Impact of Prehospital Pain Management on Emergency Department Management of Injured Children

OBJECTIVE

Provision of analgesia for injured children is challenging for Emergency Medical Services (EMS) clinicians. Little is known about the effect of prehospital analgesia on emergency department (ED) care. We aimed to determine the impact of prehospital pain interventions on initial ED pain scale scores, timing and dosing of ED analgesia for injured patients transported by EMS.

METHODS

This is a planned, secondary analysis of a prospective multicenter cohort of children with actual or suspected injuries transported to one of 11 PECARN-affiliated EDs from July 2019-April 2020. Using Wilcoxon rank sum for continuous variables and chi-square testing for categorical variables, we compared the change in EMS-to-ED pain scores and timing and dosing of ED-administered opioid analgesia in those who did and those who did not receive prehospital pain interventions.

RESULTS

We enrolled 474 children with complete prehospital and ED pain management data. Prehospital interventions were performed on 262/474 (55%) of injured children and a total of 88 patients (19%) received prehospital opioids. Children who received prehospital opioids with or without adjunctive non-pharmacologic pain management experienced a greater reduction in pain severity and were more likely to receive ED opioids in higher doses earlier and throughout their ED care. Non-pharmacologic pain interventions alone did not impact ED care.

CONCLUSIONS

We demonstrate that prehospital opioid analgesia is associated with both a significant reduction in pain severity at ED arrival and the administration of higher doses of opioid analgesia earlier and throughout ED care.

Prehospital Evaluation of the FAST-ED as a Secondary Stroke Screen to Identify Large Vessel Occlusion Strokes

Introduction: The Field Assessment Stroke Triage for Emergency Destination (FAST-ED) was developed to identify Large Vessel Occlusion Strokes (LVOS) presenting out of hospital, although there is limited prospective research validating its use in this setting. This study evaluated the test characteristics of the FAST-ED to identify LVOS when used as a secondary stroke screen in the prehospital environment. Secondary analysis compared the performance of the CPSS and the FAST-ED in identifying an LVOS. Methods: This prospective, observational study was conducted from April 2018 to December 2019 in a municipal EMS system with all ALS ambulance response. The FAST-ED was implemented as a secondary screening tool for emergent stroke patients who had at least one positive Cincinnati Prehospital Stroke Screen (CPSS) item. CPSS and FAST-ED scores were extracted from prehospital electronic care reports, while the presence of LVOS was extracted from hospital records. Results: A total 1,359 patients were enrolled; 55.3% female, 47.5% white, with a mean age of 69.4 (SD 15.8). In this cohort, 11.3% of patients experienced an LVOS. The mean FAST-ED for a patient experiencing an LVOS was 5.33 (95%CI 4.97-5.69) compared to 3.06 (95%CI 2.95-3.12) (p < 0.001). A score of greater or equal to 4 yielded the highest combination of sensitivity (77.78%) and specificity (65.34%) with positive likelihood ratio 2.24 (95% CI 2.00-2.52) and negative likelihood ratio 0.34 (95% CI 0.25-0.46). Area under the ROC curve was 0.77 (95%CI 0.73, 0.81). A CPSS with all three items positive demonstrated a sensitivity of 73.20% and 69.57% specificity, with an ROC area of 0.73 (95% CI 0.70-0.77). When comparing a FAST-ED ≥4 to a CPSS of all positive items, there was no significant difference in sensitivity (p > 0.05), and the FAST-ED had a significantly lower specificity than the CPSS (p < 0.005). Conclusion: As stroke care advances, EMS agencies must consider their destination triage needs. This study suggests agencies must consider the use of single versus secondary scales, and to determine the ideal sensitivity and specificity for their system.

Prehospital ECG with ST-depression and T-wave inversion are associated with new onset heart failure in individuals transported by ambulance for suspected acute coronary syndrome

BACKGROUND

Prehospital electrocardiogram(s) (ECG) can improve early detection of acute coronary syndrome (ST-segment elevation myocardial infarction [STEMI], non-STEMI, and unstable angina) and inform prehospital activation of cardiac catheterization lab; thus, reducing total ischemic time and improving patient outcomes. Less is known, however, about the association of prehospital ECG ischemic findings and long term adverse clinical events. With this in mind, this study was designed to examine the: 1) frequency of prehospital ECGs for acute myocardial ischemia (ST-elevation, ST-depression, and/or T-wave inversion); and, 2) whether any of these specific ECG features are associated with adverse clinical events within 30 day of initial presentation to the emergency department (ED).

METHODS

We included consecutive patients ≥ 21 years during a five-year period (2013-2017), who were transported by ambulance to the ED with non-traumatic chest pain and/or anginal equivalent(s) and had a prehospital 12‑lead ECG. Two cardiologists (LG, EC), blinded to clinical data, interpreted the 12‑lead ECGs applying current guideline based ischemia criteria. Adverse clinical events, return to ED, and rehospitalization evaluated at 30-days.

RESULTS

We identified 3646 patients (mean age, 59.7 years ±15.7; 45% female) with ECGs, of which N = 3587 had data on the three ischemic markers of interest. Of these, 1762 (49.1%) had ECG evidence of ischemia. In adjusted logistic regression models, those with T-wave inversion had a higher odds (OR = 1.59) of new onset heart failure, while ST-elevation was associated with lower odds (OR = 0.69). Patients with ST-depression had higher odds of new onset heart failure and death within 30 days (OR = 1.29, 1.49 respectively), but this association attenuated after controlling for other ECG features.

CONCLUSIONS

ST-depression and/or T-wave inversion are independent predictors of new onset heart failure, within 30 days of initial ED presentation. Our study in a large cohort of patients, suggests that using ECG ST-elevation alone may not capture patients with ischemia who may benefit from aggressive anti-ischemic therapies to reduce myocardial damage with resultant heart failure.

A Novel Use of NEMSIS to Create a PECARN-Specific EMS Patient Registry

Background: Research networks need access to EMS data to conduct pilot studies and determine feasibility of prospective studies. Combining data across EMS agencies is complicated and costly. Leveraging the National EMS Information System (NEMSIS) to extract select agencies' data may be an efficient and cost-effective method of providing network-level data. Objective: Describe the process of creating a Pediatric Emergency Care Applied Research Network (PECARN) specific NEMSIS data set and determine if these data were nationally representative. Methods: We established data use agreements (DUAs) with EMS agencies participating in PECARN to allow for agency identification through NEMSIS. Using 2019 NEMSIS version 3.4.0 data for EMS events with patients 18 years old and younger, we compared PECARN NEMSIS data to national NEMSIS data. Analyzed variables were selected for their ability to characterize events. No statistical analyses were utilized due to the large sample, instead, differences of ±5% were deemed clinically meaningful. Results: DUAs were established for 19 EMS agencies, creating a PECARN data set with 305,188 EMS activations of which 17,478 (5.7%) were pediatric. Of the pediatric activations, 17,140 (98.1%) were initiated through 9-1-1 and 9,487 (55.4%) resulted in transport by the documenting agency. The national data included 36,288,405 EMS activations of which 2,152,849 (5.9%) were pediatric. Of the pediatric activations 1,704,141 (79.2%) were initiated through 9-1-1 and 1,055,504 (61.9%) were transported by the documenting agency. Age and gender distributions were similar between the two groups, but the PECARN-specific data under-represents Black and Latinx patients. Comparison of EMS provider primary impressions revealed that three of the five most common were similar with injury being the most prevalent for both data sets along with mental/behavioral health and seizure. Conclusion: We demonstrated that NEMSIS can be leveraged to create network specific data sets. PECARN's EMS data were similar to the national data, though racial/ethnic minorities and some primary impressions may be under-represented. Additionally, more EMS activations in PECARN study areas originated through 9-1-1 but fewer were transported by the documenting agency. This is likely related to the type of participating agencies, their ALS response level, and the diversity of the communities they serve.

Inter-Rater Reliability of the FAST-ED in the Out-of-Hospital Setting

Introduction: Patients experiencing a large vessel occlusion stroke (LVOS) may require endovascular-capable centers and benefit from direct transport to such facilities, creating a need for an accurate prehospital assessment. The Field Assessment Stroke Triage for Emergency Destination (FAST-ED) is a secondary scale to identify LVOS. Currently, there is limited prospective evidence validating the use of the FAST-ED in the prehospital environment. This study aimed to evaluate the inter-rater reliability of the FAST-ED between patient care providers in the prehospital setting.Methods: This prospective study was conducted between 4/1/2018 and 7/1/2018 in a single municipal EMS agency that staffs two providers per ambulance with at least one being a paramedic. Patients were included based on paramedic impression that the patient was both having a stroke and greater than 18 years old. Each provider independently performed and documented a FAST-ED assessment on eligible patients. Data analysis consisted of performing inter-rater reliability using Cohen's Kappa on the FAST-ED score between primary and secondary providers. The FAST-ED was analyzed on an item level, an aggregate level (cumulative of all items), and using the defined cut point of ≥4. A sub-analysis determined if inter-rater reliability changed across provider certification.Results: There were 231 patients included in this analysis with an average age of 68.5 years and 135 (58.4%) female. Inter-rater reliability varied across individual items in the scale from 90.1% agreement to 82.5%. When analyzing inter-rater reliability of the aggregate FAST-ED score, the scale demonstrated 70.1% agreement (Kappa 0.66), considered substantial agreement. FAST-ED scores were analyzed using a cut point of ≥4. When using this cut point, there was 92.2% (Kappa 0.81) agreement between primary and secondary caregiver, demonstrating almost perfect agreement. Agreement was substantial across provider certifications including paramedics and EMTS.Conclusion: This study demonstrated high inter-rater reliability of the FAST-ED scale when performed in the prehospital setting on patients suspected of having a stroke. There were minimal differences in reliability based on provider certification, and item level analysis indicated substantial inter-rater reliability.

Multicenter Evaluation of Prehospital Seizure Management in Children

BACKGROUND

Seizures are a common reason why emergency medical services (EMS) transports children by ambulance. Timely seizure cessation prevents neurologic morbidity, respiratory compromise, and mortality. Implementing recommendations from an evidence-based pediatric prehospital guideline may enhance timeliness of seizure cessation and optimize medication dosing.

OBJECTIVE

We compared management of pediatric prehospital seizures across several EMS systems after protocol revision consistent with an evidence-based guideline.

METHODS

Using a retrospective, cross-sectional approach, we evaluated actively seizing patients (0-17 years old) EMS transported to a hospital before and after modifying local protocols to include evidence-based recommendations for seizure management in three EMS agencies. We electronically queried and manually abstracted both EMS and hospital data at each site to obtain information about patient demographics, medications given, seizure cessation and recurrence, airway interventions, access obtained, and timeliness of care. The primary outcome of the study was the appropriate administration of midazolam based on route and dose. We analyzed these secondary outcomes: frequency of seizure activity upon emergency department (ED) arrival, frequency of respiratory failure, and timeliness of care.

RESULTS

We analyzed data for 533 actively seizing patients. Paramedics were more likely to administer at least one dose of midazolam after the protocol updates [127/208 (61%) vs. 232/325 (71%), p = 0.01, OR = 1.60 (95% CI: 1.10-2.30)]. Paramedics were also more likely to administer the first midazolam dose via the preferred intranasal (IN) or intramuscular (IM) routes after the protocol change [(63/208 (49%) vs. 179/325 (77%), p < 0.001, OR = 3.24 (2.01-5.21)]. Overall, paramedics administered midazolam approximately 14 min after their arrival, gave an incorrect weight-based dose to 130/359 (36%) patients, and gave a lower than recommended dose to 94/130 (72%) patients. Upon ED arrival, 152/533 (29%) patients had a recurrent or persistent seizure. Respiratory failure during EMS care or subsequently in the ED occurred in 90/533 (17%) patients.

CONCLUSIONS

Implementation of an evidence-based seizure protocol for EMS increased midazolam administration. Patients frequently received an incorrect weight-based dose. Future research should focus on optimizing administration of the correct dose of midazolam to improve seizure cessation.

Development of a Content Valid and Reliable Prehospital Environmental Falls Risk Assessment Tool for Older Adults

Introduction: The aging population reintroduces the need to establish early identification of falls risk as a means of primary and secondary prevention of falls. While there are several existing tools to assess environmental risk factors developed for consumers or home health providers, assessment of environmental falls risk by emergency medical services (EMS) providers represents a novel approach to primary and secondary prevention. The purpose of this study was to evaluate a content valid and reliable assessment of environmental fall risk to be performed in the prehospital setting. Methods: This was a mixed methods study, conducted from August, 2015 to September, 2017 in Mecklenburg County, NC, utilizing qualitative methodology to develop content valid items for an environmental falls risk assessment and quantitative methodology to assess those items for interrater reliability. Content validity was assessed using 2 expert panels. Expert Panel One was tasked with assessing validity of a construct to indicate an increased risk of an in-home fall for elderly individuals and expert Panel Two was responsible for assessing the likelihood of an EMS professional to identify a construct during their course of patient care. To assess reliability of the identified content valid items, 5 paramedics were recruited for interrater reliability (IRR) testing of the validated falls risk assessment tool. Each paramedic and their partner received education on documentation and deployment of the tool. Crews independently documented presence or absence of each item with pair agreement assessed using Cohen's kappa (κ). Results: A total of 87 items were identified for assessment through review of validated scales and relevant literature, with the content validation process reducing to 9 the number of items tested in the field for reliability. A total of 57 paired assessments were completed and included in analysis. One item returned almost perfect agreement (κ = 0.87), 5 items returned moderate agreement (κ = 0.41-0.54), with the remaining 3 items illustrating fair agreement (κ = 0.33-0.39). Conclusion: We developed a construct valid and reliable assessment of environmental falls risk to be performed in the prehospital setting. Further trials should be conducted using this tool to determine appropriate cut scores and deployment in the prehospital setting to help with primary and secondary fall prevention.

Validity of the Pediatric Early Warning Score and the Bedside Pediatric Early Warning Score in Classifying Patients Who Require the Resources of a Higher Level Pediatric Hospital

Introduction: The pediatric early warning score (PEWS) and the bedside pediatric early warning score (BPEWS) are validated tools that help determine the need for critical care in children with acute medical conditions. These tools could be used by EMS and have not been evaluated outside of the hospital. This study retrospectively tested the validity of these tools in the prehospital setting to identify children who needed a hospital with higher level pediatric resources. Methods: This was a multi-center retrospective validation of screening tools using prehospital and in-hospital data obtained from 3 EMS agencies. EMS patient records from April 1, 2013 to April 30, 2015 were used to identify subjects for this analysis. Pediatric patients were retrospectively classified using the PEWS based on the clinical information documented in the EMS medical record. Those with PEWS scores greater than 4 were matched to a subject with scores less than 4 based on age, gender, and paramedic primary impression. Hospital medical record review was then used to determine whether the patient required a hospital with higher level pediatric resources. These classifications were used to calculate sensitivity, specificity, and resultant 95% confidence intervals. The analysis was repeated for included subjects who had sufficient data to calculate BPEWS. Results: There were 386 patients enrolled. A PEWS ≥ 4 demonstrated a sensitivity of 62.8 (95% CI 53.6-71.4) and a specificity of 55.9 (95% CI 49.6-61.9) in identifying a patient who required a hospital with higher level pediatric resources. There were 44 pairs of patients that had sufficient EMS data documented to calculate a BPEWS. A BPEWS ≥ 7 demonstrated a sensitivity of 46.4 (95% CI 27.5-66.1) and a specificity of 76.7 (95% CI 64.0-86.6) to correctly classify a patient who required a hospital with higher level pediatric resources. Conclusion: In the prehospital setting neither PEWS nor BPEWS exhibited sufficient sensitivity for clinical use to accurately identify children who need a hospital with higher level pediatric resources. Further research should be conducted to identify variables that are captured by prehospital care providers and are associated with children who need a hospital with higher level pediatric resources.

Paramedic-Identified Enablers of and Barriers to Pediatric Seizure Management: A Multicenter, Qualitative Study

Background: Seizures have the potential to cause significant morbidity and mortality, and are a common reason emergency medical services (EMS) are requested for a child. An evidence-based guideline (EBG) for pediatric prehospital seizures was published and has been implemented as protocol in multiple EMS systems. Knowledge translation and protocol adherence in medicine can be incomplete. In EMS, systems-based factors and providers' attitudes and beliefs may contribute to incomplete knowledge translation and protocol implementation. Objective: The purpose of this study was to identify paramedic attitudes and beliefs regarding pediatric seizure management and regarding potential barriers to and enablers of adherence to evidence-based pediatric seizure protocols in multiple EMS systems. Methods: This was a qualitative study utilizing semi-structured interviews of paramedics who recently transported actively seizing 0-17 year-old patients in 3 different urban EMS systems. Interviewers explored the providers' decision-making during their recent case and regarding seizures in general. Interview questions explored barriers to and enablers of protocol adherence. Two investigators used the grounded theory approach and constant comparison to independently analyze transcribed interview recordings until thematic saturation was reached. Findings were validated with follow-up member-checking interviews. Results: Several themes emerged from the 66 interviewed paramedics. Enablers of protocol adherence included point-of-care references, the availability of different routes for midazolam and availability of online medical control. Systems-level barriers included equipment availability, controlled substance management, infrequent pediatric training, and protocol ambiguity. Provider-level barriers included concerns about respiratory depression, provider fatigue, preferences for specific routes, febrile seizure perceptions, and inaccurate methods of weight estimation. Paramedics suggested system improvements to address dose standardization, protocol clarity, simplified controlled substance logistics, and equipment availability. Conclusions: Paramedics identified enablers of and barriers to adherence to evidence-based pediatric seizure protocols. The identified barriers existed at both the provider and systems levels. Paramedics identified multiple potential solutions to overcome several barriers to protocol adherence. Future research should focus on using the findings of this study to revise seizure protocols and to deploy measures to improve protocol implementation. Future research should also analyze process and outcome measures before and after the implementation of revised seizure protocols informed by the findings of this study.

Multicenter Analysis of Transport Destinations for Pediatric Prehospital Patients

BACKGROUND

Although all emergency departments (EDs) should be ready to treat children, some may have illnesses or injuries that require higher-level pediatric resources that are not available at all hospitals. There are no national guidelines for emergency medical services (EMS) providers about when to directly transport children to hospitals with higher-level pediatric resources, with the exception of severe trauma. Variability exists in EMS protocols about when children warrant transport to hospitals with higher-level pediatric care.

OBJECTIVE

The objective was to determine how frequently pediatric patients are transported by EMS to hospitals with higher-level pediatric resources and to evaluate distribution patterns based on illness and injury severity.

METHODS

We conducted a retrospective analysis of all pediatric (age 0-18 years) transports in three large EMS systems between November 2014 and November 2016. Each community had a hospital with higher-level pediatric resources that was within a 30-minute transport time from any location. Patients were included if they were transported by ground ambulance and the request originated in the 9-1-1 system. We assessed the frequency of transports to a hospital with higher-level pediatric resources. Data were stratified by chief complaint of illness or injury and severity. Potential risk for severe injury was defined as meeting the physiologic step of the field triage guidelines and potential risk for severe illness was defined as having an abnormal vital sign after adjusting for patient age.

RESULTS

A total of 41,345 pediatric patients were transported by a participating EMS agency to an ED and had complete destination data. A total of 55% of all EMS-transported pediatric patients were transported to a hospital with higher-level pediatric resources. There was variation by site (range = 45%-71%) in the percentage of children who went to a hospital with higher-level pediatric resources. Patients over 15 years of age went to general EDs (57%) more often than younger patients. When stratified by severity, 60% of those with potentially severe illness and 74% of those with potentially severe trauma were transported to a hospital with higher-level pediatric resources.

CONCLUSIONS

EMS providers commonly transport children to hospitals with higher-level pediatric resources. However, more than one-quarter of children with potentially severe injuries and illnesses are transported to general EDs.

Consensus-based Criterion Standard for the Identification of Pediatric Patients Who Need Emergency Medical Services Transport to a Hospital with Higher-level Pediatric Resources

BACKGROUND

Emergency medical services (EMS) providers must be able to identify the most appropriate destination facility when treating children with potentially severe medical illnesses. Currently, no validated tool exists to assist EMS providers in identifying children who need transport to a hospital with higher-level pediatric care. For such a tool to be developed, a criterion standard needs to be defined that identifies children who received higher-level pediatric medical care.

OBJECTIVE

The objective was to develop a consensus-based criterion standard for children with a medical complaint who need a hospital with higher-level pediatric resources.

METHODS

Eleven local and national experts in EMS, emergency medicine (EM), and pediatric EM were recruited. Initial discussions identified themes for potential criteria. These themes were used to develop specific criteria that were included in a modified Delphi survey, which was electronically delivered. The criteria were refined iteratively based on participant responses. To be included, a criterion required at least 80% agreement among participants. If an item had less than 50% agreement, it was removed. A criterion with 50% to 79% agreement was modified based on participant suggestions and included on the next survey, along with any new suggested criteria. Voting continued until no new criteria were suggested and all criteria received at least 80% agreement.

RESULTS

All 11 recruited experts participated in all seven voting rounds. After the seventh vote, there was agreement on each item and no new criteria were suggested. The recommended criterion standard included 13 items that apply to patients 14 years old or younger. They included IV antibiotics for suspicion of sepsis or a seizure treated with two different classes of anticonvulsive medications within 2 hours, airway management, blood product administration, cardiopulmonary resuscitation, electrical therapy, administration of specific IV/IO drugs or respiratory assistance within 4 hours, interventional radiology or surgery within 6 hours, intensive care unit admission, specific comorbid conditions with two or more abnormal vital signs, and technology-assisted children seen for device malfunction.

CONCLUSION

We developed a 13-item consensus-based criterion standard definition for identifying children with medical complaints who need the resources of a hospital equipped to provide higher-level pediatric services. This criterion standard will allow us to create a tool to improve pediatric patient care by assisting EMS providers in identifying the most appropriate destination facility for ill children.

Assessment of Key Health and Wellness Indicators Among North Carolina Emergency Medical Service Providers

OBJECTIVE

The objective of this study was to characterize key health indicators in Emergency Medical Services (EMS) personnel and identify areas for intervention in order to ensure a strong and capable emergency health workforce.

METHODS

Participants were EMS personnel delivering patients to 4 regional tertiary care emergency departments within North Carolina (NC). After transferring patient care and agreeing to participate, height, weight, and blood pressure (BP) measurements were recorded and each participant completed a questionnaire regarding demographics, activity levels, alcohol consumption, smoking, and medical history. Data were analyzed descriptively.

RESULTS

A sample of 452 EMS personnel from across NC was enrolled. The cohort was predominantly male (74.1%) and employed full-time (85.5%). The prevalence of overweight and obesity (80.3%) among EMS personnel was higher than the NC population (65.6%) and the general United States (US) population (70.8%). A previous diagnosis of high BP was reported by only 18.3% of participants, but 65.1% had elevated BP at the time of measurement. Alcohol consumption in the past 30 days among participants (55.4%) was slightly higher than state estimates (48.0%) and similar to national estimates (57.1%). However, heavy drinking (22.2%) and binge drinking (28.8%) were reported at much higher rates than state (5.6% and 15.2%, respectively) and national (6.6% and 18.3%, respectively) estimates. The prevalence of current smoking (21.5%) and quit attempts (48.8%) in the cohort was similar to state (21.8% and 55.0%, respectively) and national (21.2% and 55.7%, respectively) estimates. Likewise, the proportion of EMS providers meeting the Center for Disease Control's activity guidelines (49.6%) was similar to that found in the NC (46.8%) and the general US (48.0%) populations.

CONCLUSIONS

These findings suggest a high prevalence of overweight and obesity, heavy drinking, binge drinking, and high BP among NC EMS personnel. Similar to fire service personnel, these rates are higher than the general US population. As such, they suggest areas where intervention would have the greatest positive impact on the health and performance of the EMS workforce.

Randomized Controlled Feasibility Trial of Intranasal Ketamine Compared to Intranasal Fentanyl for Analgesia in Children with Suspected Extremity Fractures

OBJECTIVES

We compared the tolerability and efficacy of intranasal subdissociative ketamine to intranasal fentanyl for analgesia of children with acute traumatic pain and investigated the feasibility of a larger noninferiority trial that could investigate the potential opioid-sparing effects of intranasal ketamine.

METHODS

This randomized controlled trial compared 1 mg/kg intranasal ketamine to 1.5 μg/kg intranasal fentanyl in children 4 to 17 years old with acute pain from suspected isolated extremity fractures presenting to an urban Level II pediatric trauma center from December 2015 to November 2016. Patients, parents, treating physicians, and outcome assessors were blinded to group allocation. The primary outcome, a tolerability measure, was the frequency of cumulative side effects and adverse events within 60 minutes of drug administration. The secondary outcomes included the difference in mean pain score reduction at 20 minutes, the proportion of patients achieving a clinically significant reduction in pain in 20 minutes, total dose of opioid pain medication in morphine equivalents/kg/hour (excluding study drug) required during the emergency department (ED) stay, and the feasibility of enrolling children presenting to the ED in acute pain into a randomized trial conducted under U.S. regulations. All patients were monitored until 6 hours after their last dose of study drug or until admission to the hospital ward or operating room.

RESULTS

Of 629 patients screened, 87 received the study drug and 82 had complete data for the primary outcome (41 patients in each group). The median (interquartile range) age was 8 (6-11) years and 62% were male. Baseline pain scores were similar among patients randomized to receive ketamine (73 ± 26) and fentanyl (69 ± 26; mean difference [95% CI] = 4 [-7 to 15]). The cumulative number of side effects was 2.2 times higher in the ketamine group, but there were no serious adverse events and no patients in either group required intervention. The most common side effects of ketamine were bad taste in the mouth (37; 90.2%), dizziness (30; 73.2%), and sleepiness (19; 46.3%). The most common side effects of fentanyl were sleepiness (15; 36.6%), bad taste in the mouth (9; 22%), and itchy nose (9; 22%). No patients experienced respiratory side effects. At 20 minutes, the mean pain scale score reduction was 44 ± 36 for ketamine and 35 ± 29 for fentanyl (mean difference = 9 [95% CI = -4 to 23]). Procedural sedation with ketamine occurred in 28 ketamine patients (65%) and 25 fentanyl patients (57%) prior to completing the study.

CONCLUSIONS

Intranasal ketamine was associated with more minor side effects than intranasal fentanyl. Pain relief at 20 minutes was similar between groups. Our data support the feasibility of a larger, noninferiority trial to more rigorously evaluate the safety, efficacy, and potential opioid-sparing benefits of intranasal ketamine analgesia for children with acute pain.

Factors Associated with Delayed Cooling in Cardiac Arrest Patients

Therapeutic hypothermia has been shown to improve neurologic outcome in medical cardiac arrest patients, yet little is known about factors that delay target temperature achievement. Our primary aim was to identify factors associated with not achieving our institutional "door-to-cool" (DTC) performance goal (emergency department [ED] arrival to temperature of 34°C) of ≤4 hours. Secondary aims included whether achievement of DTC goal was associated with timing of bolus neuromuscular blockade (NMB), survival, or functional outcome. This was a retrospective cohort study of a medical cardiac arrest quality improvement (QI) database that included patients treated from November 2007 to August 2012. The database was queried for patient demographics, arrest characteristics, specific cooling techniques used, whether patients underwent emergent computed tomography imaging or cardiac catheterization, and patient outcomes. Logistic regression was used to assess the factors associated with DTC goal performance and outcomes. We enrolled 327 patients, median age 58, median return of spontaneous circulation (ROSC) time of 21 minutes (interquartile range [IQR] 14-29 minutes), and shockable initial rhythm in 61%. One hundred forty-four (44%) patients survived to hospital discharge, 133 (41%) with good functional outcome, as defined as cerebral performance category 1-2. Induction with cold IV fluids [OR 0.50 (CI: 0.29-0.85)] and NMB administration within 2 hours of ED arrival [OR 2.95 (CI: 1.17-7.43)] was associated with achieving DTC goal. Logistic regression showed that achievement of DTC goal ≤4 hours [OR 0.59 (0.32-1.09)] was not associated with good functional outcome. In our single-center cohort, initiation of cold intravenous fluids (IVF) and early NMB administration were associated with improved DTC goal performance of 4 hours. However, patients achieving DTC goals were not associated with improved outcomes.

Evidence-Based Guidelines for Fatigue Risk Management in EMS: Formulating Research Questions and Selecting Outcomes

BACKGROUND

Greater than half of Emergency Medical Services (EMS) personnel report work-related fatigue, yet there are no guidelines for the management of fatigue in EMS. A novel process has been established for evidence-based guideline (EBG) development germane to clinical EMS questions. This process has not yet been applied to operational EMS questions like fatigue risk management. The objective of this study was to develop content valid research questions in the Population, Intervention, Comparison, and Outcome (PICO) framework, and select outcomes to guide systematic reviews and development of EBGs for EMS fatigue risk management.

METHODS

We adopted the National Prehospital EBG Model Process and Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework for developing, implementing, and evaluating EBGs in the prehospital care setting. In accordance with steps one and two of the Model Process, we searched for existing EBGs, developed a multi-disciplinary expert panel and received external input. Panelists completed an iterative process to formulate research questions. We used the Content Validity Index (CVI) to score relevance and clarity of candidate PICO questions. The panel completed multiple rounds of question editing and used a CVI benchmark of ≥0.78 to indicate acceptable levels of clarity and relevance. Outcomes for each PICO question were rated from 1 = less important to 9 = critical.

RESULTS

Panelists formulated 13 candidate PICO questions, of which 6 were eliminated or merged with other questions. Panelists reached consensus on seven PICO questions (n = 1 diagnosis and n = 6 intervention). Final CVI scores of relevance ranged from 0.81 to 1.00. Final CVI scores of clarity ranged from 0.88 to 1.00. The mean number of outcomes rated as critical, important, and less important by PICO question was 0.7 (SD 0.7), 5.4 (SD 1.4), and 3.6 (SD 1.9), respectively. Patient and personnel safety were rated as critical for most PICO questions. PICO questions and outcomes were registered with PROSPERO, an international database of prospectively registered systematic reviews.

CONCLUSIONS

We describe formulating and refining research questions and selection of outcomes to guide systematic reviews germane to EMS fatigue risk management. We outline a protocol for applying the Model Process and GRADE framework to create evidence-based guidelines.

Evaluating clinical care in the prehospital setting: Is Rapid Emergency Medicine Score the missing metric of EMS?

INTRODUCTION

The Rapid Emergency Medicine Score (REMS) was developed to predict emergency department patient mortality. Our objective was to utilize REMS to assess initial patient acuity and evaluate clinical change during prehospital care.

METHODS

All non-cardiac arrest emergency transports from April 1, 2013 to March 31, 2014 were analyzed from a single EMS agency. Using age, pulse rate, mean arterial pressure, respiratory rate, oxygen saturation, and Glasgow Coma Scale, initial and final REMS were calculated. Change in REMS was calculated by initial minus final with a positive number indicating clinical improvement. Descriptive analyses were performed calculating means and 95% confidence intervals.

RESULTS

There were 61,346 patients analyzed with an average initial REMS of 4.3 (95% CI: 4.2-4.3) and an average REMS change of 0.37 (95% CI: 0.36-0.38). Those patients classified with the highest dispatch priority had the highest initial REMS (5.8; 95% CI: 5.5-6.2) and the greatest change (0.95; 95% CI: 0.72-1.17). Patients transported with high priority had greater initial REMS, as well as greater improvement in REMS (high priority 7.3 [95% CI: 7.1-7.4], change 0.61 [95% CI: 0.53-0.69]; middle priority 5.3 [95% CI: 5.2-5.4], change 0.55 [95% CI: 0.51-0.59]; low priority 3.9 [95% CI: 3.8-3.9], change 0.32 [95% CI: 0.31-0.33]).

CONCLUSION

Descriptive analyses indicate that as dispatch and transport priorities increased in severity so too did initial REMS. The largest change in REMS was seen in patients with the highest dispatch and transport priorities. This indicates that REMS may provide system level insight into evaluating clinical changes during care.

Prehospital Opioid Administration in the Emergency Care of Injured Children

OBJECTIVE

Prior studies have identified provider and system characteristics that impede pain management in children, but no studies have investigated the effect of changing these characteristics on prehospital opioid analgesia. Our objectives were to determine: 1) the frequency of opioid analgesia and pain score documentation among prehospital pediatric patients after system wide changes to improve pain treatment, and 2) if older age, longer transport times, the presence of vascular access and pain score documentation were associated with increased prehospital administration of opioid analgesia in children.

METHODS

This was a retrospective cross-sectional study of pediatric patients aged 3-18 years assessed by a single EMS system between October 1, 2011 and September 30, 2013. Prior to October 2011, the EMS system had implemented 3 changes to improve pain treatment: (1) training on age appropriate pain scales, (2) protocol changes to allow opioid analgesia without contacting medical control, and (3) the introduction of intranasal fentanyl. All patients with working assessments of blunt, penetrating, lacerating, and/or burn trauma were included. We used descriptive statistics to determine the frequency of pain score documentation and opioid analgesia administration and logistic regression to determine the association of age, transport time, and the presence of intravenous access with opioid analgesia administration.

RESULTS

Of the 1,368 eligible children, 336 (25%) had a documented pain score. Eleven percent (130/1204) of children without documented contraindications to opioid administration received opioids. Of the children with no documented pain score and no protocol exclusions, 9% (81/929) received opioid analgesia, whereas 18% (49/275) with a documented pain score ≥4 and no protocol exclusions received opioids. Multivariate analysis revealed that vascular access (OR = 11.89; 95% CI: 7.33-19.29), longer patient transport time (OR = 1.07; 95% CI: 1.04-1.11), age (OR 0.93; 95% CI: 0.88-0.98) and pain score documentation (OR 2.23; 95% CI: 1.40-3.55) were associated with opioid analgesia.

CONCLUSIONS

Despite implementation of several best practice recommendations to improve prehospital pain treatment, few children have a documented pain score and even fewer receive opioid analgesia. Children with longer transport times, successful IV placement, and/or documentation of pain score(s) were more likely to receive prehospital analgesia.

Study protocol of a randomised controlled trial of intranasal ketamine compared with intranasal fentanyl for analgesia in children with suspected, isolated extremity fractures in the paediatric emergency department

INTRODUCTION

Fentanyl is the most widely studied intranasal (IN) analgesic in children. IN subdissociative (INSD) ketamine may offer a safe and efficacious alternative to IN fentanyl and may decrease overall opioid use during the emergency department (ED) stay. This study examines the feasibility of a larger, multicentre clinical trial comparing the safety and efficacy of INSD ketamine to IN fentanyl and the potential role for INSD ketamine in reducing total opioid medication usage.

METHODS AND ANALYSIS

This double-blind, randomised controlled, pilot trial will compare INSD ketamine (1 mg/kg) to IN fentanyl (1.5 μg/kg) for analgesia in 80 children aged 4-17 years with acute pain from a suspected, single extremity fracture. The primary safety outcome for this pilot trial will be the frequency of cumulative side effects and adverse events at 60 min after drug administration. The primary efficacy outcome will be exploratory and will be the mean reduction of pain scale scores at 20 min. The study is not powered to examine efficacy. Secondary outcome measures will include the total dose of opioid pain medication in morphine equivalents/kg/hour (excluding study drug) required during the ED stay, number and reason for screen failures, time to consent, and the number and type of protocol deviations. Patients may receive up to 2 doses of study drug.

ETHICS AND DISSEMINATION

This study was approved by the US Food and Drug Administration, the local institutional review board and the study data safety monitoring board. This study data will be submitted for publication regardless of results and will be used to establish feasibility for a multicentre, non-inferiority trial.

TRIAL REGISTRATION NUMBER

NCT02521415.

Electrocardiographic diagnosis of ST segment elevation myocardial infarction: An evaluation of three automated interpretation algorithms

OBJECTIVE

To assess the validity of three different computerized electrocardiogram (ECG) interpretation algorithms in correctly identifying STEMI patients in the prehospital environment who require emergent cardiac intervention.

METHODS

This retrospective study validated three diagnostic algorithms (AG) against the presence of a culprit coronary artery upon cardiac catheterization. Two patient groups were enrolled in this study: those with verified prehospital ST-elevation myocardial infarction (STEMI) activation (cases) and those with a prehospital impression of chest pain due to ACS (controls).

RESULTS

There were 500 records analyzed resulting in a case group with 151 patients and a control group with 349 patients. Sensitivities differed between AGs (AG1=0.69 vs AG2=0.68 vs AG3=0.62), with statistical differences in sensitivity found when comparing AG1 to AG3 and AG1 to AG2. Specificities also differed between AGs (AG1=0.89 vs AG2=0.91 vs AG3=0.95), with AG1 and AG2 significantly less specific than AG3.

CONCLUSIONS

STEMI diagnostic algorithms vary in regards to their validity in identifying patients with culprit artery lesions. This suggests that systems could apply more sensitive or specific algorithms depending on the needs in their community.

Characteristics of ST Elevation Myocardial Infarction Patients Who Do Not Undergo Percutaneous Coronary Intervention After Prehospital Cardiac Catheterization Laboratory Activation

OBJECTIVES

To assess the clinical and electrocardiographic characteristics of patients diagnosed with ST elevation myocardial infarction (STEMI) that are associated with an increased likelihood of not undergoing percutaneous coronary intervention (PCI) after prehospital Cardiac Catheterization Laboratory activation in a regional STEMI system.

METHODS

We performed a retrospective analysis of prehospital Cardiac Catheterization Laboratory activations in Mecklenburg County, North Carolina, between May 2008 and March 2011. Data were extracted from the prehospital patient record, the prehospital electrocardiogram, and the regional STEMI database. The independent variables of interest included objective patient characteristics as well as documented cardiac history and risk factors. Analysis was performed using descriptive statistics and logistic regression.

RESULTS

Two hundred thirty-one prehospital activations were included in the analysis. Five independent variables were found to be associated with an increased likelihood of not undergoing PCI: increasing age, bundle branch block, elevated heart rate, left ventricular hypertrophy, and non-white race. The variables with the most significance were any type of bundle branch block [adjusted odds ratios (AOR), 5.66; 95% confidence interval (CI), 1.91-16.76], left ventricular hypertrophy (AOR, 4.63; 95% CI, 2.03-10.53), and non-white race (AOR, 3.53; 95% CI, 1.76-7.08). Conversely, the only variable associated with a higher likelihood of undergoing PCI was the presence of arm pain (AOR, 2.94; 95% CI, 1.36-6.25).

CONCLUSIONS

Several of the above variables are expected electrocardiogram mimics; however, the decreased rate of PCI in non-white patients highlights an area for investigation and process improvement. This may guide the development of prehospital STEMI protocols, although avoiding false positive and inappropriate activations.

2015 Pediatric Research Priorities in Prehospital Care

BACKGROUND

Pediatric prehospital research has been limited, but work in this area is starting to increase particularly with the growth of pediatric-specific research endeavors. Given the increased interest in pediatric prehospital research, there is a need to identify specific research priorities that incorporate the perspective of prehospital providers and other emergency medical services (EMS) stakeholders.

OBJECTIVES

To develop a list of specific research priorities that is relevant, specific, and important to the practice of pediatric prehospital care.

METHODS

Three independent committees of EMS providers and researchers were recruited. Each committee developed a list of research topics. These topics were collated and used to initiate a modified Delphi process for developing consensus on a list of research priorities. Participants were the committee members. Topics approved by 80% were retained as research priorities. Topics that were rejected by more than 50% were eliminated. The remaining topics were modified and included on subsequent surveys. Each survey allowed respondents to add additional topics. The surveys were continued until all topics were either successfully retained or rejected and no new topics were suggested.

RESULTS

Fifty topics were identified by the three independent committees. These topics were included on the initial electronic survey. There were 5 subsequent surveys. At the completion of the final survey a total of 29 research priorities were identified. These research priorities covered the following study areas: airway management, asthma, cardiac arrest, pain, patient-family interaction, resource utilization, seizure, sepsis, spinal immobilization, toxicology, trauma, training and competency, and vascular access. The research priorities were very specific. For example, under airway the priorities were: "identify the optimal device for effectively managing the airway in the prehospital setting" and "identify the optimal airway management device for specific disease processes."

CONCLUSION

This project developed a list of relevant, specific, and important research priorities for pediatric prehospital care. Some similarities exist between this project and prior research agendas but this list represents a current, more specific research agenda and reflects the opinions of working EMS providers, researchers, and leaders.

KEY WORDS

emergency medical technician; research; emergency medical services; priorities.

Troponin Marker for Acute Coronary Occlusion and Patient Outcome Following Cardiac Arrest

INTRODUCTION

The utility of troponin as a marker for acute coronary occlusion and patient outcome after out-of-hospital cardiac arrest (OHCA) is unclear. We sought to determine whether initial or peak troponin was associated with percutaneous coronary intervention (PCI), OHCA survival or neurological outcome.

METHODS

Single-center retrospective-cohort study of OHCA patients treated in a comprehensive clinical pathway from November 2007 to October 2012. Troponin I levels were acquired at presentation, four and eight hours after arrest, and then per physician discretion. Cardiac catheterization was at the cardiologist's discretion. Survival and outcome were determined at hospital discharge, with cerebral performance category score 1-2 defined as a good neurological outcome.

RESULTS

We enrolled 277 patients; 58% had a shockable rhythm, 44% survived, 41% good neurological outcome. Of the 107 (38%) patients who underwent cardiac catheterization, 30 (28%) had PCI. Initial ED troponin (median, ng/mL) was not different in patients requiring PCI vs no PCI (0.32 vs 0.09, p=0.06), although peak troponin was higher (4.19 versus 1.57, p=0.02). Of the 85 patients who underwent cardiac catheterization without STEMI (n=85), there was no difference in those who received PCI vs no PCI in initial troponin (0.22 vs 0.06, p=0.40) or peak troponin (2.58 vs 1.43, p=0.27). Regarding outcomes, there was no difference in initial troponin in survivors versus non-survivors (0.09 vs 0.22, p=0.11), or those with a good versus poor neurological outcome (0.09 vs 0.20, p=0.11). Likewise, there was no difference in peak troponin in survivors versus non-survivors (1.64 vs 1.23, p=0.07), or in those with a good versus poor neurological outcome (1.57 vs 1.26, p=0.14).

CONCLUSION

In our single-center patient cohort, peak troponin, but not initial troponin, was associated with higher likelihood of PCI, while neither initial nor peak troponin were associated with survival or neurological outcome in OHCA patients.

Utilizing Geographic Information Systems to Identify Clusters of Severe Sepsis Patients Presenting in the Out-of-Hospital Environment

Understanding the geographic distribution of critical illness within a community may provide public health stakeholders with information that can be used to expedite access to specialized care. We hypothesized that severe sepsis patients transported by emergency medical services (EMS) exhibit geospatial clustering and that prehospital providers would recognize sepsis more frequently in patients transported from sepsis clusters. Retrospective review of a prospective, observational study of patients with severe sepsis transported to the emergency department (ED) by EMS and treated with early goal-directed therapy (EGDT).

INCLUSION CRITERIA

suspected infection, 2 or more criteria for systemic inflammation, and either systolic blood pressure <90 mmHg after a fluid bolus or lactate >4 mmol/liter.

EXCLUSION CRITERIA

age <18 or need for immediate surgery. Patient location at the time of EMS activation was recorded. Analysis of the addresses identified clusters, defined as a location in which EMS transported more than one patient experiencing the above associated signs and symptoms of septic shock. Other data collected included self-reported patient location as private residence or chronic care facility. One hundred sixty severe sepsis patients transported by EMS were eligible for analysis, presenting from 125 locations. Ninety-one patients (57%) presented from a private residence and 69 (37%) from a chronic care facility. Fifty (31%) patients were transported from 15 locations, with 25 of those transported from just 4 locations. Cluster patients tended to be older, come from medical facilities, and were more likely to have sepsis recognized by prehospital providers. Results from this study demonstrate low pre-hospital recognition of sepsis, as well as geospatially clustered presentations, most notably from skilled nursing facilities. Community education, public health initiatives, and EMS interventions could be targeted in such clusters of cases in order to both improve sepsis recognition and potentially expedite time-sensitive interventions.

A Brief Educational Intervention Improves Medication Safety Knowledge in Grandparents of Young Children

BACKGROUND AND OBJECTIVES

Increasing grandparent-grandchild interactions have not been targeted as a potential contributing factor to the recent surge in pediatric poisonings. We hypothesized that in grandparents with a young grandchild, a single educational intervention based on the PROTECT "Up & Away" campaign will improve safe medication knowledge and storage at follow-up from baseline.

METHODS

This prospective cohort study validated the educational intervention and survey via cognitive debriefing followed by evaluation of the educational intervention in increasing safe medication storage. Participants had to read and speak English and have annual contact with one grandchild ≤ 5-years-old. Participants were recruited from a convenience sample of employees in a regional healthcare system. They completed a pre-intervention survey querying baseline demographics, poisoning prevention knowledge, and medication storage, followed by the educational intervention and post-intervention survey. Participants completed a delayed post-intervention survey 50-90 days later assessing medication storage and poisoning prevention knowledge. Storage sites were classified as safe or unsafe a priori; a panel classified handwritten responses.

RESULTS

120 participants were enrolled; 95 (79%) completed the delayed post-intervention survey. Participants were predominantly female (93%) and white (76%); 50% had a clinical degree. Participants averaged 1.9 grandchildren. Initially, 23% of participants reported safe medication storage; this improved to 48% after the intervention (OR 6.4; 95% CI = 2.5-21.0). 78% of participants made at least one improvement in their medication storage after the intervention even if they did not meet all criteria for safe storage. Participants also demonstrated retention of poisoning prevention knowledge.

CONCLUSIONS

This brief educational intervention improved safe medication storage and poisoning prevention knowledge in grandparents of young children; further evaluation of this intervention is warranted.

Introduction of performance coaching during cardiopulmonary resuscitation improves compression depth and time to defibrillation in out-of-hospital cardiac arrest

INTRODUCTION

Quality cardiopulmonary resuscitation (CPR) and timely defibrillation are associated with increasing survival to hospital discharge from out-of-hospital cardiac arrest (OHCA). The objective of this study was to demonstrate that performance coaching during an OHCA would improve compression depth and time to defibrillation (TTD).

METHODS

This study was conducted in a single emergency medical services (EMS) agency and utilized data collected from 815 patients treated between 1/1/2012 and 12/31/2013. The intervention used multiple Plan-Do-Study-Act (PDSA) cycles to train fire captains to translate performance data into active direction. Testing began in simulation with small-scale expansions prior to system-wide implementation. Performance metrics included average (reported as a percentage) and actual compression depth (reported in millimeters), and TTD (an average in seconds). Analysis was conducted using Xbar and S control charts with standard assessment of special cause for performance data. A statistical shift was seen in means and standard deviations for both depth metrics.

RESULTS

Average depth of compressions improved from 69.8% (SD=28.0%) to 80.4 (SD=21.8%). Depth of compressions delivered increased from 43.6mm (SD=8.2mm) to 47.2mm (SD=8.1mm). Analysis of the S charts indicates a statistical shift in process variation for TTD.

CONCLUSION

Early results indicate that utilization of a CPR coach during OHCA improves compression depth and TTD. Further data are needed to assess sustainability.

Implementation of prehospital dispatch protocols that triage low-acuity patients to advice-line nurses

INTRODUCTION

Although EMS agencies have been designed to efficiently provide medical assistance to individuals, the overuse of 9-1-1 as an alternative to primary medical care has resulted in the need for new methods to respond to this increasing demand. Our study analyzes the efficacy of classifying specific low-acuity calls that can be transferred to an advice-line nurse for further medical instruction. The objectives of our study were to analyze the impact of implementing this protocol and resultant patient feedback regarding the transfer to an advice-line nurse.

METHODS

We collected data for retrospective review from April 2011 to April 2012 from a single municipal EMS agency with an average annual call volume of approximately 90,000. Medical Priority Dispatch System response codes were assigned to calls based on patient acuity. Patients classified under Omega response codes were assessed for eligibility of transfer to nurse advice lines. Exclusion criteria included the following: if the call was placed by a third-party caller; if the patient refused to be transferred to the advice-line nurse; anytime the MPDS system was not used; if the patient was referred from a skilled nursing facility, school, or university nursing office, or physician's office. Telephone surveys were conducted for those patients who spoke to an advice-line nurse and did not receive an ambulance response 24 hours after calling 9-1-1 to obtain patient feedback.

RESULTS

The database included 1660 patients initially classified as Omega and eligible for transfer to an advice-line nurse. After applying the exclusion criteria, 329 (19.8%) patients were ultimately transferred to an advice-line nurse and 204 (12.3%) received no ambulance response. Of those patients who were not transported by ambulance 118 (57.8%), patients completed telephone follow-up, with 104 (88.1%) reporting the nontransport option met their health-care needs and 108 (91.5%) responding they would accept the transfer again for a similar complaint.

CONCLUSION

We identified an average of two patients per day as eligible for transfer to the nurse advice line, with less than one patient successfully completing the Omega protocol per day. While impact was limited, there was a decrease in ambulance response.

An assessment of depression, anxiety, and stress among nationally certified EMS professionals

OBJECTIVES

The primary objective of this study was to estimate the prevalence and severity of depression, anxiety, and stress among a cohort of nationally certified emergency medical services (EMS) professionals. The secondary objective was to determine whether there were differences between individuals who were experiencing depression, anxiety, or stress and those who were not.

METHODS

This was a questionnaire-based, case-control analysis of nationally certified emergency medical technician (EMT)-Basics and paramedics who applied for national recertification in 2009. The three outcome variables of interest included measures of depression, anxiety, and stress, and were assessed using the Depression Anxiety Stress Scale-21 (DASS-21). Descriptive statistics and investigator-controlled backwards-selection logistic regression modeling were utilized to quantify the prevalence of depression, anxiety, and stress and to predict the association of demographic and work-life characteristics with each outcome.

RESULTS

A total of 64,032 individuals were eligible to renew their national certification and 34,340 (53.6%) individuals returned a questionnaire. The DASS-21 classified 1,589 (6.8%, 95% confidence interval [CI] = 6.4%-7.1%) EMS professionals as depressed, 1,406 (6.0%, 95% CI = 5.7%-6.3%) as anxious, and 1,382 (5.9%, 95% CI = 5.6%-6.2%) as stressed. Multivariable logistic regression estimates showed that paramedics (odds ratio [OR] = 1.31, 95% CI = 1.22-1.39), those working in county or municipal services (OR = 1.36, 95% CI = 1.16-1.60) or private services (OR = 1.32, 95% CI = 1.14-1.52), and those with ≥16 years of EMS experience (OR = 1.28, 95% CI = 1.01-1.62) had an increased odds of depression. A stepwise increase was found when estimating the effects of self-reported general health on the odds of anxiety (very good, OR = 1.84, 95% CI = 1.53-2.22; good, OR = 3.88, 95% CI = 3.32-4.67; fair/poor, OR = 10.81, 95% CI = 8.14-14.34). Likewise, paramedics (OR = 1.32, 95% CI = 1.23-1.42), those working in a private EMS system (OR = 1.35, 95% CI = 1.16-1.56), and those with ≥16 years of EMS experience (OR = 1.67, 95% CI = 1.28-2.18) had an increased odds of stress.

CONCLUSIONS

This study was able to estimate the prevalence of depression, anxiety, and stress among a large cohort of nationally certified EMS professionals and identified statistically significant demographic and work-life characteristics that predicted depression, anxiety, and stress. Future research should attempt to follow EMS professionals prospectively to determine specific characteristics associated with occupational traumatic exposure and the development of depression, anxiety, and stress.

Abstract WP233: Prehospital Stroke Screen Accuracy in a State with an Emergency Medical Services Protocol for Routing Patients to Acute Stroke Centers

Background: A growing number of states are enacting legislation or regulations that direct emergency medical service (EMS) routing to state designated or Joint Commission Certified Stroke Centers, based on prehospital stroke screens performed by EMS providers.

Objective: Assess the sensitivity and specificity of the Cincinnati Prehospital Stroke Screen (CPSS) and the Los Angeles Prehospital Stroke Screen (LAPSS) when performed by EMS providers in the context of a state-wide EMS stroke patient transport protocol.

Methods: We used a validated method of deterministic matching to link a statewide Prehospital Medical Information System database, that includes prehospital stroke screen results, to a Statewide Emergency Department (ED) Surveillance System database containing ED disposition diagnosis ICD-9 codes. We compared EMS stroke screen results to the ED ICD-9 codes for ischemic and hemorrhagic stroke and TIA.

Results: Over a 24 month period, we identified 3,901 linked records with a prehospital impression of acute stroke. This included 2,419 (62%) records with a completed and conclusive stroke screen result. There were 1,202 patients (50%) with a completed CPSS and 1,217 patients (50%) with a completed LAPSS. Ninety-four EMS agencies from 65 of the state’s 100 counties were represented in the complete data. The CPSS was 80% (95% CI 76-83%) sensitive and 46% (95% CI 42-50%) specific, whereas the LAPSS was 73% (95% CI 69-76%) sensitive and 42% (95% CI 38-46%) specific for identifying patients with an ED diagnosis of stroke or TIA.

Conclusion: When performed and conclusively recorded by many different EMS agencies across one state, the CPSS and LAPSS had similar test characteristics. If prehospital screening is to be used to determine transport diversion to acute stroke centers, improving the specificity of these screens would be optimum.

Assessing the influence of insulation on intravenous fluid infusion temperature

OBJECTIVES

Inducing therapeutic hypothermia using chilled saline in resuscitated cardiac arrest patients has been shown to be feasible and effective. Limited research exists assessing the efficiency of this cooling method. The objective of this study was to assess the change in temperature of 4°C saline upon exiting an infusion set in the laboratory setting while varying conditions of fluid delivery.

METHODS

Efficiency was studied by assessing change in fluid temperature (°C) during the infusion under four laboratory conditions. Each condition was performed four times using 1-L bags of normal saline. Fluid was infused into a 1000-mL beaker through 10 gtt/mL tubing. Flow rate was controlled using a tubing clamp and in-line transducer with a flow meter, while temperature was continuously monitored in a side port at the terminal end of the intravenous (IV) tubing using a digital thermometer. The four conditions included different insulation methods. Descriptive statistics and analysis of variance were performed to assess changes in fluid temperature.

RESULTS

The mean (±SD) fluid temperature at time 0 was 3.2°C (95% confidence interval [CI] = 3.0 to 3.4 °C) with no significant difference in starting temperature between groups (p = 0.45). When flow rate was constant, it was determined that fluid temperatures were significantly cooler when infused using a chilled, gel-filled sleeve around the saline bag (p < 0.006).

CONCLUSIONS

In a laboratory setting, the most efficient method of infusing cold fluid appears to be a method that both keeps the bag of fluid insulated and infused at a faster rate.

Rates of Cardiac Catheterization Cancelation for ST-Segment Elevation Myocardial Infarction After Activation by Emergency Medical Services or Emergency Physicians

Background—

For patients with an acute ST-segment elevation myocardial infarction, cardiac catheterization laboratory (CCL) activation by emergency medical technicians or emergency physicians has been shown to substantially reduce treatment times. One drawback to this approach involves overtriage, whereby CCL staffs are activated for patients who ultimately do not require emergent coronary angiography or for patients who undergo angiography but are not found to have coronary artery occlusion.

Methods and Results—

We examined CCL activation at 14 primary angioplasty hospitals to determine the course of management, including the rate of inappropriate activation. Among 3973 activations (29% by emergency medical technicians, 71% by emergency physicians) between December 2008 and December 2009, appropriate CCL activations occurred for 3377 patients (85%), with 2598 patients (76.9% of appropriate activations) receiving primary percutaneous coronary intervention. Reasons for inappropriate activations (596 patients; 15%) included ECG reinterpretations (427 patients; 72%) or the fact that the patient was not a CCL candidate (169 patients; 28%). The rate of cancellation because of reinterpretation of emergency medical technicians' ECG (6% of all activations) was more common than for cancellation because of reinterpretation of emergency physicians' ECG (4.6%).

Conclusions—

This represents the first report of the rates of CCL cancellation for ST-segment elevation myocardial infarction system activation by emergency medical technicians and emergency physicians in a large group of hospitals organized within a statewide program. The high rate of coronary intervention and relatively low rate of inappropriate activation suggest that systematic CCL activation by emergency personnel on a broad scale is feasible and accurate, and these rates set a benchmark for ST-segment elevation myocardial infarction systems.

Evaluation of occupational injuries in an urban emergency medical services system before and after implementation of electrically powered stretchers

Musculoskeletal injuries are frequently reported among Emergency Medical Services (EMS) professionals. The objective of this study was to evaluate occupational injuries in an urban EMS system before and after implementation of hydraulic stretchers. Data for this analysis were obtained from Austin Travis County EMS (A/TCEMS). In December 2006, A/TCEMS placed into service electrically powered patient stretchers. The pre-intervention period was between 01/01/1999 and 12/31/2006, and the post-intervention period was between 01/01/2007 and 4/30/2008. Incidence rate calculations were performed for four injury sub-groups and rate ratios (RRs) and corresponding 95% confidence interval (CI) were presented. There were 2087 and 706 person-years of observation pre- and post-intervention, respectively. The incidence rates for overall injury pre-intervention and post-intervention were 61.1 and 28.8 per 100 FTE, with a corresponding RR of 0.47 (95% CI 0.41-0.55) indicating a significant decrease in the rate of injury. The subcategory of stretcher-related injuries had the lowest RR (0.30; 95% CI 0.17-0.52) when comparing pre- and post-intervention time periods.

The association between emergency medical services field performance assessed by high-fidelity simulation and the cognitive knowledge of practicing paramedics

OBJECTIVES

The objective of this study was to assess the association between the performance of practicing paramedics on a validated cognitive exam and their field performance, assessed on a simulated emergency medical services (EMS) response.

METHODS

This was an observational study of paramedics from a single-tiered, urban, advanced life support EMS agency. A high-fidelity simulated response to a medical emergency on environmentally realistic sound stages, and the cognitive portion of the national paramedic certification exam, were each assessed as pass or fail. Participants were randomly assigned to one of six simulations designed by the agency's educational staff, medical director, and representatives from the National Registry of EMTs to be equivalently difficult. Simulations were pilot tested to assess content and face validity. Each participant was classified as failing a simulation scenario if his or her score was one standard deviation (SD) below the population mean.

RESULTS

There were 107 paramedics who participated in the study. Participants reported a median of 7.7 years of service (interquartile range [IQR] = 4.1 to 12.8 years). Simulation scores were normally distributed. Ninety-two (86.0%) participants received a passing score for the simulation and 77 (72.0%) passed the cognitive exam. There were 70 (65.4%) individuals who passed both the simulation and the cognitive exam, eight (7.5%) who failed both the simulation and the cognitive exam, 22 (20.6%) who passed the simulation but failed the cognitive exam, and seven (6.5%) who failed the simulation but passed the cognitive exam. There was a significant association between passing the cognitive exam and passing the simulation (chi-square p-value = 0.02).

CONCLUSIONS

This study simultaneously assessed cognitive knowledge and simulated field performance. Utilization of these measurement techniques allowed for the assessment and comparison of field performance and cognitive knowledge. Results demonstrated an association between a practicing paramedic's performance on a cognitive examination and field performance, assessed by a simulated EMS response.

The association between ambulance hospital turnaround times and patient acuity, destination hospital, and time of day

INTRODUCTION

The availability of ambulances to respond to emergency calls is related to their ability to return to service from the hospital. Extended hospital turnaround times decrease the number of available unit hours ambulances are deployed, which in turn can increase coverage costs or sacrifice coverage.

OBJECTIVE

To determine whether ambulance turnaround times were associated with patient acuity, destination hospital, and time of day.

METHODS

This retrospective analysis of ambulance hospital turnaround times utilized 12 months of data from a single, countywide, metropolitan emergency medical services (EMS) service. Turnaround time was defined as the interval between the time of ambulance arrival at the hospital and the time the ambulance became available to respond to another call. Independent variables included patient acuity (low [BLS nonemergency transport], medium [ALS care and nonemergency transport], and high [ALS care and emergency transport]), destination hospital (seven regional hospitals), and time of day (one-hour intervals). Data analysis consisted of descriptive statistics, t-tests, and linear regression.

RESULTS

Of the 61,094 patient transports, the mean turnaround time was 35.6 minutes (standard deviation [SD] = 16.5). Turnaround time was significantly associated with patient acuity (p < 0.001). High-acuity calls had a mean turnaround time of 52.5 minutes (SD = 21.5), whereas moderate-acuity and low-acuity calls had mean turnaround times of 42.0 minutes (SD = 16.4) and 32.5 minutes (SD = 14.4), respectively. A statistically significant relationship between destination hospital and turnaround time was found, with the differences in means ranging from 30 seconds to 8 minutes. Similarly, time of day was associated with turnaround time, with the longest turnaround times occurring between 0600 and 1500 hours.

CONCLUSION

This study demonstrated that patient acuity, destination hospital, and time of day were associated with variation in ambulance turnaround times. Research describing other system characteristics such as current emergency department census and patient handoff procedures may further demonstrate areas for improvement in HTAT. Results from this analysis may be used to inspire EMS administrators and EMS medical directors to start tracking these times to create a predictive model of EMS staffing needs.

Disaster preparedness of nationally certified emergency medical services professionals

OBJECTIVES

During disasters, the public expects that emergency care will be available at a moment's notice. As such, an emergency medical services (EMS) workforce that is trained and prepared for disasters is imperative. The primary objectives of this study were to quantify the amount of individual-level training EMS professionals receive in terrorism and disaster-preparedness, as well as to assess EMS professionals' participation in multiagency disaster drills across the United States. Characteristics of those most likely to have received individual-level training or participated in multiagency disaster drills were explored. The secondary objectives were to assess EMS professional's perception of preparedness and to determine whether the amount of training individuals received was correlated with their perceptions of preparedness.

METHODS

A structured survey was administered to nationally certified EMT-Basics and paramedics as part of their 2008 recertification paperwork. Outcome variables included individual-level preparedness training, participation in multiagency disaster drills, and perception of preparedness. Descriptive statistics and logistic regression modeling were used to quantify the amount of training received. Spearman rank correlation coefficients were used to analyze whether training was correlated with an individual's perception of preparedness.

RESULTS

There were 46,127 EMS professionals who had the opportunity to complete the recertification questionnaire; 30,570 (66.3%) responded. A complete case analysis was performed on 21,438 respondents. Overall, 19,551 respondents (91.2%) reported receiving at least 1 hour of individual-level preparedness training, and 12,828 respondents (59.8%) reported participating in multiagency disaster drills, in the prior 24 months. Spearman rank correlation coefficients revealed that hours of individual-level preparedness training were significantly correlated with the perception of preparedness.

CONCLUSIONS

While areas where EMS should focus attention for improvement were identified, a majority of nationally certified EMT-Basics and paramedics reported participating in both individual and multiagency disaster-preparedness training. A large majority of respondents reported feeling adequately prepared to respond to man-made and natural disasters and the perception of preparedness correlated with hours of training.

Comparison of first-attempt success between tibial and humeral intraosseous insertions during out-of-hospital cardiac arrest

BACKGROUND

Intraosseous (IO) needle insertion is often utilized in the adult population for critical resuscitation purposes. Standard insertion sites include the proximal humerus and proximal tibia, for which limited comparison data are available.

OBJECTIVE

This study compared the frequencies of IO first-attempt success between humeral and tibial sites in out-of-hospital cardiac arrest.

METHODS

This observational study was conducted in an urban setting between August 28, 2009, and October 31, 2009, and included all medical cardiac arrest patients for whom resuscitative efforts were performed. Cardiac arrest protocols stipulate that paramedics insert an IO line for initial vascular access. During the first month of the study, the proximal humerus was the preferred primary insertion site, whereas the tibia was preferred throughout the second month. The primary outcome was first-attempt success, defined as secure IO needle position in the marrow cavity and normal fluid flow. Any needle dislodgment during resuscitation was also recorded. The association between first-attempt IO success and initial IO insertion location was analyzed using a test of independent proportions and 95% confidence intervals (CIs) for the difference in proportions.

RESULTS

There were 88 cardiac arrest patients receiving IO placement, with 58 (65.9%) patients receiving their initial IO attempt in the tibia. The rate of first-time IO success at the tibia was significantly higher than that observed at the humerus (89.7% vs. 60.0%; p < 0.01). There were 18 initial successes at the humerus; for six (33.3%) of these, the needle became dislodged during resuscitation, compared with 52 initial successes at the tibia, with three (5.8%) dislodgments. The rate of total success for initial IO placements was significantly lower for the humerus (40.0%) compared with that for the tibia (84.5%; p < 0.01) during resuscitation efforts.

CONCLUSIONS

In this subset of patients, tibial IO needle placement appeared to be a more effective insertion site than the proximal humerus. Success rates were higher with a lower incidence of needle dislodgments. Further randomized studies are required in order to validate these results.

The association between intra-arrest therapeutic hypothermia and return of spontaneous circulation among individuals experiencing out of hospital cardiac arrest

INTRODUCTION

Therapeutic hypothermia has been shown to improve both mortality and neurologic outcomes following pulseless ventricular tachycardia and fibrillation. Animal data suggest intra-arrest induction of therapeutic hypothermia (IATH) improves frequency of return of spontaneous circulation (ROSC). Our objective was to evaluate the association between IATH and ROSC.

METHODS

This was a retrospective analysis of individuals experiencing non-traumatic cardiac arrest in a large metropolitan area during a 12-month period. Six months into the study a prehospital IATH protocol was instituted whereby patients received 2000ml of 4°C normal saline directly after obtaining IV/IO access. The main outcome variables were prehospital ROSC, survival to admission, and to discharge. A secondary analysis was conducted to assess the relationship between the quantity of cold saline infused and the likelihood of prehospital ROSC.

RESULTS

551 patients met inclusion criteria with all the elements available for data analysis. Rates of prehospital ROSC were 36.5% versus 26.9% (OR 1.83; 95% CI 1.19-2.81) in patients who received IATH versus normothermic resuscitation respectively. While the frequency of survival to hospital admission and discharge were increased among those receiving IATH, the differences did not reach statistical significance. The secondary analysis found a linear association between the amount of cold saline infused and the likelihood of prehospital ROSC.

CONCLUSION

The infusion of 4°C normal saline during the intra-arrest period may improve rate of ROSC even at low fluid volumes. Further study is required to determine if intra-arrest cooling has a beneficial effect on rates of ROSC, mortality, and neurologic function.

Association Between Prehospital Time Intervals and ST-Elevation Myocardial Infarction System Performance

Background—

Among individuals experiencing an ST segment–elevation myocardial infarction, current guidelines recommend that the interval from first medical contact to percutaneous coronary intervention be ≤90 minutes. The objective of this study was to determine whether prehospital time intervals were associated with ST-elevation myocardial infarction system performance, defined as first medical contact to percutaneous coronary intervention.

Methods and Results—

Study patients presented with an acute ST-elevation myocardial infarction diagnosed by prehospital ECG between May 2007 and March 2009. Prehospital time intervals were as follows: 9-1-1 call receipt to ambulance on scene ≤10 minutes, ambulance on scene to 12-lead ECG acquisition ≤8 minutes, on-scene time ≤15 minutes, prehospital ECG acquisition to ST-elevation myocardial infarction team notification ≤10 minutes, and scene departure to patient on cardiac catheterization laboratory table ≤30 minutes. Time intervals were derived and analyzed with descriptive statistics and logistic regression. There were 181 prehospital patients who received percutaneous coronary intervention, with 165 (91.1) having complete data. Logistic regression indicated that table time, response time, and on-scene time were the benchmark time intervals with the greatest influence on the probability of achieving percutaneous coronary intervention in ≤90 minutes. Individuals with a time from scene departure to arrival on cardiac catheterization laboratory table of ≤30 minutes were 11.1 times (3.4 to 36.0) more likely to achieve percutaneous coronary intervention in ≤90 minutes than those with extended table times.

Conclusions—

In this patient population, prehospital timing benchmarks were associated with system performance. Although meeting all 5 benchmarks may be an ideal goal, this model may be more useful for identifying areas for system improvement that will have the greatest clinical impact.

The association between prehospital endotracheal intubation attempts and survival to hospital discharge among out-of-hospital cardiac arrest patients

OBJECTIVES

The benefit of prehospital endotracheal intubation (ETI) among individuals experiencing out-of-hospital cardiac arrest (OOHCA) has not been fully examined. The objective of this study was to determine if prehospital ETI attempts were associated with return of spontaneous circulation (ROSC) and survival to discharge among individuals experiencing OOHCA.

METHODS

This retrospective study included individuals who experienced a medical cardiac arrest between July 2006 and December 2008 and had resuscitation efforts initiated by paramedics from Mecklenburg County, North Carolina. Outcome variables were prehospital ROSC and survival to hospital discharge, while the primary independent variable was the number of prehospital ETI attempts.

RESULTS

There were 1,142 cardiac arrests included in the analytic data set. Prehospital ROSC occurred in 299 individuals (26.2%). When controlling for initial arrest rhythm and other confounding variables, individuals with no ETI attempted were 2.33 (95% confidence interval [CI] = 1.63 to 3.33) times more likely to have ROSC compared to those with one successful ETI attempt. Of the 299 individuals with prehospital ROSC, 118 (39.5%) were subsequently discharged alive from the hospital. Individuals having no ETI were 5.46 (95% CI = 3.36 to 8.90) times more likely to be discharged from the hospital alive compared to individuals with one successful ETI attempt.

CONCLUSIONS

Results from these analyses suggest a negative association between prehospital ETI attempts and survival from OOHCA. In this study, the individuals most likely to have prehospital ROSC and survival to hospital discharge were those who did not have a reported ETI attempt. Further comparative research should assess the potential causes of the demonstrated associations.

An assessment of key health indicators among emergency medical services professionals

INTRODUCTION

Ensuring the health and productivity of emergency medical services (EMS) professionals is important. However, there has been no known national baseline assessment of the health and wellness of EMS professionals in the United States. According to Healthy People 2010, top indicators of personal health include physical activity, body mass index (BMI), and smoking prevalence.

OBJECTIVES

The objectives of this study included quantifying existing health conditions and describing key health indicators among EMS professionals. It was hypothesized that work-life characteristics were associated with existing health conditions and key health indicators.

METHODS

Data utilized for this analysis were obtained from a 2007 questionnaire included in biennial national recertification packets. This questionnaire utilized validated items from the Behavioral Risk Factor Surveillance System (BRFSS) and the Longitudinal EMT Attributes and Demographics Study (LEADS). Along with common demographic characteristics, items inquired about existing health conditions (diabetes, asthma, hypertension, myocardial infarction, angina, stroke, and/or high blood cholesterol level), general health, physical activity, and smoking status. Descriptive analyses were performed utilizing chi-square tests, and logistic regression was utilized to describe associations between existing health conditions and the key health indicators.

RESULTS

There were 58,435 individuals who became recertified in 2007, with 30,560 (52%) returning questionnaires. Individuals with missing data were removed, leaving 19,960 individual records. There were 4,681 (23.5%) individuals who reported at least one existing health condition. The mean BMI for the study participants was 27.69 kg/m(2). There were 5,742 (28.8%) individuals classified as having normal weight and 5,146 (25.8%) who were obese. The overwhelming majority of individuals did not meet the Centers for Disease Control and Prevention (CDC) recommendations for physical activity (15,022, 75.3%). There were 3,394 (17.0%) individuals classified as current smokers. Finally, logistic regression analysis indicated that when controlling for work-life characteristics and age, BMI and level of physical fitness were associated with preexisting health conditions.

CONCLUSION

This study was the first known baseline assessment of EMS professionals regarding the key health indicators identified by Healthy People 2010. Investigations regarding the impact of health and wellness in relation to workforce stability should be undertaken. Further research should also be conducted to identify strategies to improve the health of the EMS workforce.

Hearing problems among a cohort of nationally certified EMS professionals

PURPOSE

The objectives of this study were to estimate the prevalence of hearing problems among a national cohort of emergency medical service (EMS) professionals, determine factors associated with hearing problems, and estimate the percentage of EMS professionals who utilize hearing protection.

METHODS

Utilizing results from a questionnaire, individuals who reported hearing problems were compared to individuals who had not. Multivariable logistic regression was performed to identify variables associated with hearing problems. Finally, items regarding use of hearing protection were assessed to estimate the percentage of usage among EMS professionals.

RESULTS

In total, 1,058 (57%) participants responded to the questionnaire. Of those, 1,024 (97%) who completed the hearing problems question were utilized for analysis. There were 153 (14.9%) cases of self-reported hearing problems. The final logistic regression model included lifetime occupational noise exposure 0.99 (95% CI = 0.9997-1.0002), report of previous back problems (odds ratio (OR) = 2.74, 95% CI = 1.8340-4.1042), large community size (OR = 1.67, 95% CI = 1.1211-2.4843), and minority status (OR = 0.61, 95% CI = 0.3719-0.9867). Finally, 213 (20.8%) individuals reported utilizing some form of hearing protection at their main EMS job.

CONCLUSION

The results from this analysis are the first national estimates of the prevalence of self reported hearing problems among EMS professionals. This study was also the first to estimate the percentage of EMS professionals who self reported the utilization of hearing protection.