions, we report associated improvements to key indicators: Chart reviews revealed significant improvements in clinical quality. A comparison of pre- andpost-intervention audited charts reveals a decrease in cases requiring remediation (11% to 5%, odds ratio [OR] 0.43 [95% confidence interval (CI) 0.20–0.85], p = 0.01). The proportion of charts rated as clinically acceptable rose from 48% to 84% (OR 6 [95% CI 3.9–9.1], p < 0.001). The proportion of misplaced endotracheal tubes fell (3.8% baseline to 0.6%, OR 0.16 [95% CI 0.004–1.06], (exact) p = 0.05), corresponding to improved adherence to an airway placement policy mandating use of airway confirmation devices andsecuring devices (0.7% compliance to 98%, OR 714 [95% CI 64–29,334], (exact) p < 0.001). Intravenous catheter insertion in unstable cases increased from 67% of cases to 92% (OR 1.31 [95% CI 1.09–1.71], p = 0.004). EMS administration of aspirin to patients with suspected ischemic chest pain improved from 2% to 77% (OR 178 [95% CI 35–1,604], p < 0.001). Conclusions. We suggest that implementation of a physician medical direction is associated with improved clinical indicators andoverall quality of care at an established EMS system     

U SE OF E MERGENCY M EDICAL S ERVICES FOR S USPECTED A CUTE C ARDIAC I SCHEMIA AMONG D EMOGRAPHIC AND C LINICAL P ATIENT S UBGROUPS : T HE REACT T RIAL

Objective. Barriers to the use of emergency medical services (EMS) and patient delay in seeking care can limit the receipt or effectiveness of reperfusion therapies and the availability of prehospital emergency cardiac care. The Rapid Early Action for Coronary Treatment (REACT) trial was designed to determine the impact of a community intervention on use of EMS among demographic and clinical subgroups of patients with suspected acute cardiac ischemia. Methods. A randomized controlled community trial was conducted in 20 pair-matched communities in the United States. One community from each pair received an 18-month, multicomponent community education program. Data were collected at 44 participating hospitals during a four-month baseline period and throughout the 18-month trial, using medical record abstracts to collect information on mode of transport to the hospital and other sociodemographic and clinical variables. Eligible patients were persons aged ≥30 years presenting with chest pain or discomfort to emergency departments (EDs) who were admitted and discharged with a cardiac-related diagnoses (ICD 410-414, 427-429, 440, 786.9). Results. The net change in the odds of EMS use was an increase of 34% in intervention compared with control communities [adjusted odds ratio (OR) 1.34, 95% CI 1.07–1.67]. We observed greater increases in the odds of EMS use among patients who had chronic or other cardiac diagnoses (adjusted OR 1.53, 95% CI 1.18–1.99, and adjusted OR 1.52, 95% CI 1.17–1.97, respectively) than in those diagnosed as having acute ischemia (adjusted OR 1.14, 95% CI 0.91-1.44). We observed greater increases in odds of EMS use in those who were retired (adjusted OR 1.62, 95% CI 1.29–2.04) or had systolic blood pressure (SBP) at or below 160?mm Hg upon presentation to the ED (adjusted OR 1.55, 95% CI 1.26–1.91 for SBP 100-160 mm Hg; 1.61, 95% CI 0.88–2.97 for SBP <100?mm Hg). Conclusions. The REACT trial demonstrated a significant impact on the use of EMS among patients admitted to the hospital for suspected acute myocardial infarction, with greater increases among patients with chronic or other cardiac ICD-9 discharge diagnoses, those presenting with lower SBP, and retired persons.     

Derivation of a Termination-of-resuscitation Guideline for Emergency Medical Technicians Using Automated External Defibrillators

OBJECTIVES: To determine the association between characteristics of cardiac arrest and survival to hospital discharge following failed resuscitation by defibrillation-trained emergency medical technicians (EMT-Ds), and to propose an out-of-hospital termination-of-resuscitation (TOR) guideline for EMT-Ds. METHODS: A 22-month retrospective review of 700 out-of-hospital primary cardiac arrest patients in a large emergency medical services (EMS) system who received exclusively EMT-D care. RESULTS: Seven hundred primary cardiac arrest patients were identified. Follow-up was obtained in 662 cases (94.6%). Of these, 36 (5.4%) achieved a return of spontaneous circulation (ROSC) prior to transport. Among the 626 patients who failed to achieve ROSC at any time, two (0.3%) survived to discharge. Multivariate analysis showed that ROSC at any time had the strongest association with survival [odds ratio (OR) 45.5; 95% confidence interval (95% CI) = 8.5 to 243.7]. A shock prior to transport (OR 6.9; 95% CI = 1.2 to 40.3) and cardiac arrest witnessed by EMS personnel (OR 4.4; 95% CI = 1.0 to 18.5) were also independently associated with survival. These variables were incorporated into a TOR guideline. The guideline was 100% sensitive (95% CI = 99.1 to 100) in identifying survivors and had 100% negative predictive value (95% CI = 75.3 to 100) for identifying nonsurvivors of out-of-hospital cardiac arrest in the study population. CONCLUSIONS: In this EMS system, cardiac arrest patients may be considered for out-of-hospital TOR following EMT-D resuscitation attempts when there has been no ROSC, no shock has been given, and the arrest was not witnessed by EMS personnel. These guidelines require prospective validation.     

Effect of Airway-Securing Method on Prehospital Endotracheal Tube Dislodgment

Abstract

Objective. We compared the effectiveness of common airway-securing techniques in preventing endotracheal tube (ETT) dislodgment in the prehospital setting. Methods. This was a prospective, observational, multicenter study conducted at 42 emergency medical services (EMS) agencies. EMS providers completed structured, closed-response data forms for all endotracheal intubation (ETI) attempts during an 18-month period. We included all successful intubations as well as failed ETIs in which ETT securing was performed. EMS providers indicated methods used to secure the ETT, including the use of adhesive tape to the face (face tape), tape wrapped around the neck (neck tape), woven twill or umbilical tape (twill tape), intravenous or oxygen tubing (tubing), commercial tube holders, and manual stabilization/none. Providers also indicated the concurrent use of a cervical collar and/or cervical immobilization device (CID) with backboard. ETT dislodgment was reported by providers. We evaluated the rates and odds of ETT dislodgment for each tube-securing technique using multivariate logistic regression. Results. Of 1,732 patients undergoing tube-securing efforts, ETT dislodgment occurred in 51 (2.9%). ETT dislodgment rates were as follows: tube held manually, four of 32 (12.5%); face tape, 13 of 292 (4.5%); neck tape, nine of 205 (4.4%); twill tape, zero of 67 (0%); tubing, one of 30 (3.3%); commercial tube holders, 25 of 1,111 (2.3%); cervical collar, two of 121 (1.7%); and CID, 12 of 377 (3.2 %). On multivariate regression, when compared with securing the tube with face tape, only manually holding the tube in place showed a significant difference in the odds of dislodgment (odds ratio [OR] 5.0, 95% confidence interval [CI] 1.2–15.2). Whereas cardiac arrest and trauma did not increase the odds of ETT dislodgment (OR 1.3, 95% CI 0.7–2.6; and OR 0.3, 95% CI 0.1–1.4, respectively), patient age less than 5 years was associated with ETT dislodgment (OR 6.6, 95% CI 2.2–19.7). Conclusion. In this multicenter observational series, the odds of ETT dislodgment were similar for face tape, neck tape, twill tape, plastic tubing, and commercial tube holders. ETT dislodgment did not occur with woven twill tape. Patients under 5 years of age are at heightened risk for ETT dislodgment.     

Prompt Advanced Life Support Improves Survival from Ventricular Fibrillation

Objective. To determine whether the interval between the arrival of basic life support (BLS) providers and the arrival of advanced life support (ALS) providers is associated with patient outcome after cardiac arrest. Methods. We conducted a retrospective cohort study of all witnessed, out-of-hospital ventricular fibrillation (VF) cardiac arrests between January 1, 1991, and December 31, 2007. Eligible patients (n = 1,781) received full resuscitation efforts from both BLS and ALS providers. Results. The BLS-to-ALS arrival interval was a significant predictor of survival to hospital discharge (odds ratio [OR] 0.96, 95% confidence interval [CI] 0.93–0.99); the likelihood of survival decreased by 4% for every minute that ALS arrival was delayed following BLS arrival. Other significant predictors of survival were whether the arrest occurred in public (OR 1.48, 95% CI 1.19–1.85), whether a bystander administered cardiopulmonary resuscitation (CPR) (OR 1.34, 95% CI 1.07–1.68), and the interval between the 9-1-1 call and BLS arrival (OR 0.78, 95% CI 0.73–0.83). Conclusions. We found that a shorter BLS-to-ALS arrival interval increased the likelihood of survival to hospital discharge after a witnessed, out-of-hospital VF cardiac arrest. We conclude that ALS interventions may provide additional benefits over BLS interventions alone when utilized in a well-established, two-tiered emergency medical services (EMS) system already optimized for rapid defibrillation. The highest priorities in any EMS system should still be early CPR and early defibrillation, but timely ALS services can supplement these crucial interventions.     

Factors Related to the Sensitivity of Emergency Medical Service Impression of Stroke

Abstract

Objectives. To examine factors related to sensitivity of emergency medical services (EMS) stroke impression. Methods. We reviewed ambulance and hospital records of all patients transported to Long Island College Hospital between January 1, 2009 and January 1, 2011 by the hospital-based EMS with a discharge diagnosis of stroke or a confounding diagnosis, and compared EMS impression to hospital discharge diagnosis. We examined relationships between EMS diagnostic sensitivity and age, gender, ethnicity, NIH Stroke Scale (NIHSS), motor signs, aphasia, neglect, lesion side, circulation, stroke type, EMS provider level, and documented Cincinnati Pre-hospital Stroke Scale (CPSS) with contingency analysis and logistic regression. Results. Stroke was validated in 18% (56/310) of patients and 50% (28/56) of these were missed by EMS. EMS diagnostic sensitivity was 50% (95% CI: 36–64%), and was related to NIHSS quartile (p = 0.014), with higher sensitivities in 2nd (69%; 95% CI: 44–86%) and 3rd (75%; 95% CI: 47–91%) vs. 1st (20%; 95% CI: 7–45%) and 4th (45%; 95% CI: 21–72%) quartiles, motor signs (62 vs. 14%, p = 0.002), and documented CPSS (84 vs. 32%, p = 0.0002). EMS impression was independently related to NIHSS quartile (1st vs. 2nd adjusted OR = 9.61, 1.13–122.03, p = 0.038) and CPSS (adjusted OR = 12.58, 2.22–111.06, p = 0.003). Conclusion. Stroke was missed more frequently when CPSS was not documented, in patients without motor signs, and in patients with moderate–severe stroke. The sensitivity of prehospital screening for patients with moderate–severe stroke might be improved by including additional non-motor signs and by stressing indications for when screens should be performed.     

Does second EMS unit response time affect outcomes of OHCA in multi-tiered system? A nationwide observational study

ObjectivesThe time dependence of a multi-tier response for out-of-hospital cardiac arrest (OHCA) is unclear. The aim of this study was to evaluate the time-dependent effect of EMS response type in a multi-tiered system on the clinical outcomes of OHCA.MethodsAdult EMS-treated OHCA of presumed cardiac etiology who were not witnessed by EMS between January 2015 and December 2017 were included. The main exposure was EMS response type: single-tier response, early multi-tier response (0–18 min from call to second EMS arrival), and late multi-tier response (19 min from call to second EMS arrival). The primary outcome was good neurologic recovery at the time of discharge from the hospital. Multivariate logistic regression analysis was performed, adjusting for patient–community and prehospital variables.ResultsAmong 54,436 patients, 29,995 patients (55.1%), 21,552 patients (39.6%), and 2889 patients (5.3%) were treated by single-tiered EMS, early multi-tiered EMS, and late multi-tiered EMS, respectively. Good neurological recovery and survival to discharge were more frequent in the early multi-tiered response group (6.4% and 9.7%) than in the single-tiered response group (4.8% and 7.5%) or late multi-tiered response group (3.1% and 5.8%). Compared to the single-tiered response group, the early multi-tiered response group was more likely to have good neurological recovery (adjusted OR, 95% CI: 1.15 [1.06–1.26]), but the late multi-tiered response group was less likely to have good neurological recovery (adjusted OR, 95% CI: 0.76 [0.61–0.96]).ConclusionIn our basic to intermediate–tiered EMS system, early multi-tier response was associated with improved survival and good neurological recovery.     

Systematic Review and Meta-analysis of the Effects of Caffeine in Fatigued Shift Workers: Implications for Emergency Medical Services Personnel

Abstract

Background: Emergency Medical Services (EMS) workers may experience fatigue as a consequence of shift work. We reviewed the literature to determine the impact of caffeine as a countermeasure to fatigue in EMS personnel and related shift workers. Methods: We employed the GRADE methodology to perform a systematic literature review and search multiple databases for research that examined the impact of caffeine on outcomes of interest, such as patient and EMS personnel safety. For selected outcomes, we performed a meta-analysis of pooled data and reported the pooled effect in the form of a Standardized Mean Difference (SMD) with corresponding 95% confidence intervals. Results: There are no studies that investigate caffeine use and its effects on EMS workers or on patient safety. Four of 8 studies in shift workers showed that caffeine improved psychomotor vigilance, which is important for performance. Caffeine decreased the number of lapses on a standardized test of performance [SMD = 0.75 (95% CI: 0.30 to 1.19), p = 0.001], and lessened the slowing of reaction time at the end of shifts [SMD = 0.52 (95% CI: 0.19 to 0.85); p = 0.002]. Finally, 2 studies reported that caffeine reduced sleep quality and sleep duration. Conclusions: Although the quality of evidence was judged to be low to moderate, when taken together, these studies demonstrate that caffeine can improve psychomotor performance and vigilance. However, caffeine negatively affects sleep quality and sleep duration. More systematic, randomized studies need to be conducted in EMS workers in order to address the critical outcomes of health and safety of EMS personnel and patients. The risk/benefit ratio of chronic caffeine use in shift workers is currently unknown.     

Failed extubation in a tertiary-level hospital intensive care unit,Pretoria, South Africa

Background A prospective cohort study sought to measure the incidence and outcomes of failed extubation in Dr George Mukhari Academic Hospital intensive care unit (ICU), as well as to identify possible factors associated with failed extubation. Methods Data were collected over a 6-month period from 1 July 2015 to 31 December 2015. Pre-intubation parameters recorded on the data collection sheet included secretions, Glasgow Coma Scale (GCS), fluid balance, Tobin index, partial pressure of carbon dioxide (pCO₂ ), partial pressure of oxygen (PaO₂ ), comorbidities and weaning method. Results A total of 242 patients were enrolled over the 6-month study period. Of the 242 patients, 86 were excluded owing to pre-set exclusion criteria (death before extubation; tracheostomy before extubation; re-intubation >72 hours post extubation). An extubation failure rate of 16.7% (n=26) was observed. The incidence of ventilator-associated pneumonia in the failed extubation group was 19.23%, whereas death was recorded in 42.31% of patients who failed extubation. The average length of ICU stay in the reintubated group was 11.58 days, and 4.04 days for successfully extubated patients. Only low GCS had a statistically significant impact on failed extubation: p=0.0025; odds ratio (OR) for low v. normal 5.13 (95% confidence interval (CI) 1.78 - 14.79). Other predictor variables measured did not reach statistical significance. Weaning method: p=0.3737, OR for No T-piece v. T-piece 1.65 (95% CI 0.547 - 4.976); comorbidities: p=0.5914, OR for two or more comorbidities v. no comorbidities 2.079 (95% CI 0.246 - 17.539), no comorbidities v. single comorbidity 0.802 (95% CI 0.211 - 3.043); fluid balance: p=0.6625, OR for negative v. positive fluid balance 0.571 (95% CI 0.170 - 1.916), OR for neutral v. positive fluid balance <0.001 (95% CI <0.001 - >999.999); pCO₂ : p=0.7510, OR for high v. normal pCO₂ 1.344 (95% CI 0.346 - 5.213), OR for low v. normal pCO₂ 1.515 (95% CI 0.501 - 4.576); PaO₂ : p=0.4405, OR for high v. normal 1.156 (95% CI 0.382 - 3.494); OR for low v. normal PaO₂ 2.638 (95% CI 0.553 - 12.587); Tobin index (Fischer’s exact test): p=0.7476. Conclusion Low pre-extubation GCS is a predictor of failed extubation. Contributions of the study The study is a prospective observational study conducted in a high-volume referral hospital. It adds valuable scientific information to a growing body of data on the topic of extubation failure. It further reinforces the importance of extubation failure and the requirement for due diligence to be paid before a patient is extubated.     

Factors influencing critical care nurses’ intentions to use physical restraints adopting the theory of planned behaviour: A cross-sectional multicentre study

BackgroundStudies addressing critical care nurses' practices regarding physical restraints have focused on individual nurses' knowledge and attitudes but lack the understanding of other social influences that could affect nurses’ intentions to use them.ObjectiveThe objective of this study was to determine critical care nurses’ attitudes, subjective norms, perceived behavioural control, and intentions to use physical restraints in intubated patients and the relationship between them and sociodemographic, professional, and contextual factors using a survey approach.MethodsA cross-sectional, multicentre study was conducted in a convenience sample of 12 intensive care units from eight hospitals in Spain (n = 354). The Physical Restraint-Theory of Planned Behaviour questionnaire and a researcher-developed survey were used to collect structural and clinical data from each unit. Multilevel model analysis was used.ResultsCritical care nurses showed a moderate level of intention to use physical restraints 12.52 (standard deviation = 3.81) [3–21]. More than a half (52%) agreed restraints were safe. The highest perceived barrier against physical restraint use was patient cooperation. Although nurses did not feel that others expected them to use restraints, they did not perceive high levels of disapproval of such practice. Nurses who had received previous training on restraints and who worked in units with a flexible family visitation policy, an informed consent form for restraint use, analgosedation and restraint protocols, and nurse-driven analgosedation management reported lower levels of intention to use restraints. Working in smaller units (beta −1.81; 95% confidence interval [CI]: −0.18, −3.44) and working in units with a consent form for restraint use (beta −4.82; 95% CI: −2.80, −6.85) were the variables with the highest impact on nurses’ intentions to use restraints.ConclusionsCritical care nurses’ intentions to use physical restraints are moderate and are influenced by intrapersonal, patient, and contextual factors. Nurses who work in units with organisational policies and alternatives to restraints demonstrated lower levels of intention to use them.     

Association between ambulance response time and neurologic outcome in patients with cardiac arrest

PurposeEmergency medical services (EMS) response time is one of prehospital factors associated with survival rate of patients with out-of-hospital cardiac arrest (OHCA). The objective of this study was to determine whether short EMS response time was associated with improved neurologic outcome of patients with OHCA through prospective analysis.MethodsWe performed a prospective observational analysis of collected data from KoCARC registry between October 2015 and December 2016. OHCA patients aged 18 years or older with presumed cardiac etiology by emergency physicians in emergency department were included in this study.ResultsOf 3187 cardiac arrest patients enrolled in the KoCARC registry, 2309 patients were included in the final analysis. Response time threshold was 11.5 min for prehospital return of spontaneous circulation and 7.5 min for survival to discharge and favorable neurologic outcome. Patients in the ≤7.5 min response time group showed increased odds of survival to discharge (OR: 1.54, 95% CI: 1.13–2.10, p = .006) and favorable neurologic recovery (OR: 2.01, 95% CI: 1.36–2.99, p = .001). When response time was decreased by 1 min, all outcomes were improved (survival to discharge, OR: 1.08; 95% CI: 1.04–1.12, p < .001; favorable neurological outcome, OR: 1.14, 95% CI: 1.07–1.21, p < .001).ConclusionWe found that shorter EMS response time could lead to favorable neurologic outcome in patients with OHCA of presumed cardiac origin. EMS response time threshold associated with improved favorable outcome was ≤7.5 min.     

National Characteristics of Emergency Medical Services Responses for Older Adults in the United States

Objective: Older adults, those aged 65 and older, frequently require emergency care. However, only limited national data describe the Emergency Medical Services (EMS) care provided to older adults. We sought to determine the characteristics of EMS care provided to older adults in the United States. Methods: We used data from the 2014 National Emergency Medical Services Information System (NEMSIS), encompassing EMS response data from 46 States and territories. We excluded EMS responses for children <18 years, interfacility transports, intercepts, non-emergency medical transports, and standby responses. We defined older adults as age ≥65 years. We compared patient demographics (age, sex, race, primary payer), response characteristics (dispatch time, location type, time intervals), and clinical course (clinical impression, injury, procedures, medications) between older and younger adult EMS emergency 9-1-1 responses. Results: During the study period there were 20,212,245 EMS emergency responses. Among the 16,116,219 adult EMS responses, there were 6,569,064 (40.76%) older and 9,547,155 (59.24%) younger adults. Older EMS patients were more likely to be white and the EMS incident to be located in healthcare facilities (clinic, hospital, nursing home). Compared with younger patients, older EMS patients were more likely to present with syncope (5.68% vs. 3.40%; OR 1.71; CI: 1.71–1.72), cardiac arrest/rhythm disturbance (3.27% vs. 1.69%; OR 1.97; CI: 1.96–1.98), stroke (2.18% vs. 0.74%; OR 2.99; CI: 2.96–3.02) and shock (0.77% vs. 0.38%; OR 2.02; CI: 2.00–2.04). Common EMS interventions performed on older persons included intravenous access (32.02%), 12-lead ECG (14.37%), CPR (0.87%), and intubation (2.00%). The most common EMS drugs administered to older persons included epinephrine, atropine, furosemide, amiodarone, and albuterol or ipratropium. Conclusion: One of every three U.S. EMS emergency responses involves older adults. EMS personnel must be prepared to care for the older patient.     

Use of Out-of-hospital Interventions for the Pediatric Patient in an Urban Emergency Medical Services System

OBJECTIVE: To determine appropriateness of out-of-hospital interventions by emergency medical services (EMS) personnel on children with respiratory illnesses. METHODS: A retrospective, cross-sectional study was performed on a random sample of 304 children transported by an urban EMS system during 1994. Data were abstracted from EMScan (a computerized database of all EMS dispatches) and the EMS narrative records. Appropriate utilization of interventions was determined by comparison with the standard EMS protocol for respiratory complaints in this system. An assessment of whether interventions were inappropriately underutilized or inappropriately overutilized was made. Effect of severity of illness, patient age, transport times, and use of medical command on the use of interventions was evaluated. RESULTS: Two hundred three patients (67%) were classified as having respiratory distress. Overall, 56% of the patients received appropriate interventions, 39% received one or two inappropriate interventions, and 5% received three or more inappropriate interventions. Rates of inappropriate utilization with 95% CI for each intervention were: oxygen 16% (95% CI = 12 to 20), assisted ventilation 2% (95% CI = 0.5 to 4), medication use 9% (95% CI = 6 to 13), vascular access 11% (95% CI = 7 to 14), phlebotomy 9% (95% CI = 6 to 13), and cardiac monitoring 18% (95% CI = 14 to 22). Oxygen and medications were underutilized (p < 0.005), whereas vascular access, cardiac monitoring, and phlebotomy were overutilized (p < 0.005). Online medical command (used in 9% of transports) improved appropriate use of vascular access [OR 8.3 (95% CI = 3 to 25) (p < 0.001)] and cardiac monitoring [OR = 3 (95% CI = 1 to 8) (p < 0.05)]. CONCLUSIONS: Emergency medical services personnel underutilized oxygen and medications and overutilized vascular access, phlebotomy, and cardiac monitoring in children with respiratory illness in this urban setting. Increasing patient age, transport times, and illness severity tend to increase the use of certain interventions, while contact with online medical direction seems to improve appropriate use of interventions.     

Identifying potential predictors of high-quality oral anticoagulation assessed by time in therapeutic international normalized ratio range: a prospective, long-term, single-center, observational study

BackgroundThe efficacy and risks of oral anticoagulation are largely associated with maintaining the quality of anticoagulation control. Nevertheless, few studies have addressed which factors, if any, are associated with this control.ObjectiveThis study aimed to identify predictors of high-quality oral anticoagulation.MethodsA prospective observational study enrolled all adult patients on intended long-term oral anticoagulation attending a public anticoagulation clinic. Patients with high-quality anticoagulation, defined as percentage of time in therapeutic international normalized ratio (INR) range (TTR) ≥66%, were compared with those with poor anticoagulation control (TTR <66%). Measures included cognitive, psychological, and relevant behavioral factors, in addition to traditionally implicated ones, such as age, comorbidity, and concurrent medications.ResultsParticipation was requested from all 233 patients followed up at the anticoagulation clinic. Eighty-six did not meet the inclusion criteria (49 due to intended anticoagulation duration <90 days, 37 due to the need for a caregiver responsible for medications). A total of 147 patients were enrolled, of whom 13 (8.8%) were lost to follow-up. Therefore, data were analyzed from 134 patients (mean [SD] age, 55 [14.2] years [range, 19–87 years]), who were followed up for a mean (SD) duration of 272 (87) days. The total mean TTR was 64.7%, which is comparable to values achieved in clinical trials. The good-control group had 61 patients (45.5%) (mean TTR, 77.7% [8.5%]) and the poor-control group had 73 patients (54.5%) (mean TTR, 50.4 [11.7%]). On multivariate logistic regression analysis, high-quality anticoagulation was independently associated with regular vitamin K intake, expressed by its variability in daily dosage (odds ratio [OR] = 0.79; 95% CI, 0.64–0.98); male sex (OR = 2.41; 95% CI, 1.06–5.49); duration of anticoagulation treatment >2 months (OR = 3.23; 95% CI, 1.25–8.36); presence of family support (OR = 3.32; 95% CI, 1.16–9.48); functional and cognitive ability to take medications as prescribed, defined as good medication management capacity (MMC; as assed using the Drug Regimen Unassisted Grading Scale) (OR = 4.18; 95% CI, 1.63–10.68); and no regular use of alcohol (OR = 8.59; 95% CI, 1.45–51.09).ConclusionsThe data suggest that independent predictors of high-quality oral anticoagulation included regular vitamin K intake, male sex, duration of anticoagulation treatment >2 months, presence of family support, good MMC, and no regular alcohol use. These findings may help clinicians to decide whether to start anticoagulation in intermediate-risk patients, to identify patients who will require closer attention on their anticoagulation management, and to direct their efforts to improve the quality of oral anticoagulation.     

Association between adopting emergency department crowding interventions and emergency departments' core performance measures

ObjectivesTo estimate the association between adopting emergency department (ED) crowding interventions and emergency departments' core performance measures.MethodsWe analyzed the National Hospital Ambulatory Medical Care Survey (NHAMCS) data from 2007 to 2015. The outcome variables are ED length of stay for discharged and admitted patients, boarding time, wait time and percentage of patients who left ED before being seen (LWBS). The independent variables are whether or not a hospital adopted each of the 20 crowding interventions. Controlling for patient-level, hospital level and temporal confounders we analyze and report results using multivariable logit model.ResultsBetween 2007 and 2015, NHAMCS collected data for 269,721 ED visit encounters, representing a nationwide of about 1.18 billion separate ED visits. Of 20 crowding interventions we tested, using adopting bedside registration (OR = 0.89, 95% CI = 0.75–0.98, P < .05), electronic dashboard (OR = 0.86, 95% CI = 0.76–0.98, P < .05), kiosk check-in technology (OR = 0.56, 95% CI = 0.41–0.83, P < .001), physician based triage (OR = 0.86, 95% CI = 0.73–0.99, P < .05) full capacity protocol (OR = 0.91, 95% CI = 0.79–0.99, P < .05) are associated with decrease in the odds of prolonged wait time. Adopting kiosk check-in (OR = 0.55, 95% CI = 0.35–0.85, P < .05) is associated with a decrease in the odds of prolonged boarding time. Using wireless communication devices (OR = 0.77, 95% CI = 0.57–0.97, P < .05), bedside registration (OR = 0.77, 95% CI = 0.64–0.094, P < .05) and pooled nursing (OR = 0.84, 95% CI = 0.72–0.98, P < .05) are associated with decrease in the odds of a patient LWBS.ConclusionsMajority of interventions did not significantly associated with ED' core performance measures.     

Violence against emergency medical services personnel

Background. Emergency medical services (EMS) providers may be exposed to violent behavior while performing their routine duties. Objectives. To determine the prevalence of violence against EMS providers in the prehospital setting and to determine factors associated with such violence. Methods. Consecutive medical calls for EMS agencies in a southern California metropolitan area were prospectively analyzed for one month. Following each call, prehospital personnel recorded information about any episodes of violence (verbal or physical) during the run as well as variables felt to be associated with these behaviors. Results. There were 4,102 cases available for analysis. Overall, some sort of violence occurred in 8.5% (349/4,102) of patient encounters. Of this reported violence, 52.7% (184/349) was directed against prehospital care providers, while 47.3% (165/349) was directed against others. The prevalence of violence directed against prehospital care personnel was therefore 4.5% (184/4,102). Patients accounted for most (89.7%; 165/184) of this violent behavior. The type of violence varied, with 20.7% (38/184) being verbal only, 48.9% (90/184) being physical, and 30.4% (56/184) constituting both verbal and physical attacks. Male sex, patient age, and hour of the day were significantly associated with episodes of violence. Logistic regression analysis provided odds ratios (ORs) with confidence intervals (CIs) for factors that were predictive of violent behavior. These included police presence (OR 2.8; 95% CI 1.8-4.4), apparent presence of gang members (OR 2.9; 95% CI 1.6-5.3), perceived psychiatric disorder (OR 5.9; 95% CI 3.5-9.9), and perceived presence of alcohol or drug use (OR 7.0; 95% CI 4.4-11.2). Conclusion. Emergency medical services providers in some areas are at substantial risk for encountering violence in the prehospital setting. Certain situational factors may be used to predict the risk of encountering violence. Training, protocols, and protective gear for dealing with violent situations should be encouraged for all prehospital personnel. PREHOSPITAL EMERGENCY CARE 2002;6:186-190     

Outcomes of Prehospital Chemical Sedation With Ketamine Versus Haloperidol and Benzodiazepine or Physical Restraint Only

Objective: The goal of this study is to describe complications and outcomes of prehospital ketamine use for agitation as compared to other methods of physical or chemical restraint such as haloperidol plus benzodiazepine or physical restraint only. Methods: We conducted a single-center retrospective review of patient encounters in which restraint was administered in the prehospital setting. At the beginning of our study window, only physical restraint was available to paramedics managing agitated patients but subsequently, haloperidol and benzodiazepines were introduced, followed by ketamine 2 years later. By comparing patients before and after each transition, we divided subjects into 3 cohorts based on restraint type: physical restraint, haloperidol plus benzodiazepine, and ketamine. Demographic data were collected, and outcome measures included intubation rate, need for additional physical or chemical restraint, emergency department (ED) length of stay, need for hospital admission, and employee injury. Results: Of 214 subjects included in the study, 95 patients were administered ketamine, 68 received haloperidol and benzodiazepine, and 51 were physically restrained. Eleven of the patients (11.6%) who received ketamine were intubated. Compared to patients who received haloperidol plus benzodiazepine, patients who received ketamine were more likely to be intubated (odds ratio [OR]?=?8.77, 95% confidence interval [CI], 1.10–69.68) and were more likely to require additional chemical restraint when compared to haloperidol/benzodiazepine or physical restraint only (OR =2.94, 95% CI, 1.49–5.80, and OR =2.15, 95% CI, 1.07–4.31, respectively). There were no differences between the 2 chemical sedation groups in terms of ED length of stay or hospital admission rate. Conclusions: This study demonstrates a lower intubation rate in patients administered ketamine than prior literature in association with a lower weight-based dosing regimen. Ketamine use was correlated with a higher frequency of intubation and a greater need for additional chemical restraint when compared with other restraint modalities, though exogenous factors such as provider preference may have impacted this result. There was no difference in ED length of stay or admission rate between the ketamine and haloperidol plus benzodiazepine groups. Further prospective study is needed to determine whether there is a subset of patients for whom ketamine would be beneficial compared to other therapies.