Education of paramedics regarding aspirin use

The Demographics and Education of Emergency Medical Services (EMS) Professionals: A National Longitudinal Investigation

Objectives

The objectives of this study were to assess longitudinal and cross-sectional changes in Emergency Medical Technician (EMT)-Basics and Paramedics: (1) demographics, (2) employment characteristics, and (3) initial Emergency Medical Services (EMS) education.

Methods

These data were collected between 1999 and 2008 employing survey techniques aimed at collecting valid data. A random, stratified sample was utilized to allow results to be generalizable to the nationally certified EMS population. Survey weights that were adjusted for each stratum’s response were estimated. Weighted percentages, averages for continuous variables, and 95% confidence intervals (CIs) were calculated. Significant changes over time were noted when the CIs did not overlap.

Results

In all 10 years of data collection, the proportion of EMT-Paramedics who were male was greater than the proportion of EMT-Basics who were male. A substantial proportion of respondents performed EMS services for more than one agency: between 39.8% and 43.5% of EMT-Paramedics and 18.4% and 22.4% of EMT-Basic respondents reported this. The most common type of employer for both EMT-Basics and EMT-Paramedics was fire-based organizations. About one-third of EMT-Basics (32.3%-40.1%) and almost one-half of EMT-Paramedics (43.1%-45.3%) reported that these organizations were their main EMS employer. Rural areas (<25,000 residents) were the most common practice settings for EMT-Basics (52.1%-63.7%), while more EMT-Paramedics worked in urban settings (65.2%-77.7%).

Conclusions

This analysis serves as a useful baseline to measure future changes in the EMS profession. This study described the demographic and work-life characteristics of a cohort of nationally certified EMT-Basics and Paramedics over a 10-year period. This analysis also summarized initial EMS education changes over time.

BentleyMA, ShobenA, LevineR. The demographics and education of Emergency Medical Services (EMS) professionals: a national longitudinal investigation. Prehosp Disaster Med. 2016;31(Suppl. 1):s18–s29.

Prehospital Use of Aspirin Rarely Is Associated with Adverse Events

Introduction:

Aspirin is commonly administered for acute coronary syndromes in the prehospital setting. Few studies have addressed the incidence of adverse effects associated with prehospital administration of aspirin. Objective: To determine the incidence of adverse events following the administration of aspirin by prehospital personnel.

Methods:

Multi-center, retrospective, case series that involved all patients who received aspirin in the prehospital setting from (01 August 1999–31 January 2000). Patient encounter forms of the emergency medical services (EMS) of a metropolitan fire department were reviewed. All patients who had a potential cardiac syndrome (i.e., chest pain, dyspnea) as documented on the EMS forms were included in the review. Exclusion criteria included failure to meet inclusion criteria, and chest pain secondary to apparent noncardiac causes (i.e., trauma). Hospital charts were reviewed from a subset of patients at the participating hospitals. The major outcome was an adverse event following prehospital administration of aspirin. This outcome was evaluated during the EMS encounter, at emergency department discharge, or at six and 24-hours post-aspirin ingestion. An adverse event secondary to aspirin ingestion was defined as anaphylaxis or allergic reactions, such as rash or respiratory changes.

Results:

A total of 25,600 EMS encounter forms were reviewed, yielding 2,399 patients with a potential cardiac syndrome. Prior to EMS arrival, 585 patients had received aspirin, and 893 were administered aspirin by EMS personnel. No patients had an adverse event during the EMS encounter. Of these patients, 229 were transported to participating hospitals and 219 medical records were available for review with no adverse reactions recorded during their hospital course.

Conclusion:

Aspirin is rarely associated with adverse events when administered by prehospital personnel for presumed coronary syndromes.

Effects of an Educational Intervention on Prehospital Pain Management

INTRODUCTION

Pain is a common symptom evaluated by emergency medical services (EMS) providers. Hospital pain management programs began in the early 1990s based on a multidisciplinary approach and principles of total quality improvement. To date, these programs have had limited exposure in the prehospital setting.

OBJECTIVES

To evaluate the effects of a pain management educational intervention (EI) for paramedic caregivers.

METHODS

All ambulance providers from ten urban and suburban fire departments and two private ambulance companies participated in a three-hour EI during a quality improvement project. A survey was performed prior to the EI and repeated one month after the EI. A two-month collection of EMS runs for pain complaints was performed prior to the EI and repeated one month after the EI. Data analysis was performed using descriptive statistics and chi-square tests.

RESULTS

The authors reviewed 397 surveys and 439 EMS runs for pain. Overall, after the EI, paramedics' knowledge of basic pain management principles increased from 57.3% to 74.9% (17.5%; 95% confidence interval (CI): 14.9%-20.2%; p < 0.001). Paramedics' utilization of nonpharmacologic pain therapies improved by 32.2% (95% CI: 25.3%-39.2%; p < 0.001), but there was no significant change in the use of pain medication (20.2% to 24.5%). There were 51.0% (95% CI: 44.1%-57.9%; p < 0.001) improvement in documentation of pain severity, 24% (95% CI: 21.2%-26.8%; p < 0.001) improvement in documentation of pain characteristics, and 13% (95% CI: 7.4%-18.7%; p < 0.001) improvement in pain reassessment following intervention.

CONCLUSION

As a result of a three-hour educational intervention, paramedics had an increased understanding of pain principles, were more likely to provide prehospital nonpharmacologic pain therapy, and were more likely to document the results of their interventions.

Reasons prehospital personnel do not administer aspirin to all patients complaining of chest pain

INTRODUCTION

Aspirin is administered to patients with acute coronary syndromes (ACSs), but prehospital providers do not administer aspirin to all patients with chest pain that could be secondary to an ACS.

OBJECTIVE

To identify reasons prehospital providers fail to administer aspirin to all patients complaining of chest pain.

METHODS

A convenience sample of prehospital providers was surveyed as they transported patients with a chief complaint of chest pain to the emergency department. The providers were asked if they had given aspirin, nitroglycerin, or oxygen, or if they utilized a monitor. If the medications had not been administered, the paramedic was asked about the reason. The patient's age and previous cardiac history also was recorded.

RESULTS

A total of 52 patients with chest pain who were transported were identified over eight weeks, and all of the providers agreed to participate in the study. Only 13 of the patients (25%) received aspirin. Reasons given for not administering aspirin to the other 39 patients included: (1) chest pain was not felt to be cardiac in 13 patients (33%); (2) 10 patients already had taken aspirin that day (26%); (3) the medical provider was a basic-level emergency medical technician (EMT)-Basic and could not administer aspirin to six patients (15%); (4) pain subsided prior to arrival of emergency medical services (EMS) in these three patients; and (5) other reasons were provided for the remaining seven patients.

CONCLUSIONS

The most common reason that paramedics did not administer aspirin was the paramedic's belief that the chest pain was not of a cardiac nature. Another common reason for not giving aspirin was the inability of EMT-Basic providers to administer aspirin.

The effect of simple interventions on paramedic aspirin administration rates

OBJECTIVE

To determine the baseline rate of aspirin administration by paramedics and to assess the effect of two interventions (protocol change and brief educational intervention) on that rate.

METHODS

The advanced life support transport provider's clinical database was retrospectively queried to identify calls involving adult patients with chest pain or paramedic impression of suspected cardiac event (possible acute coronary syndrome [ACS]). The study includes data from January 1, 1999, to June 30, 2002, which was divided into three distinct periods. Period 1 was the baseline, period 2 was after the protocol change intervention, and period 3 was after the brief educational intervention. The chest pain protocol indicates patients with chest pain should be treated with aspirin.

RESULTS

During period 1, 548 of 3,635 (15.1%) patients with possible ACS received aspirin. During period 2, 1,941 of 7,236 (26.8%) patients with possible ACS received aspirin (chi(2) p<0.0001; odds ratio [OR]=2.06; 95% confidence interval [CI]=1.86-2.29). During period 3, 749 of 2,026 (37%) patients with possible ACS received aspirin (chi(2) p<0.0001; OR=1.60; 95% CI=1.44-1.78). Comparing period 1 with period 3, after both interventions, there was a 22% absolute improvement in aspirin administration rates (chi(2) p<0.0001; OR=3.30; 95% CI=2.91-3.76).

CONCLUSION

Aspirin is underutilized in treating patients with suspected ACS. Two brief interventions can lead to modest increases in aspirin administration rates. Even after these interventions, aspirin administration rates remain low.

Acute coronary syndrome: pharmacotherapy

Acute coronary syndrome (ACS) refers to the spectrum of cardiac disease, from unstable angina to ST-segment-elevation myocardial infarction. In the emergency medical services (EMS) setting, ACS may be more broadly thought to include patients with chest pain or other symptoms believed to have a cardiac origin who have evidence of ischemia or acute myocardial infarction on a 12-lead electrocardiogram, or symptomatic patients with a previous cardiac event or known cardiac disease. Pharmacologic management of these patients is based on the use of three primary classes of drugs: those that affect clotting, those that establish and maintain hemodynamic control, and those that relieve pain. Many of these agents have been evaluated in large clinical trials for in-hospital use, and a number of ongoing studies are assessing their efficacy in the prehospital setting. The appropriateness of prehospital use of specific agents within each class depends on proper patient selection, the necessity of immediate intervention, ease of use in the field, expertise of EMS personnel, and cost-effectiveness of therapy. This consensus group reviewed agents from all three classes (including aspirin, GPIIb/IIIa inhibitors, unfractionated and low-molecular-weight heparins, fibrinolytics, beta-adrenergic blockers, calcium antagonists, nitrates, and morphine) for their overall indication, applicability to the prehospital setting, and current prehospital use.