Emergency Medical Center Research Articles

Abstract 19180: Targeted Simulation and Education to Improve Cardiac Arrest Recognition and Telephone Cpr in an Emergency Medical Dispatch Centre

Introduction: Patient outcome after out of hospital cardiac arrest (OHCA) is dependent on emergency medical dispatchers ability to recognize OHCA and provide effective telephone-assisted CPR instructions to bystanders. The American Heart Association recommends continuous quality monitoring to ensure implementation of educational interventions in emergency medical dispatch centres. Objective: Improve dispatcher recognition of OHCA and time to first telephone assisted chest compression. Method: Weak aspects of cardiac arrest calls in our dispatch centre were identified, and targeted interventions to improve recognition of agonal respiration and cardiac arrest and to shorten time to first chest compression were implemented. Specifically; 1) Video-based lectures focusing on agonal respiration and continuous coaching 2) Simulation training 3) Structured dispatcher feedback 4) Electronic telephone-assisted CPR training program. Dispatch logs, ambulance records and audio files of confirmed OHCA’s were analyzed before and after the intervention. Recognition of cardiac arrest was reported as (1) recognized, (2) not recognized and (3) delayed recognition (defined as failure to initially clarify consciousness or abnormal breathing before moving on to further questioning). Results: 289 and 221calls were included before and after intervention, respectively. Recognition of cardiac arrest improved from 74% to 89% (p<0.001), and delayed recognition was reduced from 14% to 5% (p=0.001). Agonal respiration continues to challenge dispatchers, but misinterpretation of abnormal breathing decreased from 25% to 8% (p<0.001) of calls. Median time to first chest compression was reduced by 30 seconds (204 vs. 174 seconds, respectively, p=0,039) Conclusion: Targeted simulation and education significantly increased recognition of OHCA and reduced time to first chest compression. Continuous focus and targeted dispatcher training are important to ensure quality of care for OHCA patients.

An outbreak of acute delirium from exposure to the synthetic cannabinoid AB-CHMINACA

Background: Synthetic cannabinoid containing products are a public health threat as reflected by a number of outbreaks of serious adverse health effects over the past 4 years. The designer drug epidemic is characterized by the rapid turnover of synthetic cannabinoid compounds on the market which creates a challenge in identifying the particular etiology of an outbreak, confirming exposure in cases, and providing current information to law enforcement. Results: Between 28 May 2014 and 8 June 2014, 35 patients were evaluated and treated at the University of Florida Health Medical Center in Gainesville following reported exposure to a synthetic cannabinoid containing product obtained from a common source. Patients demonstrated acute delirium (24) and seizures (14), and five required ventilator support and ICU-level care; none died. The presence of N-[(1S)-1-(aminocarbonyl)-2-methylpropyl]-1-(cyclohexylmethyl)-1H-indazole-3-carboxamide (AB-CHMINACA), or one of its predicted metabolites was confirmed in 15 of 21 cases. A rapid public health response and aggressive public messaging prevented further morbidity, identified the source, and led to law enforcement seizure of the implicated product. Discussion: The significance of this outbreak lies as much in the rapid occurrence of unpredictable, life-threatening adverse health effects from a newly identified synthetic cannabinoid compound as it does in the multidisciplinary investigation and novel partnership between local public health, the laboratory, and the chemical industry, resulting in termination of the outbreak. Conclusion: A coordinated response and collaboration between law enforcement, the local public health, emergency medical services and Health Center staff, were all key interventions in preventing a more substantial public health outbreak resulting from use of a novel synthetic cannabinoid compound. Real time collaborations between toxicology laboratories, suppliers of analytical standards and the public health system may be useful in the face of future novel chemical exposures.

Abstract 15159: Differential Recovery Between Regional Cerebral Oxygen Saturation and Physiological Parameters in Cardiopulmonary Arrest Patients After Return of Spontaneous Circulation

Objective: We aimed to clarify the change in rSO2, blood pressure (BP) and arterial oxygen saturation (SpO2) in CPA patients who got return of spontaneous circulation (ROSC). Method: We measured rSO2 in CPA patients who were transferred to two tertiary emergency medical centers. On arrival, rSO2 sensor was attached to the forehead of patients, and monitored continuously during cardiopulmonary resuscitation. In the patients who got ROSC, we compared change in rSO2 and BP, SpO2, and evaluated the correlation between rSO2 and physiological parameters. Result: There were 79 CPA patients transferred to the tertiary emergency medical centers, and 38 patients got ROSC(Mean Age 74.8,M:F=25:13). rSO2 increased after ROSC, and showed the significance after 10 minutes after ROSC. Median rSO2 just after ROSC (ROSC 0) was 54.4% (47.2-59.5), and 66.0% (61.8-70.0) in 10 minutes after ROSC (ROSC 10) (Figure, p<0.01 ROSC 0 vs ROSC 10). However, in BP and SpO2, there were no significant difference between in ROSC 0 and ROSC 10. BP rather showed lower tendency in ROSC 10 compared to ROSC 0. BP; 97mmHg (82.0-127) vs 82.0mmHg (67.0-120), SpO2; 86.0% (70.8-95.0) vs 93.0% (76.0-98.3) Conclusion: We clarified that there is a delay in rSO2 recovery compared to BP, SpO2 recovery after ROSC in CPA patients. It might be a therapeutic point to correct the delay in rSO2 recovery.

Bystander resuscitation rate increased more than six times between 2003 and 2013 in the City of Prague

Purpose of the study: Since 1.1.2003, systematic approach to dispatcher-assisted resuscitation (D-CPR) was introduced in Prague emergency medical dispatch centre. During following years great improvement of dispatcher skills and knowledge of cardiac arrest management was achieved. Following that, also a lot of public promotion effort took place (printed and social media promotion of bystander CPR, placing of “bystander-CPR promoting stickers” to all public transport vehicles in Prague, etc.). The aim of this study is to evaluate bystander resuscitation (B-CPR) rates in pre-hospital cardiac arrest in period from 1.1.2003 to 31.12.2013.

Recognition of out of hospital cardiac arrest in the emergency medical communication center improves survival

s / Resuscitation 96S (2015) 5–42 25 had been allocated as control group (CG)with a standard ILS course and 12 courses as intervention group (IG)with an interactive, video supported and directed targeted–training in NTS, according to the ILS course regulation. Self-assessment was conducted by an aftercourse-questionnaire for all participants with statements around the elements of the Anaesthetists Non-Technical Skills (ANTS) as behavioural marker.3,4,5 Results: 330 surveys had been validated positively (IG n=139 andCGn=191). The distribution of the overall resultwith reference to ANTS behavioural in IG and CG shows a statistically significant difference (p=0.001) between responder trends (IG median 1.0, IQR 1.0–2.0; CGmedian 1.50, IQR 1.0–2.0). In detail we determined differences in the skill category “Decision making” (p=0.024) and “Situational awareness” (p<0.001). The skill category “Teamwork” (p=0.566) and “Taskmanagement” (p=0.143) are statistically similar in both groups. Conclusions: Out of our results we recommend the use of NTS specific targeted–training in ILS provider courses, especially to improve “Decision making” and “Situational awareness” performances.

Changes and trends of pre-hospital emergency disease spectrum in Beijing in 2003–12: a retrospective study

BackgroundPre-hospital emergency call is a crucial indicator of emergency disease spectrum. Since Beijing has changed substantially in economy and population, analysis of the trend of the emergency disease spectrum can greatly contribute to pre-hospital emergency planning. MethodsIn this 10-year retrospective study, pre-hospital emergency records of Beijing Emergency Medical Center, the only pre-hospital emergency system of Beijing Government, in 2003–12 were collected. Medical Priority Dispatch System was used to classify the call demands. Linear regression models were used to examine the trends. This study was exempt from ethical approval. Findings2 410 575 cases were collected. Non-pre-hospital requests, which were identified when the crew arrived, were excluded. Uncompleted and unidentified cases were further excluded, and 2 278 415 cases (94·5%) were included in the analysis. The number of pre-hospital emergency call demands soared from 150 656 in 2003 to 309 297 in 2012 (205·3%; p=0·158). The top five call demands throughout the decade were trauma-related demands (25·4%, including falls [5·0%], traffic or transportation incidents [7·2%], and traumatic injuries [13·1%]), general injuries (17·7%), heart problems (11·4%), unconsciousness or fainting (10·0%), and breathing problems (8·1%). These were also the top five fastest growing call demands. InterpretationCompared with the population growth in 2003–12 (145·4%), pre-hospital emergency calls increased much more, which shows a growing demand for ambulance service. By contrast with cities in developed countries, the proportion of trauma-related cases was constantly the highest among call demands, much higher than that in San Francisco (15·7%) in 2009, and is continuously increasing. This could be a result of accelerated city construction and rapid rise in vehicle quantity (244·8%). On the basis of the changes and trends of pre-hospital emergency disease spectrum, specific training programmes for emergency medical service staff and improvement in related medical devices are recommended. FundingResearch Special Fund for Public Welfare Industry of Health from the National Health and Family Planning Commission of China.

A Relationship between the Injury Characteristics of Trauma Patients and Hospitalization in a Region

The purpose of this study was to investigate the association between the injury characteristic factors and hospitalization of trauma patients in a single region. This study was conducted in 193 subjects transferred to the emergency medical center at a hospital in U Metropolitan City from January 1 to December 31, 2013. The analysis was performed using an SPSS WIN 20.0 program. As for the emergency treatment items at the pre-hospital stage, emergency patients treated with a cervical plate were 15.49 times more likely to be hospitalized than those treated with Stability assistance (p=.001). As for hospitalization based on the final diagnosis for all of the trauma patients at the in-hospital stage, they were 4.91 times more likely to be hospitalized due to fracture than due to scratches/others (p=0.028). As shown in the results of this study, there are a diversity of complicated injury types and accident characteristics. It is therefore necessary to make institutional reinforcement and supplement injury prevention programs.

응급의료기관에 근무하는 1급 응급구조사의 직업 불안정성 및 직무열의가 이직의도에 미치는 영향

=Abstract= Purpose: This study aimed to identify the effects of job insecurity and job engagement on turnover intention of paramedics who work in emergency medical institutions. Methods: From October 14 to 28, 2014, data were collected by structured questionnaires from 171 paramedics who were working in emergency medical institutions. The data were analyzed by using SPSS/WIN 21.0. Results: Of the 171 subjects, 57.3% were temporary employees, of whom 87.5% were working in regional emergency medical centers. The mean scores were 3.19 for job insecurity, 4.58 for job engagement, and 3.28 for turnover intention. The correlation between the variables showed that the higher the job insecurity of the participants, the higher their turnover intention (r=.397, p<.001). Moreover, the higher their job engagement, the lower their turnover intention (r=-.354, p<.001). The variable that most significantly affected turnover intention was job insecurity. The coefficient of determination (R)

Increased Medical Emergency Calls During A Severe Air Pollution Episode In 2013 In Jinan, China

Introduction: In winter 2012-13, severe haze pollution affected major cities in central and eastern China, including Jinan. We investigated whether total medical emergency calls and calls for Central Nervous Systems Syndromes (CNS) increased during this episode and whether emergency calls were associated with particles with aerodynamic diameter ≤10um (PM10) in Jinan, China. Methods: Data on daily medical emergency calls (total and CNS calls) were obtained from Jinan Medical Emergency Center. CNS include dizziness, coma, convulsion, stroke, epilepsy, headache and paralysis. Analysis includes 2 time periods: 1) Dec 1, 2011- Feb 29, 2012 (lower pollution period), and 2) Dec 1, 2012- Feb 28, 2013 (high pollution period). Poisson time series models were used to estimate the change in emergency calls associated with heavy pollution period using an indicator variable, and with day-to-day variation in PM10 levels using a continuous variable. The models were adjusted for temporal trends, temperature, relative humidity and day of the week. Associations were estimated for multiple lag structures. Results: Air pollution levels were high in both the lower and higher air pollution periods with PM10 at 123 ug/m3 and 238 ug/m3, respectively. Compared to lower pollution period, daily number of total calls were significantly higher in the high pollution period (adjusted OR: 1.08; 95% CI: 1.05, 1.11), while the increase of CNS calls was marginally significant. We found positive associations between total calls and PM10 concentrations on lag 0- to lag 5- day. The strongest association was observed for lag 3-day [OR: 1.03; 95% CI: 1.01, 1.05, per IQR increment (121 ug/m3)]. The associations for calls for CNS showed similar patterns. Discussion: Air pollution levels are alarmingly high in winter in Jinan. Results indicate that substantial health benefits would result from efforts to prevent future severe episodes of haze pollution.

Outcomes for out-of-hospital cardiac arrests across 7 countries in Asia: The Pan Asian Resuscitation Outcomes Study (PAROS)

BackgroundThe Pan Asian Resuscitation Outcomes Study (PAROS) Clinical Research Network (CRN) was established in collaboration with emergency medical services (EMS) agencies and academic centers in Japan, Singapore, South Korea, Malaysia, Taiwan, Thailand, and UAE-Dubai and aims to report out-of-hospital cardiac arrests (OHCA) and provide a better understanding of OHCA trends in Asia. Methods and resultsThis is a prospective, international, multi-center cohort study of OHCA across the Asia-Pacific. Each participating country provided between 1.5 and 2.5 years of data from January 2009 to December 2012. All OHCA cases conveyed by EMS or presenting at emergency departments were captured.66,780 OHCA cases were submitted to the PAROS CRN; 41,004 cases were presumed cardiac etiology. The mean age OHCA occurred varied from 49.7 to 71.7 years. The proportion of males ranged from 57.9% to 82.7%. Proportion of unwitnessed arrests ranged from 26.4% to 67.9%. Presenting shockable rhythm rates ranged from 4.1% to 19.8%. Bystander cardiopulmonary resuscitation (CPR) rates varied from 10.5% to 40.9%, however <1.0% of these arrests received bystander defibrillation. For arrests that were with cardiac etiology, witnessed arrest and VF, the survival rate to hospital discharge varied from no reported survivors to 31.2%. Overall survival to hospital discharge varied from 0.5% to 8.5%. Survival with good neurological function ranged from 1.6% to 3%. ConclusionsSurvival to hospital discharge for Asia varies widely and this may be related to patient and system differences. This implies that survival may be improved with interventions such as increasing bystander CPR, public access defibrillation and improving EMS.

Assessment of Geographic Variations regarding the Transportation of Stroke Patients in Korea

Introduction Stroke recently became the second cause of death in Korea. Nevertheless, many studies have reported that the delay of emergency medical service (EMS) transportation in specific areas is a major obstacle to reduce the mortality and morbidity of stroke. The objective of this study was to assess geographic variation regarding this factor at the national level in Korea throughout a funnel plot. Setting Emergency departments. Methods Data were obtained from the “2010 Emergency Medicine Annual Report” published by the National Emergency Medical Centre of Korea. This report describes the general characteristics of eligible Emergency Departments (EDs) across Korea. Therefore, we were able to calculate retrospectively the percentage of stroke patients who reached an ED within 3 hours after the development of symptoms against the volume of total visiting patients according to area. Subsequently, we generated a correlation matrix between ratio of stroke patients who visited EDs within the therapeutic period and ratio of usage of EMS ambulances. Results We found that four areas out of 16 administrative divisions in Korea were located beyond the lower control limit and one area was between the lower warning and lower control limits, according to a funnel plot showing the percentage of patients within the therapeutic period of stroke against the total volume of patients according to area. The ratio of stroke patients who visited EDs within the therapeutic period was significantly correlated with the ratio of use of EMS ambulances to a moderately positive degree (r=0.51; p&lt;0.05). Conclusions Encouraging the public in Korea to use an EMS ambulance in case of stroke may shorten the pre-hospital delay.

Epidemiologic and Clinical Characteristics of Patients Presenting with Renal Colic in Korea.

To investigate the epidemiologic and clinical characteristics of renal colic in Korea. Forty-six participating emergency departments provide their essential informa­tion to the National Emergency Medical Center. We extracted the National Emergency Department Informa­tion System data from January to December 2010. We analyzed data on demographics, visit time, chief com­plaints, mode of arrival, outcome, and length of stay. A total of 23,653 patients with renal colic visited the 46 emergency departments, and this patient population comprised 1.8% of all emergency department visits. The median patient age was 45 years, and the male-to-female ratio was 2:1. The peak time of inci­dence for patients with renal colic occurred between 06:00 and 10:00 h. The peak incidence occurred in Au­gust, whereas the lowest incidence occurred in winter. The most common chief complaint was flank pain, followed by abdominal pain and hematuria. The median length of stay in the emergency department was 171 min, and female patients stayed longer in the emergency department relative to male patients. The medi­an length of stay was shorter for weekend visits than for weekday visits. Most patients were discharged from the emergency department; only 6% of patients were admitted. Monday was the day with the highest ad­mission rate. The length of stay did not correlate with age, whereas the admission rate increased with age. The epidemiologic and clinical features derived from this study may facilitate further investigations aimed at understanding the etiology of renal colic.

Relationships among communication competence, self-efficacy, and job satisfaction in Korean nurses working in the emergency medical center setting.

The communication competence of nurses working in emergency medical center settings is essential to establish a therapeutic nurse-patient relationship. Education and strategic development are required to improve the communication competence of emergency room (ER) nurses. This study was conducted to determine the relationships among individual communication competence, self-efficacy, and job satisfaction in Korean nurses in the emergency medical center setting. A cross-sectional descriptive design was adopted. The study sample included 214 nurses at 11 emergency medical centers in Seoul and Kyunggi-Do, Korea. Measures used included the Global Interpersonal Communication Competence, self-efficacy scale, and job satisfaction scale. The collected data were analyzed using the SPSS version 18.0 statistical software program and included descriptive statistics (frequency, percentage, mean, standard deviation, independent t test, analysis of variance, and Pearson's correlation coefficient). The degrees of communication competence and self-efficacy of ER nurses were good, with higher scores than the median values. However, the degree of job satisfaction was poor, indicating a lower score than the median value. Religious affiliation and previous participation in communication education each had a significant impact on communication competence. Religious affiliation and time of worse duty each had a significant impact on self-efficacy. Length of career (year) in the emergency medical center and type of hospital each had a significant impact on job satisfaction. Positive correlations were identified among communication competence, self-efficacy, and job satisfaction. This study supported the presence of significant correlations among communication competence, self-efficacy, and job satisfaction. Thus, it is necessary to develop training programs that are customized to individual characteristics such as self-efficacy and job satisfaction to improve the communicative competence of ER nurses.

The effect of Cincinnati Prehospital Stroke Scale on telephone triage of stroke patients: evidence-based practice in emergency medical services.

The emergency medical service is designed to recognize and transfer critically ill patients. Evidence-based practice has rarely been emphasized in the emergency medical service field, especially in the dispatch center. To identify the effect of the Cincinnati Prehospital Stroke Scale (CPSS) on telephone triage of stroke patients by telephone triage nurses at the emergency medical dispatch center and to compare CPSS with the National Guidelines for Telephone Triage Tool (NGTT). A quasi-empirical study was conducted from June 2013 to June 2014. The setting of the study was the Mashhad dispatch center of the EMS. Two hundred and forty-six patients were randomly allocated to the CPSS intervention group (n = 121) and the NGTT control group (n = 125). True triage, triage error and odds ratio were statistically reported. The mean age of the patients was 70.9 ± 12.7 years. Of all the cases, 77.7 and 65.6% of patients in the intervention and the control groups, respectively, were accurately triaged. Under-triage cases were 10.7 and 13.6% of the patients in the intervention and the control groups. Odds ratio was 1.14 (95% confidence interval 0.62-2.07) for the CPSS compared with the NGTT. CPSS is more efficient for use by telephone triage nurses in identifying stroke. The use of CPSS assists nurses by reducing the triage error and supports the evidence-based care. It needs to be developed to cover signs and symptoms of posterior-circulation stroke patients.

Descriptions and presentations of sepsis – A qualitative content analysis of emergency calls

BackgroundSepsis is a serious condition which requires early treatment. We often fail to recognize sepsis patients in the chain of prehospital care. Knowledge of how sepsis is expressed in calls to the emergency medical communication centre (EMCC) is limited. An increased understanding could lead to earlier identification of patients with sepsis. ObjectiveThe aim of this study was to describe the descriptions of sepsis used during communication between the caller and the emergency medical dispatcher (EMD). MethodsTo achieve the aim of the study, an inductive approach of qualitative content analysis was used. In total, 29 consecutive patients, who arrived at the emergency department by ambulance and received a diagnosis of sepsis according to the International Classification of Diseases (ICD)-10, were included in the study. For each case, the corresponding emergency call recording from the EMCC was transcribed verbatim. Main categories and subcategories from the text were abstracted. ResultsFrom fifteen subcategories, three main categories were abstracted: “Deterioration”, “Physical signs and symptoms” and “Difficulties establishing satisfactory contact with the patient.” The way laymen and professionals expressed themselves seemed to differ. ConclusionsSepsis was described in terms of the physical symptoms, changes of condition and communication abilities of the patient. This knowledge could lead to the identification of keywords which could be incorporated in the decision tool used by the EMD to increase sepsis identification, but further research is required.

A retrospective analysis of severe multiple trauma with secondary thrombocytosis

Objective To estimate the clinic features of severe multiple trauma with secondary thrombocytosis as a factor influencing the prognosis. Methods A retrospective single-center study was carried out in 680 patients with severe multiple trauma survived longer than 72 hours in Chongqing Emergency Medical Center from March 2010 through March 2013. The variables including age, gender, ISS (injury severity score) , APACHE Ⅱ score, splenectomy and the usages of vasopressors, blood products transfusion, hematopoietic medicines and anticoagulant were analyzed. The prognosis indices including total in-hospital mortality after 72 hours, length of hospital stay and morbidity of thrombo-embolism were explored. The clinic characteristics and prognosis of severe multiple trauma with secondary thrombocytosis (platelet count more than 450 ×109L-1) were evaluated. T test or rank sum test was used for comparison between measurement data and Chi-square test or Fisher's exact test was used for comparison between enumeration data. Results Thrombocytosis was identified in 99 (14.56%) patients and it occurred one week after injury with median time of 27 days (ranged from 8 days to 304 days) , and maintained for (18.62 ±4.38) d. The median of platelet count was 584 × 109L-1 (lowest 478 × 109L-1, highest 1 072 ×109L-1) in severe multiple trauma patients with thrombocytosis. The proportions of splenectomy, prolonged use of vasopressors and employment of hematopoietic medicines or anticoagulant were significantly higher in patients with thrombocytosis than those in patients without thrombocytosis (14.14% vs.7.06% , P =0.03; 62.63% vs.39.07%, P <0.01; 28.28% vs.6.71%, P <0.01; 90.91% vs.19.45% , P< 0.01) . The highest D-Dimer level presenting in patients with thrombocytosis during the time of platelet increasing was significantly more common than that in patients of non-thrombocytosis group 7 days after trauma [(11.68 ±11.90) vs. (5.05 ±5.11) , P =0.004]. However, the mortality, length of hospital stay and morbidity of thrombo-embolism were not significantly increased in patients with thrombocytosis compared with patients without thrombocytosis [8.08% vs.8.78% , P =0.82; 34 d (28.5, 54.5) d vs. 45 d (23, 67) d, P =0.41; 10.10% vs.10.50% , P =0.91]. Conclusion There was a higher rate of secondary thrombocytosis in severe multiple trauma patients. The factors such as splenectomy, vasopressors, hematopoietic medicines and so on might induce the reactive thrombocytosis in trauma patients. Thrombocytosis might increase the incidence of thromboembolism in severe multiple trauma patients without appropriate prophylactic anticoagulation. For the sake of prophylaxis, employment of anti-platelet agent might be the appropriately therapeutic strategy for patients suffering from severe multiple trauma with secondary thrombocytosis accompanying risk factors of arterial thrombo-embolism. Key words: Multiple trauma; Thrombocytosis; Thromboembolism; Anticoagulation; Prognosis

Relationship Between Low Back Pain With Quality of Life, Depression, Anxiety and Stress Among Emergency Medical Technicians.

Background:Musculoskeletal disorders have become increasingly common among healthcare providers. They have become the most common cause of work-related disabilities among nurses.Objectives:The current cross-sectional study aimed to measure the prevalence of back pains among emergency medical technicians (EMTs), and association of back pain with quality of life, depression, anxiety and stress.Materials and Methods:One hundred and eighty registered nurses working as EMTs at the Hamadan Emergency Medical Center were selected by consensus. Data collection tools were Demographic, Perceived Quality-of-Life, Short Form Health Survey (SF-36), and Depression Anxiety Stress Scales (DAS21) and pain scale measurements.Results:Data showed that while 50.7% of the participants had an average awareness of the basic principles of back care, the majority (71.8%) had at least one type of back pain. There were associations between the prevalence of pain and depression (P = 0.049), pain and awareness (P = 0.035), and stress and job satisfaction (P = 0.024).Conclusions:A large number (about two-thirds) of EMTs had some sort of back pain; it is highly recommended to promote the attitude and motivation of the individuals to take care to prevent back injury and inform them of the principles of back care. Implications for primary prevention and care practice include encouraging EMTs to apply accurate principles of back care.

응급실 간호사의 감염노출 예방행위 수행정도와 영향요인

Purpose: The purpose of this study was to identify factors influencing on performance of preventive actions to be exposed to infection in emergency nurses. Methods: Participants were 200 emergency nurses working in a regional emergency medical center, 4 local emergency medical centers, and 5 local emergency medical facilities in B city. The data were analyzed with descriptive statistics, independent t-test, ANOVA, Scheff<TEX>$\acute{e}$</TEX>'s test, Pearson's correlation coefficients, and stepwise multiple regression analysis using SPSS/WIN 21.0 programs. Results: There was no difference in performance of preventive actions to be exposed to infection by socio-demographic and job-related characteristics. The results of stepwise multiple regression analysis showed that levels of perception of preventive actions to be exposed to infection (<TEX>${\beta}$</TEX>=.40, p<.001) and protective environment on exposure to infection (<TEX>${\beta}$</TEX>=.22, p<.001) were significantly associated with performance of preventive actions, explaining 26.3% of the variance. Conclusion: In conclusion, improving performance of preventive actions to be exposed to infection is important to protect emergency nurses from exposure to infection. Thus, efforts to enhance protective environment on exposure to infection and to improve perceptions of preventive actions to be exposed to infection are necessary to improve the performance of preventive actions in emergency nurses.

Characteristics of a large mumps outbreak: Clinical severity, complications and association with vaccination status of mumps outbreak cases

In recent years, large mumps outbreaks, involving mainly adolescents and young adults, have re-emerged in several countries. We investigated a large mumps outbreak, evaluated the association between mumps clinical severity (complications, hospitalization) and vaccination status (number of previous measles, mumps and rubella - MMR vaccine doses), and assessed vaccine effectiveness. The first mumps cases emerged in an ultra-orthodox boys' school in Jerusalem and were epidemiologically linked to the mumps outbreak in New York. Overall, 3130 mumps cases were notified in the Jerusalem district during September 2009-August 2011 (median age 13y, 64% males). Most cases were reported from community clinics. Patients with systemic symptoms and/or complications (419, 13.4%) were either hospitalized (n = 79) or treated in an emergency medical center (n = 340). The main complications included orchitis (3.8% males> age 12y) and meningoencephalitis (0.5%). The mumps virus genotype was G5. The distribution of previous MMR vaccine doses (n = 0,1,2) was: 24.8%, 28.3% and 46.9%, respectively. The number of previous vaccine doses was inversely associated with clinical severity. Adjusted values for MMR vaccine effectiveness against complications were estimated as 52.1% (95% CI −4 −78%) for one vaccine dose and 62.7% (95% CI 25.7–81.3%) for 2 doses. The outbreak was characterized by predominance of male students; the majority of whom had been previously vaccinated. The reported complication rate was relatively low. Vaccination status was associated with age and disease severity. The combination of limited mumps vaccine effectiveness and the specific school setting (dense learning and living conditions) probably contributed to the disease spread.

The role of the emergency medical dispatch centre (EMDC) and prehospital emergency care safety: results from an incident report (IR) system.

The role of the emergency medical dispatch centre (EMDC) is essential to ensure coordinated and safe prehospital care. The aim of this study was to implement an incident report (IR) system in prehospital emergency care management with a view to detecting errors occurring in this setting and guiding the implementation of safety improvement initiatives. An ad hoc IR form for the prehospital setting was developed and implemented within the EMDC of Verona. The form included six phases (from the emergency call to hospital admission) with the relevant list of potential error modes (30 items). This descriptive observational study considered the results from 268 consecutive days between February and November 2010. During the study period, 161 error modes were detected. The majority of these errors occurred in the resource allocation and timing phase (34.2%) and in the dispatch phase (31.0%). Most of the errors were due to human factors (77.6%), and almost half of them were classified as either moderate (27.9%) or severe (19.9%). These results guided the implementation of specific corrective actions, such as the adoption of a more efficient Medical Priority Dispatch System and the development of educational initiatives targeted at both EMDC staff and the population. Despite the intrinsic limits of IR methodology, results suggest how the implementation of an IR system dedicated to the emergency prehospital setting can act as a major driver for the development of a "learning organization" and improve both efficacy and safety of first aid care.