All Advanced Life Support Research Articles

Prehospital Surgical Airway Management Skills in a Rural Emergency Medical Service System.

The objective of this study is to describe the education, training, and use of prehospital surgical airways in a rural Emergency Medical Service (EMS) system. We conducted an internet-based survey instrument of all advanced life support (ALS) EMS agencies in a seven-county rural EMS system in Pennsylvania. ALS agencies were queried regarding basic demographic information as well as the number of surgical airways performed in the previous 10 years as well as the education and training of EMS providers in surgical airways. The survey was completed by 11 of 20 ALS EMS agencies in our region (55% rate of return). The content and frequency of training varied considerably among EMS agencies. Only four prehospital surgical airways were performed during the study period. One patient survived to hospital discharge to home. Surgical airways are an infrequently performed procedure in the rural prehospital setting.There is no universally accepted standard for teaching or evaluating the competency of this potentially life-saving procedure. Further efforts to establish a core educational curriculum appear warranted.

Paramedic Endotracheal Intubation Success Rates Before and After an Intensive Airway Management Education Session.

IntroductionAdvanced airway management by paramedics is potentially life-saving, but carries a significant risk to patient safety and can be associated with poor clinical outcome if performed incorrectly. Previously, our team had found that an intensive education intervention demonstrated an improvement in paramedic performance on a written exam and increased confidence in airway skills. This study measured intubation success and the number of attempts per patient before and after intensive paramedic airway management education intervention.MethodsA 10-hour mandatory course was taken by all advanced life support (ALS) paramedics in a provincial system (2009/04-07, n=~395). The course was done during semi-annual continuing education Emergency Health Services (EHS) in-services. These day-long courses were held in person over four months. The electronic charting database was queried for intubation attempts and successful placements 12 months before the training, during the four months of training, and 12 months post-training. The primary outcome is the difference in success rates between the before (pre-intervention) and after (post-intervention) periods. The secondary outcome is the number of attempts per patient. Stationarity of success in pre- and post-periods was tested. The model was fit tested using Maximum Likelihood regression, and variables were tested using the Wald test.ResultsA sample size of 476 intubation attempts in each of the pre- and post-periods was required to detect a 10% improvement with the pre-intervention success of 60%. A total of 1421 intubation attempts occurred; 674 pre-intervention, 604 post-intervention, and 143 during teaching. Seven attempts were excluded (success unknown). Intubation success rates improved, from 0.68 (95% CI 0.64-0.71) to 0.75 (95% CI 0.72-0.78); a difference of 0.076 (95% CI 0.03-0.12) (p = 0.001). Intubation success rates in the pre-intervention and post-intervention periods were found to be static. A significant decrease was found in the number of attempts per patient in the post-period (p = 0.005).ConclusionIntubation success increased from 68% to 75% and was maintained over the 12-month post-period. There is a potential that judgment may also have improved, based on the decreased number of attempts per patient. Limitations include missing values, paramedics’ self-reported number of attempts, and the definition of what is considered to be an attempt. In addition to previously demonstrated improvements in paramedic exam and scenario performance, this airway education intervention appears to have made a significant improvement to patient outcomes. These findings support the value of such education interventions to improve performance.

The Effect of Ambulance Staffing Models in a Metropolitan, Fire-Based EMS System

This was a retrospective study conducted from September 17, 2013 through December 31, 2013. The PB ambulances were compared to geographically matched ambulances staffed with paramedic-paramedic (PP ambulances). One PP and one PB ambulance were based at Station A; one PP and one PB ambulance were based at Station B. The primary outcome was total on-scene time. Secondary outcomes included time-to-electrocardiogram (EKG), time-to-intravenous (IV) line insertion, IV-line success rate, and percentage of protocol violations. Inclusion criteria were all patients requesting prehospital services that were attended to by these teams. Patients were excluded if they were not attended to by the study ambulance vehicles. Descriptive statistics were reported as medians and interquartile ranges (IQR). Proportions were reported with 95% confidence intervals (CI). The Mann-Whitley U test was used for significance testing (P<.05). Median on-scene times at Station A for the PP ambulance were shorter than the PB ambulance team (PP: 10.1 minutes, IQR 6.0-15; PB: 13.0 minutes, IQR 8.1-18; P=.01). This finding also was noted at Station B (PP: 13.5 minutes, IQR 8.5-19; PB: 14.3 minutes, IQR 9.9-20; P=.01). There were no differences between PP and PB ambulance teams at Station A or Station B in time-to-EKG, time-to-IV insertion, IV success rate, and protocol violation rates. In the setting of a well-developed EMS system utilizing an all-Advanced Life Support (ALS) response, this study suggests that PB ambulance teams may function well when compared to PP ambulances. Though longer scene times were observed, differences in time to ALS interventions and protocol violation rates were not different. Hybrid ambulance teams may be an effective staffing alternative, but decisions to use this model must address clinical and operational concerns. Cortez EJ , Panchal AR , Davis JE , Keseg DP . The effect of ambulance staffing models in a metropolitan, fire-based EMS system. Prehosp Disaster Med. 2017;32(2):175-179.

Background and Advantages of a Tiered EMS Response in a Large, Fire-Based EMS Model

Abstract Emergency medical services (EMS) systems vary across country, state, and even county lines. Which model provides the most effective and safe care has been hotly debated. Some models employ a fire-based EMS response, whereas others are privately funded and are completely separate from other public responders. Response can be uniform or tiered, which means that either ALS units respond to every call or calls are triaged based on their severity and units are dispatched accordingly. This requires a sophisticated dispatch algorithm that screens for emergencies of highest priority. Persse et al. sought to determine the difference in survival in out-of-hospital ventricular fibrillation arrest between a tiered response EMS model and an all advanced life support (ALS) response model within the same system.

Utilization of Warning Lights and Siren Based on Hospital Time-Critical Interventions

The objective of this study was to evaluate the time saved by usage of lights and siren (L&S) during emergency medical transport and measure the total number of time-critical hospital interventions gained by this time difference. A retrospective study was performed of all advanced life support (ALS) transports using lights and siren to this university emergency department during a three-week period. Consecutive times were measured for 112 transports and compared with measured transport times for a personal vehicle traveling the same day of the week and time of day without lights and siren. The time-critical hospital interventions are defined as procedures or treatments that could not be performed in the prehospital setting requiring a physician. The project assessed whether the patients received the hospital interventions within the average time saved using lights and siren transport. The average difference in time with versus without L&S was -2.62 minutes (95% CI: -2.60- -2.63, paired t-test p<0.0001). The average transport time with L&S was 14.5±7.9 minutes (min) (1 standard deviation/minute (min), range=1-36 min.). The average transport time without L&S was 17.1±8.3 min (range=1-40 min). Of the 112 charts evaluated, five patients (4.5%) received time-critical hospital interventions. No patients received time-critical interventions within the time saved by utilizing lights and siren. Longer distances did not result in time saved with lights and siren. Limiting lights and siren use to the patients requiring hospital interventions will decrease the risks of injury and death, while adding the benefit of time saved in these critical patients.

All-advanced life support vs tiered-response ambulance systems *

In this discussion, two principal types of ambulance deployment systems were compared and contrasted: 1) the multipurpose, sole-provider all-advanced life support (all-ALS) ambulance system in which all ambulance-related services (emergent and nonemergent) for a city or region are provided by one fleet of ambulances, each of which is staffed by ALS providers (paramedics); and 2) the tiered ambulance system (tiered) in which some 911 ambulances are staffed by paramedics and others are staffed by basic emergency medical technicians (EMT-Bs) who provide basic life support (BLS) care. When managed with advanced system status management (SSM) techniques, the multipurpose, sole-provider all-ALS ambulance system can significantly reduce response intervals while simultaneously providing both fiscal and operational efficiencies. It can also be used to readily integrate and expand the scope of services for the ambulance provider service, such as interfacility transfers, thus increasing revenues. On the other hand, in large urban centers, the tiered ambulance system can be used to reduce response intervals to critical calls, primarily through the use of sophisticated dispatch triage protocols. This approach requires fewer paramedics in the system and appears, in some systems, to also provide medical care advantages in terms of skills utilization for individual ALS providers as well as a more concentrated focus for medical supervision. Therefore, both of these deployment systems can offer certain advantages depending on local emergency medical services (EMS) system needs as well as the local philosophy of health care delivery. Applicability must therefore be considered in terms of local service demands and other factors that affect the EMS system, including catchment population, statutory and jurisdictional issues, available funding, accessibility of receiving facilities, and medical quality concerns. PREHOSPITAL EMERGENCY CARE 2000;4:1-6

International report: current state and development of health insurance and emergency medicine in Germany. the influence of health insurance laws on the practice of emergency medicine in a European country

Germany has a comprehensive health insurance system, with only 0.183% of the population being uninsured. Access to office-based medicine and to hospitals is easy and convenient. Due to enormous financial pressures, Germany is currently decreasing the number of beds in hospitals, introducing the Diagnosis Related Groups (DRG), and restricting accessibility to specialists. In contrast to Anglo-American countries, Germany follows the concept of bringing the physician to the patient in the prehospital setting, with Emergency Medical Services (EMS) physicians responding to all Advanced Life Support (ALS) calls. Despite a mature EMS system with sophisticated medical equipment and technology, both in the prehospital and hospital setting, logistical issues such as a single emergency telephone number or multidisciplinary Emergency Departments have yet to be established. Within the hospital, this “Franco-German model” considers Emergency Medicine a practice model that does not merit specialty status. Spending restrictions in the health care system, with less access to hospital beds and office-based physicians, will increase the demand for hospital-based emergency care when patients experience problems accessing the medical system. Currently, the German hospital system is unprepared to care for greater numbers of emergency patients. This may call for changes in the German health care system as well as the medical education system, with the introduction of hospital-based Emergency Medicine as its own specialty, similar to Anglo-American countries.

A LL –A DVANCED L IFE S UPPORT VS T IERED -R ESPONSE A MBULANCE S YSTEMS

In this discussion, two principal types of ambulance deployment systems were compared and contrasted: 1) the multipurpose, sole-provider all-advanced life support (all-ALS) ambulance system in which all ambulance-related services (emergent and nonemergent) for a city or region are provided by one fleet of ambulances, each of which is staffed by ALS providers (paramedics); and 2) the tiered ambulance system (tiered) in which some 911 ambulances are staffed by paramedics and others are staffed by basic emergency medical technicians (EMT-Bs) who provide basic life support (BLS) care. When managed with advanced system status management (SSM) techniques, the multipurpose, sole-provider all-ALS ambulance system can significantly reduce response intervals while simultaneously providing both fiscal and operational efficiencies. It can also be used to readily integrate and expand the scope of services for the ambulance provider service, such as interfacility transfers, thus increasing revenues. On the other hand, in large urban centers, the tiered ambulance system can be used to reduce response intervals to critical calls, primarily through the use of sophisticated dispatch triage protocols. This approach requires fewer paramedics in the system and appears, in some systems, to also provide medical care advantages in terms of skills utilization for individual ALS providers as well as a more concentrated focus for medical supervision. Therefore, both of these deployment systems can offer certain advantages depending on local emergency medical services (EMS) system needs as well as the local philosophy of health care delivery. Applicability must therefore be considered in terms of local service demands and other factors that affect the EMS system, including catchment population, statutory and jurisdictional issues, available funding, accessibility of receiving facilities, and medical quality concerns.

Introduction to the proceedings of the turtle creek consensus conference on prehospital care

ing programs and the introduction of automated external defibrillators (AEDs), improving survival of patients who experience out-of-hospital cardiac arrest continues to be a challenge for the emergency medical services (EMS) provider.’ Experts in the field of prehospital emergency care* met in Dallas, Texas, February 25-27,1999, at the ”Turtle Creek Conference,” to discuss issues related to survival of victims of out-of-hospital cardiac arrest. Six current topics were considered: public access to defibrillation, management of difficult airways in the field, biphasic defibrillation, confirmation of airway placement, the use of intravenous (IV) amiodarone for shock refractory VF, and the all-advanced life support (ALS) vs tiered-response systems. Each session began with a presentation by experts in the respective subject, after which the attendees separated into small discussion groups for that topic. Each group, led by a team leader, formulated a consensus statement, which was presented to the entire group for further discussion and for approval as reflecting the thoughts of the group as a whole. The proceedings of the Turtle Creek Conference, as published in this issue of Prehospita1 Emergency Care, represent the presentations given by the experts and the consensus statements that evolved.

Hawthorne Effect: Implications for Prehospital Research

Study objective: The phenomenon of altered behavior or performance resulting from awareness of being a part of an experimental study has been termed the "Hawthorne effect." Prehospital studies generally involve paramedics or are designed to use data collected by paramedics. Our objective was to determine whether paramedic performance, as measured by frequency of documentation, can be modified by (1) written notification of the importance of documentation, (2) written notification of a research project involving paramedic documentation, or (3) written notification of a quality-improvement audit of paramedic documentation. Design: Prospective, sequential intervention study with five study phases. Setting: Urban, all-advanced life support public utility model emergency medical services system with 55,000 emergency calls per year. Participants: One hundred forty-five paramedics who completed all ambulance run reports from August 1992 to May 1993. Results: A total of 30,828 run reports was entered into the study. Baseline undocumented parameters ranged from 3.7% to 6.5%. Compared with baseline, a memo to heighten awareness (phase 2) did not alter documentation ( P ≥.08). A medication study memo (phase 3) improved medication documentation ( P =.0005) and allergies documentation ( P =.037). A quality-improvement audit memo (phase 4) improved documentation of all parameters ( P ≤.001). Conclusion: The Hawthorne effect occurs in prehospital research. It does not require direct observation, nor does it require direct feedback. However, it may require a perceived demand for performance. The Hawthorne effect must be considered in the design of prehospital studies and interpretation of data collected by paramedics. [Campbell JP, Maxey VA, Watson WA: Hawthorne effect: Implications for prehospital research. Ann Emerg Med November 1995;26:590-594.]

Out-of-hospital deliveries: a five-year experience.

Prehospital providers regularly encounter patients with obstetrical emergencies. This study determined the frequency and outcome of out-of-hospital deliveries in an urban, all advanced life support (ALS) emergency medical services (EMS) system. Retrospective review of all out-of-hospital records that involved women delivering babies in the care of prehospital providers from 1984-1988. The EMS system answered an average of 62,000 calls during the study period. The records of these patients were identified through a computer database. A total of 81 out-of-hospital deliveries (1.4/month) occurred during the study years. The average age of the mothers was 24 years, and the average gestation period was 30 weeks. The women had an average of three previous pregnancies and two previous deliveries, and 10 were primagravida. Seventy-two (89%) of the deliveries occurred in the home. The paramedics encountered a variety of obstetrical and neonatal complications in 34% of the patient encounters. Nine neonates were delivered prior to the arrival of the paramedic team. Twenty-four neonates had Apgar scores calculated, and the one- and five-minute scores averaged eight and nine respectively. Five of the mothers had no prenatal care. Maternal complications included four patients noted to be hypertensive with the delivery, nine patients had some degree of vaginal bleeding, and in 33 patients, the prehospital providers did not deliver the placenta in the field. An EMS physician was in attendance for only two of the out-of-hospital deliveries. In this urban EMS system, out-of-hospital deliveries, especially pre-term deliveries, are a common event. There appears to be a significant number of neonatal complications that confront paramedics. Generally, the paramedics were deficient in their documentation of the neonatal assessment. Continuing educational programs for paramedics should include reviewing normal and complicated vaginal deliveries as well as ALS measures for neonates. Protocols for obstetrical emergencies need to be developed and subjected to quality improvement measures. Paramedics, especially those in urban settings, are likely to encounter obstetrical and neonatal emergencies and a significant number of associated complications. Emergency medical services systems and medical directors should have in place continuing educational programs, patient-care protocols, and continuous quality improvement measures to evaluate the care rendered to patients having out-of-hospital deliveries.

One-year survival after prehospital cardiac arrest: The Utstein style applied to a rural-suburban system

To evaluate the recently published Utstein algorithm (Ann Emerg Med 1991;20:861), the authors conducted a retrospective review of all advanced life support (ALS) trip sheets and hospital records of patients with prehospital cardiac arrests between January 1988 and December 1989. Telephone follow-up was used to determine 1-year survival rates. Of 713 arrests in the 24-month study period, 601 were of presumed cardiac etiology. Approximately 599 of these charts were available for analysis. One hundred ninety-three (32.2%) of these had return of spontaneous circulation (ROSC), 36 (6.0%) survived to hospital discharge, and 24 were alive at 1-year follow-up (4.0% of total or 67% of survivors to discharge). The Utstein style was found to be a useful algorithmic format for reporting prehospital cardiac arrest data in a manner that should allow direct comparison between emergency medical service (EMS) systems. Existing prehospital record-keeping practices (trip sheets) are easily adapted to this style of data collection, although certain data for the template (eg, resuscitations not attempted and alive at 1-year) are more difficult to ascertain. Additionally, the authors report their own experience during a 2-year period, including data that suggest that the majority of patients with cardiac arrest who survive to hospital discharge are still alive at 1 year.

The effect of base station contact on ambulance destination

Concern has been raised that a single medical control base station serving a metropolitan area may preferentially divert ambulance patients to the base station hospital. Such concern may discourage the development of regional medical control systems. During the first six months of 1988, a retrospective cross-sectional analysis was made of all advanced life support (ALS) ambulance transports and all contacts to the single base station, known as Medical Resource Hospital (MRH). Destinations of all ALS ambulance calls dispatched through the county's 911 dispatch center were analyzed to determine whether the destinations were affected by MRH contact. There were 12,396 transports to 17 area hospitals with 1,272 (10.3%) of these requiring MRH contact. We hypothesized that if MRH contact did not affect destination, the proportion of all non-MRH ALS ambulance patients received by each hospital from the 911-dispatched group would equal the proportion of patients received by each hospital after MRH contact. Five hospitals received a statistically significant (P less than .003) different percentage of MRH contact patients than their proportion of 911-dispatched patients would have predicted. The three that received more were community hospitals in outlying areas. The remaining two were a large referral hospital and a smaller community hospital located in the urban area. The MRH hospital did not have a significantly different percentage of 911-dispatched patients after MRH contact. Similarly, destinations of specific ALS ambulances (two serving in the MRH ambulance catchment area and four in distant catchment areas) were evaluated.(ABSTRACT TRUNCATED AT 250 WORDS)