Current Emergency Medical Services Research Articles

Physician perceptions and recommendations about pre-hospital emergency medical services for patients with ST-elevation acute myocardial infarction in Abu Dhabi

IntroductionPhysician perceptions about emergency medical services (EMS) are important determinants of improving pre-hospital care for cardiac emergencies. No data exist on physician attitudes towards EMS care of patients with ST-Elevation Myocardial Infarction (STEMI) in the Emirate of Abu Dhabi. ObjectivesTo describe the perceptions towards EMS among physicians caring for patients with STEMI in Abu Dhabi. MethodsWe surveyed a convenience sample of physicians involved in the care of patients with STEMI (emergency medicine, cardiology, cardiothoracic surgery and intensive care) in four government facilities with 24/7 Primary PCI in the Emirate of Abu Dhabi. Surveys were distributed using dedicated email links, and used 5-point Likert scales to assess perceptions and attitudes to EMS. ResultsOf 106 physician respondents, most were male (82%), practicing in emergency medicine (47%) or cardiology (44%) and the majority (63%) had been in practice for >10years. Less than half of the responders (42%) were “Somewhat Satisfied” (35%) or “Very Satisfied” (7%) with current EMS level of care for STEMI patients. Most respondents were “Very Likely” (67%) to advise a patient with a cardiac emergency to use EMS, but only 39% felt the same for themselves or their family. Most responders were supportive (i.e. “Strongly Agree”) of the following steps to improve EMS care: 12-lead ECG and telemetry to ED by EMS (69%), EMS triage of STEMI to PCI facilities (65%), and activation of PCI teams by EMS (58%). Only 19% were supportive of pre-hospital fibrinolytics by EMS. There were no significant differences in the responses among the specialties. ConclusionsMost physicians involved in STEMI care in Abu Dhabi are very likely to advise patients to use EMS for a cardiac emergency, but less likely to do so for themselves or their families. Different specialties had concordant opinions regarding steps to improve pre-hospital EMS care for STEMI.

Application of GIS in Determining Road Emergency Medical Service (EMS) Locations

Time is the most important factor in accidents emergency services. In general, a golden time period is defined for response to an accident and if first aid and medical assistance is accessed within this time period, victims have a greater chance of survival. The aim of this paper is to show how GIS is used to identify the best emergence system location along the road network according to accident black spots and response time. Khuzestan road network is chosen as a case study in this research and the results of Ramhormoz-Behbahan route in this province are selected to show in this paper. For this reason, the road accidents data during 2006 to 2009 in this province is analyzed. The results of this research show that the current EMS locations do not cover accident black spots even by 20 minutes response time. Therefore, new EMS locations are recommended according to accident black spots. These new EMS will decrease response time by 15 minutes and the survival chance victims will increase.

Physical Infrastructure Assessment for Emergency Medical Response

The performance of an emergency medical service (EMS) depends on the existing infrastructure and allocation of medical resources. It is challenging to implement an efficient EMS owing to the spatial complexity of the population and geographical layout within urban areas. Management of ambulance headquarters and hospitals, which are part of the physical infrastructure, should be assessed to ensure a timely response. The objective of this research is to propose a general assessment process for a prehospital EMS by evaluating the physical infrastructure. A geographic information system is adapted to visualize and analyze the EMS of a region EMS from various perspectives. In the assessment process, the EMS is evaluated with incident data and the transportation network is evaluated through spatial and temporal analyses such as service area, clustering, and spatial interpolation. As a case study, the process is applied to New Taipei City for the assessment of its prehospital EMS. The results have shown that the proposed assessment process can help discover existing deficiencies and offer suggestions to the current EMS. Regions less accessible by the EMS were discovered; the spatial coverage of historical demand incidents was 93.8% for the union of ambulance headquarters and 70.52% for the union of hospitals in their respective 3 km service areas. Cluster analysis suggested an EMS performance gain of 0.68% compared with the current situation for the construction of an additional ambulance facility and 1.45% for an additional hospital. Future work will extend the proposed process with specialized spatial and temporal data mining techniques and to apply the process to more case studies.

Pediatric emergency medical care in Yerevan, Armenia: a knowledge and attitudes survey of out-of-hospital emergency physicians.

BackgroundOut-of-hospital emergency care is at an early stage of development in Armenia, with the current emergency medical services (EMS) system having emergency physicians (EPs) work on ambulances along with nurses. While efforts are underway by the Ministry of Health and other organizations to reform the EMS system, little data exists on the status of pediatric emergency care (PEC) in the country. We designed this study to evaluate the knowledge and attitudes of out-of-hospital emergency physicians in pediatric rapid assessment and resuscitation, and identify areas for PEC improvement.MethodsWe distributed an anonymous, self-administered Knowledge and Attitudes survey to a convenience sample of out-of-hospital EPs in the capital, Yerevan, from August to September 2012.ResultsWith a response rate of 80%, the majority (89.7%) of respondents failed a 10-question knowledge test (with a pre-defined passing score of ≥7) with a mean score of 4.17 ± 1.99 SD. Answers regarding the relationship between pediatric cardiac arrest and respiratory issues, compression-to-ventilation ratio in neonates, definition of hypotension, and recognition of shock were most frequently incorrect. None of the participants had attended pediatric-specific continuing medical education (CME) activities within the preceding 5 years. χ2 analysis demonstrated no statistically significant association between physician age, length of EMS experience, type of ambulance (general vs. resuscitation/critical care), or CME attendance and pass/fail status. The majority of participants agreed that PEC education in Armenia needs improvement (98%), that there is a need for pediatric-specific CME (98%), and that national out-of-hospital PEC guidelines would increase PEC safety, efficiency, and effectiveness (96%).ConclusionsOut-of-hospital emergency physicians in Yerevan, Armenia are deficient in pediatric-specific emergency assessment and resuscitation knowledge and training, but express a clear desire for improvement. There is a need to support additional PEC training and CME within the EMS system in Armenia.

Objectives, taxonomies and competencies of community oriented and community based education applied to community paramedicine

The role of a paramedic has primarily been to provide emergency care. This role is being rethought of with discussions of developing a community paramedic. The reach of this development and expanded scope of practice remained unknown. This article reviewed scholarly literature on the topic of community paramedics to present a critical analysis and triangulation of community oriented and community based education (CBE) to current paramedic education guidelines to identify shared objectives. The focus of paramedic education was identified to be on emergency assessment and intervention. Whereas, CBE was focused on assessing community needs to develop, implement and evaluate community intervention. A limited number of shared objectives were identified. The time spent on these shared objectives was unclear. Additional education will be required to cover the unshared objectives, and the profession must consider educational standards, requirements and how to increase inter professional collaboration within health systems, academic settings and within communities, which are core objectives of community-based providers. It must also be considered if the needs for community paramedics represent the pinnacle of current emergency medical services and time to evolve organizations, the profession and standards.

Supporting decision making to improve the performance of an Italian Emergency Medical Service

An Emergency Medical Service (EMS) plays a fundamental role in providing good quality health care services to citizens, as it provides the first answer in distressing situations. Early response, one of the key factors in a successful treatment of an injury, is strongly influenced by the performance of ambulances, which are sent to rescue the patient. Here we report the research carried on by the authors on the ambulance location and management in the Milano area (Italy), as a part of a wider research project in collaboration with the EMS of Milano and funded by Regione Lombardia. The question posed by the EMS managers was clear and, at the same time, tricky: could decision making tools be applied, based on the currently available data, to provide suggestions for decision makers? To answer such a question, three different studies have been carried on: first the evaluation of the current EMS system performance through statistical analysis; then the study of operational policies which can improve the system performance through a simulation model; and finally the definition of an alternative set of posts through an optimization model. This paper describes the methodologies underlying such studies and reports on how their main findings were crucial to help the EMS in changing its organization model.

Development of an EMS Curriculum

Emergency medical services (EMS) became an American Board of Medical Specialties (ABMS) approved subspecialty of emergency medicine in September 2010. Achieving specialty or subspecialty recognition in an area of medical practice requires a unique body of knowledge, a scientific basis for the practice, a significant number of physicians who dedicate a portion of their practice to the area, and a sufficient number of fellowship programs. To prepare EMS fellows for successful completion of fellowship training, a lifetime of subspecialty practice, and certification examination, a formalized structured fellowship curriculum is necessary. A functional curriculum is one that takes the entire body of knowledge necessary to appropriately practice in the identified area and codifies it into a training blueprint to ensure that all of the items are covered over the prescribed training period. A curriculum can be as detailed as desired but typically all major headings and subheadings of the core content are identified and addressed. Common curricular components, specific to each area of the core content, include goals and objectives, implementation methods, evaluation, and outcomes assessment methods. Implementation methods can include simulation, observations, didactics, and experiential elements. Evaluation and outcomes assessment methods can include direct observation of patient assessment and treatment skills, structured patient simulations, 360° feedback, written and oral testing, and retrospective chart reviews. This paper describes a curriculum that is congruent with the current EMS core content, as well as providing a 12-month format to deploy the curriculum in an EMS fellowship program. Key words: curriculum; education; emergency medical services; fellowships and scholarships

Regionalization strategy of the emergency medical service system

A regionalization strategy is a model for improving the performance of the emergency medical service (EMS) system. The regionalization strategy has goals to provide appropriate, timely, effective, and efficient EMS in a region. However, the current EMS regionalization model in Korea is insufficient to achieve these goals due to a shortage of resources in rural regions, crowded emergency departments in metropolitan regions, and non-customized and mismatched levels of emergency departments. Recently, the concept of the regionalization model has been changed from a general regionalized model to a specialty care regionalization one. For example, the trauma care system, cardiac arrest care system, stroke care system, and ST elevation myocardial infarction care system are modern regionalization strategies to improve the performance of EMS. This is a new method of customizing and matching between region-based needs and the supply of EMS. If we can implement this strategy, we can expect improved performance of regional EMS systems.

194 Validation of Out-of-Hospital Triage Criteria for Pregnant Blunt Trauma Patients

1) To test the reliability of current emergency medical services (EMS) trauma protocols for appropriate triaging of pregnant blunt trauma patients and 2) to validate previously derived guidelines for trauma center triage of pregnant blunt trauma patients. The new guidelines include the existing county criteria plus heart rate >110 beats per minute, complaints of chest pain, history of loss of consciousness and third trimester of pregnancy.

Regional Impact of Cardiac Arrest Center Criteria on Out-of-Hospital Transportation Practices

Background. Cardiac arrest center (CAC) criteria are not well defined, nor is their potential impact on current emergency medical services (EMS) transportation practices for post–cardiac arrest (PCA) patients. In addition to the availability of emergent cardiac catheterization (CATH) and therapeutic hypothermia (TH), high-volume centers and those with PCA protocols have been associated with improved outcomes. Objectives. This study aimed 1) to identify the PCA treatment capabilities of receiving hospitals in a 10-county regional EMS system without official CAC designation and 2) to determine the proportion of PCA patients who are transported to hospitals meeting three proposed CAC definitions. We hypothesized that a majority of patients are already transported to hospitals that meet proposed CAC criteria. Methods. We distributed a survey to 34 receiving hospitals to determine availability and volume of CATH, TH, a PCA protocol, and a 24-hour intensivist. We conducted a retrospective study of adult, nontrauma cardiac arrest patients transported with a pulse from 2006 to 2008 for 16 EMS agencies. The proportions of patients transported to hospitals meeting three CAC criteria were compared: criteria A (availability of CATH and TH), criteria B (criteria A, >200 CATHs per year, and a PCA protocol), and criteria C (criteria B and a 24-hour intensivist). Results: Data were obtained from 31 of 34 hospitals (91.1%), of which 10 (32.3%) met criteria A, seven (22.6%) met criteria B, and six (19.4%) met criteria C. Of 1,193 cardiac arrest patients, 46 (3.9%) were excluded because of transport to a pediatric, closed, or out-of-region hospital. There were 335 patients (81.1%) with return of spontaneous circulation and a pulse present upon arrival at the destination facility transported to hospitals meeting criteria A, 304 patients (73.6%) transported to hospitals meeting criteria B, and 273 patients (66.1%) transported to hospitals meeting criteria C. Conclusions. In a region without official CAC designation, only one-third of hospitals meet basic CAC criteria (CATH and TH), but those facilities receive 81% of PCA patients. Fewer patients (66%) are transported to hospitals meeting more stringent CAC criteria. These data describe the potential impact of developing a CAC policy based on current transportation practices.

Emerging technologies for pediatric and adult trauma care.

Current Emergency Medical Service protocols rely on provider-directed care for evaluation, management and triage of injured patients from the field to a trauma center. New methods to quickly diagnose, support and coordinate the movement of trauma patients from the field to the most appropriate trauma center are in development. These methods will enhance trauma care and promote trauma system development. Recent advances in machine learning, statistical methods, device integration and wireless communication are giving rise to new methods for vital sign data analysis and a new generation of transport monitors. These monitors will collect and synchronize exponentially growing amounts of vital sign data with electronic patient care information. The application of advanced statistical methods to these complex clinical data sets has the potential to reveal many important physiological relationships and treatment effects. Several emerging technologies are converging to yield a new generation of smart sensors and tightly integrated transport monitors. These technologies will assist prehospital providers in quickly identifying and triaging the most severely injured children and adults to the most appropriate trauma centers. They will enable the development of real-time clinical support systems of increasing complexity, able to provide timelier, more cost-effective, autonomous care.

A system dynamics model of the fire department EMS in Taiwan

Allocation of pre-hospital EMS (Emergency Medical Service) resources and effectiveness of emergency medical training are critical to patients. The demands for EMS are expected to increase in the future. By analysing the relationship between emergency response and the survival rates, the effectiveness of EMS resources and competence of personnel were evaluated. In other words, the current EMS resources will be insufficient, and the ratio of busy ambulances will increase. Patients may need to wait for an ambulance. In this paper, indicates that three more ambulances should be added and the priorities of resources to be allocated to suffice future demands are simulated. Through arrangement of extra hours of training, ROSC of patients within the system can be enhanced. Besides, by accelerating the travel speed of ambulances and shortening the average response time to 6.5 minutes, survival rate of patients could be increased and allow the EMS teams to take another 2.6 cases.

Using a Discrete‐event Simulation to Balance Ambulance Availability and Demand in Static Deployment Systems

To improve ambulance response time, matching ambulance availability with the emergency demand is crucial. To maintain the standard of 90% of response times within 9 minutes, the authors introduce a discrete-event simulation method to estimate the threshold for expanding the ambulance fleet when demand increases and to find the optimal dispatching strategies when provisional events create temporary decreases in ambulance availability. The simulation model was developed with information from the literature. Although the development was theoretical, the model was validated on the emergency medical services (EMS) system of Tainan City. The data are divided: one part is for model development, and the other for validation. For increasing demand, the effect was modeled on response time when call arrival rates increased. For temporary availability decreases, the authors simulated all possible alternatives of ambulance deployment in accordance with the number of out-of-routine-duty ambulances and the durations of three types of mass gatherings: marathon races (06:00-10:00 hr), rock concerts (18:00-22:00 hr), and New Year's Eve parties (20:00-01:00 hr). Statistical analysis confirmed that the model reasonably represented the actual Tainan EMS system. The response-time standard could not be reached when the incremental ratio of call arrivals exceeded 56%, which is the threshold for the Tainan EMS system to expand its ambulance fleet. When provisional events created temporary availability decreases, the Tainan EMS system could spare at most two ambulances from the standard configuration, except between 20:00 and 01:00, when it could spare three. The model also demonstrated that the current Tainan EMS has two excess ambulances that could be dropped. The authors suggest dispatching strategies to minimize the response times in routine daily emergencies. Strategies of capacity management based on this model improved response times. The more ambulances that are out of routine duty, the better the performance of the optimal strategies that are based on this model.

Regionalization of Care for ST-Segment Elevation Myocardial Infarction: Is It Too Soon?

Interest in regionalization of the care of acute ST-segment elevation myocardial infarction (STEMI) has gained momentum recently. Optimal treatment of STEMI involves balancing time to treatment and reperfusion options. Primary percutaneous coronary intervention, when performed in a timely fashion, has been shown to be more effective than fibrinolysis. However, numerous practical barriers prevent many STEMI patients from receiving primary percutaneous coronary intervention. In an effort to increase beneficial primary percutaneous coronary intervention administration to STEMI patients, health care leaders have proposed regionalized STEMI care networks with advanced emergency medical services (EMS) involvement. Constructing regionalized STEMI networks presents a policy challenge because this shift in STEMI care would require changes in current EMS and emergency medicine practices. Therefore, we present various perspectives and issues that decisionmakers and system organizers must address properly before deciding whether to adopt this new model of care. Reorganizing STEMI care in a manner analogous to how trauma and stroke care are currently triaged and treated appeals intuitively; however, given the absence of evidence that STEMI regionalization actually improves patient outcomes and is cost-effective, more research is needed to determine whether STEMI regionalization is an efficient model for providing evidence-based care. The concept of STEMI regionalization represents an effort to inform policy according to evidence-based medicine, but real-world quality, geospatial, financial, cost, business, resource, and practice barriers present obstacles to implementing this concept efficiently and effectively.

Service Integration and Workforce Trends in Emergency Medical Services

o commemorate the report credited with the development of modern emergency medical services (EMS), the Institute of Medicine of the National Academies (IOM) examined the current status and future of emergency care in America. Emergency Medical Services at the Crossroads reports the IOM’s findings and provides an informative view of our nation’s EMS or prehospital emergency care system. 1 The report is part of a trend in exploring and dissecting the American system of emergency care, identifying problem areas, and making recommendations for improvement. The IOM highlights many system-wide deficiencies that inhibit EMS from accomplishing its primary mission of responding to emergencies whenever and wherever. Based on these findings, the IOM labeled the US “ill-prepared” and referred to the current EMS situation as nothing less than a “crisis.” 1 For some time, efforts have been underway to resolve many of the EMS challenges identified in the IOM’s analysis. These include promoting integration of EMS with other health care services and addressing challenges associated with maintaining a skilled and experienced workforce. More recently, health care pioneers have invested time and energy into expanding the health care role and responsibilities of EMS personnel to include more preventive and primary care tasks. 2-6 As potential momentum for the formation of future policy and research in North Carolina, these trends deserve some attention. Integration of the EMS System

The formation of the emergency medical services system.

The evolution of the emergency medical services system in the United States accelerated rapidly between 1960 and 1973 as a result of a number of medical, historical, and social forces. Current emergency medical services researchers, policy advocates, and administrators must acknowledge these forces and their limitations and work to modify the system into one that provides uniformly high-quality acute care to all patients, improves the overall public health through injury control and disease prevention programs, participates as a full partner in disease surveillance, and is prepared to address new community needs of all types.

Current emergency medical services workforce issues in the United States

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C URRENT I SSUES IN C ARDIOPULMONARY R ESUSCITATION

Current Advanced Cardiac Life Support (ACLS) guidelines and emergency medical services (EMS) clinical protocols usually recommend immediate defibrillation for victims of out-of-hospital cardiac arrest who have ventricular fibrillation (VF). However, animal studies and results from a small number of clinical investigations now suggest that a short period of chest compressions or ACLS procedures delivered before defibrillation may improve the outcome of patients with prolonged VF. Although the basic science and clinical data supporting a chest-compression-first procedure are compelling, large, multicenter randomized trials are still necessary to determine whether such protocols do indeed improve outcome. In current EMS dispatch practice, traditional cardiopulmonary resuscitation (CPR) instructions are given when needed to bystanders who report a possible cardiac arrest. Recent literature has shown that in certain circumstances, CPR instructions involving chest compressions alone may be given more quickly and can yield an equivalent, if not better, chance of survival. Although this practice is controversial, the general consensus is that any CPR is better than none at all. Therefore, telephone CPR protocols that recommend the immediate initiation of chest compressions may be preferred, particularly for callers who have no previous training in CPR.

E MERGENCY M EDICAL S ERVICES W ORKFORCE IN THE C ITY OF S ANTO D OMINGO

Santo Domingo is the largest city in the Dominican Republic. In recent years this city has experienced a significant increase in ambulance services. Objective: To describe the current emergency medical services (EMS) workforce trends in Santo Domingo. Method: This was a cross-sectional descriptive study. Emergency medical services providers working within the city of Santo Domingo filled out a nine-item self-administered questionnaire. Result: A total of 101 providers, 48 volunteer and 53 paid, returned the survey (response rates of 75% and 91.4%, respectively). The volunteers showed a mean of 7.48 ± 2.02 years of involvement in EMS, whereas the paid providers had a mean of 3.58 ± 2.91 years. When asked about planned long-term involvement in EMS, 93.8% of the volunteers responded positively, compared with 58.5% of the paid group. Nine (16.98%) of the paid providers were not satisfied with their jobs, whereas all the volunteers (100%) stated that they were satisfied; 46 (86.8%) and 27 (50.9%) of the paid providers agreed that better salary and better work hours, respectively, would influence their satisfaction. Among the volunteers, 40 (83.3%) stated that occupational health insurance would improve job satisfaction; and 39 (81.3%) stated that life insurance would bring satisfaction to their job. Logistic regression analysis showed no predictive association between job satisfaction and years of service (p = 0.342). Conclusion: Volunteers appeared to be less educated but with a higher long-term interest in EMS. Salary and better work hours seem to be important factors affecting satisfaction of paid providers, whereas occupational health and life insurance appear to affect the satisfaction of volunteers.

F EW E MERGENCY M EDICAL S ERVICES P ATIENTS WITH L OWER-EXTREMITY F RACTURES R ECEIVE P REHOSPITAL A NALGESIA

Previous literature has identified prehospital pain management as an important emergency medical services (EMS) function, and few patients transported by EMS with musculoskeletal injuries receive prehospital analgesia (PA). Objectives. 1) To describe the frequency with which EMS patients with lower-extremity and hip fracture receive prehospital and emergency department (ED) analgesia; 2) to describe EMS and patient factors that may affect administration of PA to these patients; and 3) to describe the time interval between EMS and ED medication administrations. Methods. This was a four-month (April to July 2000) retrospective study of patients with a final hospital diagnosis of hip or lower-extremity fracture who were transported by EMS to a single suburban community hospital. Data including patient demographics, fracture type, EMS response, and treatment characteristics were abstracted from review of EMS and ED records. Patients who had ankle fractures, had multiple traumatic injuries, were under the age of 18 years, or did not have fractures were excluded. Results. One hundred twenty-four patients met inclusion criteria. A basic life support (BLS)-only response was provided to 20 (16.0%). Another 38 (38.4%) received an advanced life support (ALS) response and were triaged to BLS transport. Of all the patients, 22 (18.3%) received PA. Patients who received PA were younger (64.0 vs. 77.3 years, p < 0.001) and more likely to have a lower-extremity fracture other than a hip fracture (31.8% vs. 10.7%, p < 0.004). Of all patients, 113 (91.1%) received ED analgesia. Patients received analgesia from EMS almost 2.0 hours sooner that in the ED (mean 28.4 ± 36 min vs. 146 ± 74 min after EMS scene arrival, p < 0.001). Conclusion. A minority of the study group received PA. Older patients and patients with hip fracture are less likely to receive PA. It is unclear whether current EMS system design may adversely impact administration of PA. Further work is needed to clarify whether patient need or EMS practice patterns result in low rates of PA.