Implementation of a Prehospital Protocol Change For Asthmatic Children

Background: Respiratory distress due to asthma is a common reason for pediatric emergency medical services (EMS) transports. Timely initiation of asthma treatment, including glucocorticoids, improves hospital outcomes. The impact of EMS-administered glucocorticoids on hospital-based outcomes for pediatric asthma patients is unknown. Objective: The objective of this study was to evaluate the effect of an evidence-based pediatric EMS asthma protocol update, inclusive of oral glucocorticoid administration, on time to hospital discharge. Methods: This was a retrospective cohort study of children (2–18 years) with an acute asthma exacerbation transported by an urban EMS system to 10 emergency departments over 2 years. The investigators implemented an EMS protocol update one year into the study period requiring glucocorticoid administration for all patients, with the major change being inclusion of oral dexamethasone (0.6 mg/kg, max. dose = 10 mg). Protocol implementation included mandatory paramedic training. Data was abstracted from linked prehospital and hospital records. Continuous data were compared before and after the protocol change with the Mann-Whitney test, and categorical data were compared with the Pearson χ² test. Results: During the study period, 482 asthmatic children met inclusion criteria. After the protocol change, patients were more likely to receive a prehospital glucocorticoid (11% vs. 18%, p = 0.02). Median total hospital time after the protocol change decreased from 6.1 hours (95% CI: 5.4–6.8) to 4.5 hours (95% CI: 4.2–4.8), p < 0.001. Total care time, defined as time from ambulance arrival to hospital discharge, also decreased [6.6 hours (95% CI: 5.8–7.3) vs. 5.2 hours (95% CI: 4.8–5.6), p = 0.01]. Overall, patients were less likely to be admitted to the hospital (30% vs. 21%, p = 0.02) after the change. Those with more severe exacerbations were less likely to be admitted to a critical care unit (82% vs. 44%, p = 0.02) after the change, rather than an acute care floor. Conclusions: Prehospital protocol change for asthmatic children is associated with shorter total hospital and total care times. This protocol change was also associated with decreased hospitalization rates and less need for critical care in those hospitalized. Further study is necessary to determine if other factors also contributed     

Pre-resuscitation Lactate and Hospital Mortality in Prehospital Patients

Abstract

Objective. Serum lactate elevations are associated with morbidity and mortality in trauma patients, but their value in prehospital medical patients prior to resuscitation is unknown. We sought to assess the distribution of blood lactate concentrations prior to intravenous (IV) resuscitation and examine the association of elevation on in-hospital death. Methods. A convenience sample of adult patients over 14 months who received an IV line by eight EMS agencies in Western Pennsylvania had lactate measurement prior to any IV treatment. We assessed the lactate values and any relationship between these and hospital mortality (our primary outcome) and admission to the intensive care unit (ICU). We also compared the ability of lactate to discriminate outcomes with a prehospital critical illness score using age, Glasgow Coma Score, and initial vital signs. Results. We included 673 patients, among whom 71 (11%) were admitted to the ICU and 21 (3.1%) died in-hospital. Elevated lactate (≥2 mmol/L) occurred in 307 (46%) patients and was strongly associated with hospital death after adjustment for known covariates (odds ratio = 3.57, 95% confidence interval [CI]: 1.10, 11.6). Lactate ≥2 mmol/L had a modest sensitivity (76%) and specificity (55%), and discrimination for hospital death (area under the curve [AUC] = 0.66, 95%CI: 0.56, 0.75). Compared to the prehospital critical illness score alone (AUC = 0.69, 95% CI: 0.59, 0.80), adding lactate to the score offered modest improvement (net reclassification improvement = 0.63, 95%CI: 0.23, 1.01, p < 0.05). Conclusions. Initial lactate concentration in our prehospital medical patient population was associated with hospital mortality. However, it is a modest predictor of outcome, offering similar discrimination to a prehospital critical illness score.     

Multicenter Evaluation of Prehospital Opioid Pain Management in Injured Children

Background: The National Association of Emergency Medical Services Physicians’ (NAEMSP) Position Statement on Prehospital Pain Management and the joint National Highway Traffic Safety Administration (NHTSA) and Emergency Medical Services for Children (EMSC) Evidence-based Guideline for Prehospital Analgesia in Trauma aim to improve the recognition, assessment, and treatment of prehospital pain. The impact of implementation of these guidelines on pain management in children by emergency medical services (EMS) agencies has not been assessed. Objective: Determine the change in frequency of documented pain severity assessment and opiate administration among injured pediatric patients in three EMS agencies after adoption of best practice recommendations. Methods: This is a retrospective study of children <18 years of age with a prehospital injury-related primary impression from three EMS agencies. Each agency independently implemented pain protocol changes which included adding the use of age-appropriate pain scales, decreasing the minimum age for opiate administration, and updating fentanyl dosing. We abstracted data from prehospital electronic patient records before and after changes to the pain management protocols. The primary outcomes were the frequency of administration of opioid analgesia and documentation of pain severity assessment as recorded in the prehospital patient care record. Results: A total of 3,597 injured children were transported prior to pain protocol changes and 3,743 children after changes. Opiate administration to eligible patients across study sites regardless of documentation of pain severity was 156/3,089 (5%) before protocol changes and 175/3,509 (5%) after (p = 0.97). Prior to protocol changes, 580 (18%) children had documented pain assessments and 430 (74%) had moderate-to-severe pain. After protocol changes, 644 (18%) patients had pain severity documented with 464 (72%) in moderate-to-severe pain. For all study agencies, pain severity was documented in 13%, 19%, and 22% of patient records both before and after protocol changes. There was a difference in intranasal fentanyl administration rates before (27%) and after (17%) protocol changes (p = 0.02). Conclusion: The proportion of injured children who receive prehospital opioid analgesia remains suboptimal despite implementation of best practice recommendations. Frequency of pain severity assessment of injured children is low. Intranasal fentanyl administration may be an underutilized modality of prehospital opiate administration.     

Paramedic use of succinylcholine

Objective. To investigate the impact of liberalization of paramedic management protocols for the use of morphine sulfate (MS). Methods. A retrospective database analysis tallied andcategorized MS use into seven conditions during two intervals—six months before (control) andsix months after (study) the protocol change. Results. In the control interval, 760 of 34,020 (2.2%) patients received MS. In the study interval, 999 of 30,320 (3.3%) received the drug, a 50% relative increase in MS use. MS use dramatically increased in two assessment categories: other painful medical conditions (19.0% vs. 2.8% of transports, relative risk [RR] 6.8, 95% confidence interval [CI] 5.2–8.9) andnontraumatic abdominal pain (9.2% vs. 1.9% of transports, RR 4.8, 95% CI 3.3–6.9). Conclusion. Liberalization of pain management protocols resulted in an appreciable increase in the use of MS only in medical categories, predominantly abdominal pain, with no apparent safety or misuse issues.     

Cincinnati Prehospital Stroke Scale Can Identify Large Vessel Occlusion Stroke

Objective: Accurate prehospital identification of patients with acute ischemic stroke (AIS) from large vessel occlusion (LVO) facilitates direct transport to hospitals that perform endovascular thrombectomy. We hypothesize that a cut-off score of the Cincinnati Prehospital Stroke Scale (CPSS), a simple assessment tool currently used by emergency medical services (EMS) providers, can be used to identify LVO. Methods: Consecutively enrolled, confirmed AIS patients arriving via EMS between August 2012 and April 2014 at a high-volume stroke center in a large city with a single municipal EMS provider agency were identified in a prospective, single-center registry. Head and neck vessel imaging confirmed LVO. CPSS scores were abstracted from prehospital EMS records. Spearman's rank correlation, Wilcoxon rank-sum test, and Student's t-test were performed. Cohen's kappa was calculated between CPSS abstractors. The Youden index identified the optimal CPSS cut-off. Multivariate logistic regression controlling for age, sex, and race determined the odds ratio (OR) for LVO. Results: Of 144 eligible patients, 138 (95.8%) had CPSS scores in the EMS record and were included for analysis. The median age was 69 (IQR 58–81) years. Vessel imaging was performed in 97.9% of patients at a median of 5.9 (IQR 3.6–10.2) hours from hospital arrival, and 43.7% had an LVO. Intravenous tissue plasminogen activator was administered to 29 patients, in whom 12 had no LVO on subsequent vessel imaging. The optimal CPSS cut-off predicting LVO was 3, with a Youden index of 0.29, sensitivity of 0.41, and specificity of 0.88. The adjusted OR for LVO with CPSS = 3 was 5.7 (95% CI 2.3–14.1). Among patients with CPSS = 3, 72.7% had an LVO, compared with 34.3% of patients with CPSS ≤ 2 (p < 0.0001). Conclusions: A CPSS score of 3 reliably identifies LVO in AIS patients. EMS providers may be able to use the CPSS, a simple, widely adopted prehospital stroke assessment tool, with a cut-off score to screen for patients with suspected LVO.     

EMS responses and non-transports during the COVID-19 pandemic

IntroductionThe COVID-19 pandemic may affect both use of 9–1-1 systems and prehospital treatment and transport practices. We evaluated EMS responses in an EMS region when it experienced low to moderate burden of COVID-19 disease to assess overall trends, response and management characteristics, and non-transport rates. Our goal is to inform current and future pandemic response in similar regions.MethodsWe performed a retrospective review of prehospital EMS responses from 22 urban, suburban, and rural EMS agencies in Western Pennsylvania. To account for seasonal variation, we compared demographic, response, and management characteristics for the 2-month period of March 15 to May 15, 2020 with the corresponding 2-month periods in 2016–2019. We then tested for an association between study period (pandemic vs historical control) and incidence of non-transport in unadjusted and adjusted regression. Finally, we described the continuous trends in responses and non-transports that occurred during the year before and initial phase of the COVID-19 pandemic from January 1, 2019 to May 31, 2020.ResultsAmong 103,607 EMS responses in the 2-month comparative periods of March 15 to May 15, 2016–2020, we found a 26.5% [95% CI 26.9%, 27.1%] decrease in responses in 2020 compared to the same months from the four prior years. There was a small increase in respiratory cases (0.6% [95%CI 0.1%, 1.1%]) and greater frequency of abnormal vital signs suggesting a sicker patient cohort. There was a relative increase (46.6%) in non-transports between periods. The pandemic period was independently associated with an increase in non-transport (adjusted OR 1.68; 95%CI 1.59, 1.78). Among 177,194 EMS responses occurring in the year before and during the early period of the pandemic, between January 1, 2019, and May 31, 2020, we identified a 31% decrease in responses and a 48% relative increase in non-transports for April 2020 compared to the previous year's monthly averages.ConclusionDespite a low to moderate burden of infection during the initial period of the COVID-19 pandemic, we found a decline in overall EMS response volumes and an increase in the rate of non-transports independent of patient demographics and other response characteristics.     

Measuring a Crisis: Questioning the Use of Naloxone Administrations as a Marker for Opioid Overdoses in a Large U.S. EMS System

Objective: The United States is currently experiencing a public health crisis of opioid overdoses. To determine where resources may be most needed, many public health officials utilize naloxone administration by EMS as an easily-measured surrogate marker for opioid overdoses in a community. Our objective was to evaluate whether naloxone administration by EMS accurately represents EMS calls for opioid overdose. We hypothesize that naloxone administration underestimates opioid overdose. Methods: We conducted a chart review of suspected overdose patients and any patients administered naloxone in Wake County, North Carolina, from January 2013 to December 2015. Patient care report narratives and other relevant data were extracted from electronic patient care records and the resultant database was analyzed by two EMS physicians. Cases were divided into categories including “known opioid use,” “presumed opioid use,” “no known opioid,” “altered mental status,” “cardiac arrest with known opioid use,” “cardiac arrest with no known opioid use,” or “suspected alcohol intoxication,” and then further separated based on whether naloxone was administered. Patient categories were compared by patient demographics and incident year. Using the chart review classification as the gold standard, we calculated the sensitivity and positive predictive value (PPV) of naloxone administration for opioid overdose. Results: A total of 4,758 overdose cases from years 2013–15 were identified. During the same period, 1,351 patients were administered naloxone. Of the 1,431 patients with known or presumed opioid use, 57% (810 patients) received naloxone and 43% (621 patients) did not. The sensitivity of naloxone administration for the identification of patients with known or presumed opioid use was 57% (95% CI: 54%–59%) and the PPV was 60% (95% CI: 57%–63%). Conclusion: Among patients receiving care in this large urban EMS system in the United States, the overall sensitivity and positive predictive value for naloxone administration for identifying opioid overdoses was low. Better methods of identifying opioid overdose trends are needed to accurately characterize the burden of opioid overdose within and among communities.     

Utilization of Intravenous Catheters by Prehospital Providers during Pediatric Transports

Introduction: Prehospital intravenous (IV) access in children may be difficult and time-consuming. Emergency Medical Service (EMS) protocols often dictate IV placement; however, some IV catheters may not be needed. The scene and transport time associated with attempting IV access in children is unknown. The objective of this study is to examine differences in scene and transport times associated with prehospital IV catheter attempt and utilization patterns of these catheters during pediatric prehospital encounters. Methods: Three non-blinded investigators abstracted EMS and hospital records of children 0–18 years of age transported by EMS to a pediatric emergency department (ED). We compared patients in which prehospital IV access was attempted to those with no documented attempt. Our primary outcome was scene time. Secondary outcomes include utilization of the IV catheter in the prehospital and ED settings and a determination of whether the catheter was indicated based on a priori established criteria (prehospital IV medication administration, hypotension, GCS < 13, and ICU admission). Results: We reviewed 1,138 records, 545 meeting inclusion criteria. IV catheter placement was attempted in 27% (n = 149) with success in 77% (n = 111). There was no difference in the presence of hypotension or median GCS between groups. Mean scene time (12.5 vs. 11.8 minutes) and transport time (16.9 vs. 14.6 minutes) were similar. Prehospital IV medications were given in 38.7% (43/111). One patient received a prehospital IV medication with no alternative route of administration. Among patients with a prehospital IV attempt, 31% (46/149) received IV medications in the ED and 23% (34/396) received IV fluids in the ED. Mean time to use of the IV in the ED was 70 minutes after arrival. Patients with prehospital IV attempt were more likely to receive IV medication within 30 minutes of ED arrival (39.1% vs. 19.0%, p = 0.04). Overall, 34.2% of IV attempts were indicated. Conclusions: Prehospital IV catheter placement in children is not associated with an increase in scene or transport time. Prehospital IV catheters were used in approximately one-third of patients. Further study is needed to determine which children may benefit most from IV access in the prehospital setting.     

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     

The Association between Patients’ Perception of Their Overall Quality of Care and Their Perception of Pain Management in the Prehospital Setting

Abstract

Objective. Our objective was to determine whether there is an association between a patient's impression of his or her overall quality of care and his or her satisfaction with the pain management provided. We hypothesized that satisfaction with pain management would show a significant positive association with a patient's impression of overall quality of care. Methods. This was a retrospective review of patient satisfaction data initially collected by a third-party company from January 1, 2007, to September 1, 2010. Participants were randomly selected from all transported patients, proportional to their paramedic-defined acuity level, with a goal of 100 interviews per month. The proportions of patients sampled from each acuity level were 25% priority 1 (high), 50% priority 2 (medium), and 25% priority 3 (low). Patients were excluded if there was no telephone number recorded in the prehospital patient record, no transportation was recorded, or the call was labeled as a psychiatric complaint. All satisfaction questions used a five-point Likert scale with ratings from excellent to poor, which were dichotomized for analysis. The outcome variable was the patient's perception of his or her overall quality of care. The main independent variable was the patient's rating of his or her pain management by emergency medical services (EMS) staff at the scene. Demographic variables were assessed for potential confounding. Results. There were 2,741 patients with complete data for the outcome and main independent variables; 41.7% of the respondents were male and the average age was 54.1 years (standard deviation = 22.6). The overall quality of care was rated as excellent by 65.9% of the patients, whereas 59.2% rated their pain management as excellent. Of the patients who rated their pain management as excellent, 79.0% rated the overall quality of care as excellent, whereas only 21.0% of the patients rated the overall quality of care as excellent if pain management was not excellent. When the patients rated EMS staff as excellent for both helping to control or reduce pain and explaining the medications given, they were 2.7 (95% confidence interval 1.4–5.4) times more likely to rate their overall quality of care as excellent. Conclusion. Our model indicated that pain management was associated with increased perception of overall quality of care only when EMS providers explained the medications provided and their potential side effects.     

Accuracy of EMS-Recorded Patient Demographic Data

Objective. Emergency medical services (EMS) research is frequently dependent on data recorded by prehospital personnel. Linking EMS information with hospital outcome depends on essential identifying data. We sought to determine the accuracy of these data in patients who activated EMS for chest pain andto describe the types of errors committed. Methods. We performed a retrospective, consecutive case series study of all prehospital records for patients transported by the City of Pittsburgh Bureau of EMS (annual call volume, 60,000) for chest pain to three area hospitals during a three-month interval. Demographic data, including name, date of birth (DOB), andSocial Security number (SSN), for each patient were extracted from the EMS record. These were compared to the definitive information in the hospital records. Results. 360 prehospital records were examined, with 341 matches to hospital records. The correct patient name was recorded in 301 records (83.6%), the correct DOB was recorded 284 times (78.9%), andthe correct SSN was recorded 120 times (33.3%). The overall error rate of demographic data recorded on EMS records was 73.9% (266/360). If SSN is not included as a demographic variable, then the overall error rate was 25.3% (91/360). Conclusion. The use of EMS-generated demographic data demonstrates moderate agreement andlinkage with hospital records. Name andDOB are more reliable data elements for matching than SSN. Future research should examine the impact of electronic medical records andEMS identification numbers on data reliability.     

Predictive Value of the Ontario Prehospital Stroke Screening Tool for the Identification of Patients with Acute Stroke

Background. In 2005, a prehospital stroke screening tool was implemented in Toronto, Ontario, Canada. Patients identified by paramedics through the use of this tool in the field were transported to a regional stroke center under an acute stroke protocol. Objective. To determine the positive predictive value (PPV) of the Ontario Prehospital Stroke Screening Tool for identification of acute stroke at a single stroke center. Methods. We conducted a retrospective analysis of consecutive patients transported to a regional stroke center under the prehospital acute stroke protocol over a 12-month period. Final diagnoses, treatments, andoutcomes were abstracted from a provincial registry. Rates of fibrinolysis were compared with those for the 12-month period prior to implementation of the stroke protocol. Results. Three hundred twenty-five patients were triaged under the emergency medical services (EMS) acute stroke protocol over the study period. The PPV of the screening tool was 89.5% (95% confidence interval [CI]: 85.7–92.7%) for acute stroke. Thirty-four patients (11%) had nonstroke conditions, with the most common being seizure (4%). The rate of administration of tissue plasminogen activator (tPA) for all patients with suspected stroke increased from 5.9% to 10.1% (p = 0.04) compared with the rate in the 12-month period prior to implementation of the acute stroke protocol. The tPA rate for patients arriving under the stroke protocol was 17.2%. Most patients (75%) receiving tPA arrived from outside the hospital catchment area. Conclusions. In this preliminary study, the Ontario Prehospital Stroke Screening Tool had a high PPV for acute stroke andappeared to be effective for identifying patients who required triage to a single regional stroke center. Following implementation of a citywide acute stroke protocol using this screening tool, we observed an increase in the number of patients who were eligible for andreceived fibrinolysis at our stroke center     

An Urban 9-1-1 System’s Experience with Left Ventricular Assist Device Patients

Background: Left ventricular assist devices (LVADs) are used with increasing frequency and left in place for longer periods of time. Prior publications have focused on the mechanics of troubleshooting the device itself. We aim to describe the epidemiology of LVAD patient presentations to emergency medical services (EMS), prehospital assessments and interventions, and hospital outcomes. Methods: This is a retrospective chart review of known LVAD patients that belong to a single academic center’s heart failure program who activated the 9-1-1 system and were transported by an urban EMS system to one of the center’s 2 emergency departments between January 2012 and December 2015. Identifying demographics were used to query the electronic medical record of the responding city fire agency and contracted transporting ambulance service. Two reviewers abstracted prehospital chief complaint, vital signs, assessments, and interventions. Emergency department and hospital outcomes were retrieved separately. Results: From January 2012 to December 2015, 15 LVAD patients were transported 16 times. The most common prehospital chief complaint was weakness (7/16), followed by chest pain (3/16). Of the 7 patients presenting with weakness, one was diagnosed with a stroke in the emergency department. Another patient was diagnosed with subarachnoid hemorrhage and expired during hospital admission. This was the only death in the cohort. The most common hospital diagnosis was GI bleed (3/16). The overall admission rate was 87.5% (14/16). Conclusions: EMS interactions with LVAD patients are infrequent but have high rates of admission and incidence of life-threatening diagnoses. The most common prehospital presenting symptoms were weakness and chest pain, and most prehospital interactions did not require LVAD-specific interventions. In addition to acquiring technical knowledge regarding LVADs, EMS providers should be aware of non-device-related complications including intracranial and GI bleeding and take this into account during their assessment.