Emergency Medical Services Setting Research Articles

Analgesia in adult trauma patients in physician-staffed Austrian helicopter rescue: a 12-year registry analysis

BackgroundSufficient analgesia is an obligation, but oligoanalgesia (NRS> 3) is frequently observed prehospitally. Potent analgesics may cause severe adverse events. Thus, analgesia in the helicopter emergency medical service (HEMS) setting is challenging. Adequacy, efficacy and administration safety of potent analgesics pertaining to injured patients in HEMS were analysed.MethodsObservational study evaluating data from 14 year-round physician-staffed helicopter bases in Austria in a 12-year timeframe.ResultsOverall, 47,985 (34.3%) patients received analgesics, 26,059 of whom were adult patients, injured and not mechanically ventilated on site. Main drugs administered were opioids (n=20,051; 76.9%), esketamine (n=9082; 34.9%), metamizole (n=798; 3.1%) and NSAIDs (n=483; 1.9%). Monotherapy with opioids or esketamine was the most common regimen (n=21,743; 83.4%), while opioids together with esketamine (n= 3591; 13.8%) or metamizole (n=369; 1.4%) were the most common combinations. Females received opioids less frequently than did males (n=6038; 74.5% vs. n=14,013; 78.1%; p< 0.001). Pain relief was often sufficient (> 95%), but females more often had moderate to severe pain on arrival in hospital (n=34; 5.0% vs. n=59; 3.2%; p=0.043). Administration of potent analgesics was safe, as indicated by MEES, SpO2 and respiratory rates. On 10% of all missions, clinical patient assessment was deemed sufficient by HEMS physicians and monitoring was spared.ConclusionsOpioids and esketamine alone or in combination were the analgesics of choice in physician-staffed HEMS in Austria. Analgesia was often sufficient, but females more than males suffered from oligoanalgesia on hospital arrival. Administration safety was high, justifying liberal use of potent analgesics in physician-staffed HEMS.

Comparison of Prehospital Scales for Predicting Large Anterior Vessel Occlusion in the Ambulance Setting

The efficacy of endovascular thrombectomy (EVT) for symptomatic large anterior vessel occlusion (sLAVO) sharply decreases with time. Because EVT is restricted to comprehensive stroke centers, prehospital triage of patients with acute stroke codes for sLAVO is crucial, and although several prediction scales are already in use, external validation, head-to-head comparison, and feasibility data are lacking. To conduct external validation and head-to-head comparisons of 7 sLAVO prediction scales in the emergency medical service (EMS) setting and to assess scale feasibility by EMS paramedics. This prospective cohort study was conducted between July 2018 and October 2019 in a large urban center in the Netherlands with a population of approximately 2 million people and included 2 EMSs, 3 comprehensive stroke centers, and 4 primary stroke centers. Participants were consecutive patients aged 18 years or older for whom an EMS-initiated acute stroke code was activated. Of 2812 acute stroke codes, 805 (28.6%) were excluded, because no application was used or no clinical data were available, leaving 2007 patients included in the analyses. Applications with clinical observations filled in by EMS paramedics for each acute stroke code enabling reconstruction of the following 7 prediction scales: Los Angeles Motor Scale (LAMS); Rapid Arterial Occlusion Evaluation (RACE); Cincinnati Stroke Triage Assessment Tool; Prehospital Acute Stroke Severity (PASS); gaze-face-arm-speech-time; Field Assessment Stroke Triage for Emergency Destination; and gaze, facial asymmetry, level of consciousness, extinction/inattention. Planned primary and secondary outcomes were sLAVO and feasibility rates (ie, the proportion of acute stroke codes for which the prehospital scale could be reconstructed). Predictive performance measures included accuracy, sensitivity, specificity, the Youden index, and predictive values. Of 2007 patients who received acute stroke codes (mean [SD] age, 71.1 [14.9] years; 1021 [50.9%] male), 158 (7.9%) had sLAVO. Accuracy of the scales ranged from 0.79 to 0.89, with LAMS and RACE scales yielding the highest scores. Sensitivity of the scales ranged from 38% to 62%, and specificity from 80% to 93%. Scale feasibility rates ranged from 78% to 88%, with the highest rate for the PASS scale. This study found that all 7 prediction scales had good accuracy, high specificity, and low sensitivity, with LAMS and RACE being the highest scoring scales. Feasibility rates ranged between 78% and 88% and should be taken into account before implementing a scale.

Point-of-Care Testing Practices, Failure Modes, and Risk-Mitigation Strategies in Emergency Medical Services Programs in the Canadian Province of Alberta

Emergency medical services (EMS) programs have been using point-of-care testing (POCT) for more than 20 years. However, only a handful of reports have been published in all of that time on POCT practices in field settings. To provide an overview of POCT practices and failure modes in 3 of Alberta's EMS programs, and to propose risk-mitigation strategies for reducing or eliminating these failure modes. Details about POCT practices, failure modes, and risk-mitigation strategies were gathered through (1) conversations with personnel, (2) in-person tours of EMS bases, (3) accompaniment of EMS personnel on missions, (4) internet searches for publicly available information, and (5) a review of laboratory documents. Practices were most standardized and robust in the community paramedicine program (single service provider, full laboratory oversight), and least standardized and robust in the air ambulance program (4 service providers, limited laboratory oversight). Common failure modes across all 3 programs included device inoperability due to cold weather, analytical validation procedures that failed to consider the unique challenges of EMS settings, and a lack of real-time electronic transmission of results into the health care record. A provincial framework for POCT in EMS programs is desirable. Such a framework should include appropriate funding models, laboratory oversight of POCT, and relevant expertise on POCT in EMS settings. The framework should also incorporate specific guidance on quality standards that are needed to address the unique challenges of performing POCT in field settings.

Medication Dosing Safety for Pediatric Patients: Recognizing Gaps, Safety Threats, and Best Practices in the Emergency Medical Services Setting. A Position Statement and Resource Document from NAEMSP

Background Millions of patients receive medications in the Emergency Medical Services (EMS) setting annually, and dosing safety is critically important. The need for weight-based dosing in pediatric patients and variability in medication concentrations available in the EMS setting may require EMS providers to perform complex calculations to derive the appropriate dose to deliver. These factors can significantly increase the risk for harm when dose calculations are inaccurate or incorrect. Methods We conducted a scoping review of the EMS, interfacility transport and emergency medicine literature regarding pediatric medication dosing safety. A priori, the authors identified four research topics: (1) what are the greatest safety threats that result in significant dosing errors that potentially result in harm to patients, (2) what practices or technologies are known to enhance dosing safety, (3) can data from other settings be extrapolated to the EMS environment to inform dosing safety, and (4) what impact could standardization of medication formularies have on enhancing dosing safety. To address these topics, 17 PICO (Patient, Intervention, Comparison, Outcome) questions were developed and a literature search was performed. Results After applying exclusion criteria, 70 articles were reviewed. The methods for the investigation, findings from these articles and how they inform EMS medication dosing safety are summarized here. This review yielded 11 recommendations to improve safety of medication delivery in the EMS setting. Conclusion These recommendations are summarized in the National Association of EMS Physicians® position statement: Medication Dosing Safety for Pediatric Patients in Emergency Medical Services.

A systematic review of stability of medicines used in emergency medical service settings

Background: Temperature, among several environment conditions like humidity, is known to impact medicine stability . In emergency medical service (EMS) settings, it is often challenging to control these conditions. In the GCC region including Qatar, temperature and relative humidity values may rise over 50°C and 80%, respectively, according to climate data from the Qatar Civil Aviation Authority . The aim of this systematic review is to collate and analyze data on the stability of EMS medicines exposed to temperature excursions beyond recommended limits (20-25°C with excursions up to 15-30°C) and provide evidence-based best practice recommendations on storage of medicines in EMS settings. Method: Literature on stability studies in EMS settings were obtained from PubMed, Embase, Web of Science and grey literature. Data from articles that met inclusion and exclusion criteria were collected using developed data collection forms then analyzed following PRISMA statement. The quality of articles were assessed using the Health Evidence Tool. Results: Thirteen studies were included (Table 1). Results were variable depending on the region and whether the study was done in an EMS setting or simulated in laboratory. Studies affirmed that medicines were exposed to temperatures beyond limits in EMS settings (Table 2). Medicines recommended to be refrigerated were not stable in a temperature-dependent manner. Although many medicines were stable, temperature-sensitive medicines degraded faster, while extreme cold produced various effects. No study has explored the biological effects of degradation and degradation products. Conclusion: EMS medicines are exposed to temperature extremes which may affect their stability and decrease their shelf-life. Therefore, routine stability testing during storage, replacement of exposed medicines and inclusion of temperature monitoring devices are paramount to validate the content of EMS medicines administered to end-users. We aim to collaborate with Hamad Medical Corporation Ambulance Service in Qatar to study the stability of EMS medicines in several settings including ambulances and paramedic bags of indoor and outdoor bike units.

Thinking Out of the (Big) Box: A Wearable Near-Infrared Spectroscopy Monitor for the Helicopter Emergency Medical Service

ObjectiveIn prehospital helicopter emergency medical service (HEMS) settings, the medical team has limited monitoring options, usually restricted to systemic variables. Regional tissue oxygenation (rO2) can be assessed by near-infrared spectroscopy (NIRS), but clinical NIRS monitors are unpractical (“big boxes” and additional cables) in HEMS. As an alternative, we identified a wearable, athlete training NIRS device (Moxy; Idiag, Fehraltorf, Switzerland) and hypothesized that it would be applicable in our HEMS setting. MethodsThis feasibility study was performed at the Dutch HEMS Lifeliner 1. The Moxy sensor was tested in-flight and on ground. We tested various anatomic measurement spots, and multiple conditions and interventions were imposed to track rO2. ResultsThe rO2 measurements with the wearable Moxy NIRS device are both feasible and practical in an HEMS setting. Multiple conditions and interventions were tested successfully (eg, tourniquet placement [rO2↓], muscle compression [rO2↓], reperfusion [rO2↑], oxygen administration [rO2↑], hyperemia [rO2↑], and venous congestion [rO2↓]). ConclusionOur results suggest that rO2 measurements with the wearable Moxy NIRS device are both feasible and practical in HEMS, and Moxy allows the tracking of simulated pathophysiologic effects on rO2. Future studies will have to verify our preliminary data and elucidate if and how wearable NIRS monitoring may support treatment in HEMS and improve patient outcome.

Preceptors´ experiences of student supervision in the emergency medical services: A qualitative interview study

BackgroundClinical placements play a central part in the education of future emergency medical services (EMS) staff and their development of clinical skills and competence. A key aspect of students' integration of theory and praxis and development into an independent clinician is a supportive mentorship with the preceptor. However, students report barriers for learning within the EMS, while the preceptors' experiences of their role have received scant attention in research. ObjectivesTo describe preceptors' experiences of student supervision in the EMS during clinical placements. DesignA descriptive qualitative design was used.Twenty specialist nurses were recruited among EMS staff from all parts of Sweden. MethodsData were collected using individual interviews and analyzed with latent qualitative content analysis. FindingsEMS preceptors develop a competence in combining caring and learning adapted to individual student needs when facing students with varying needs in an ever-changing healthcare setting. A trustful relationship between student and preceptor is fundamental when coping with a dual responsibility for student and patient needs. However, several aspects in the EMS setting hinders the preceptors' ability to support the development of the students' independence. Surrounding support structures are important if the preceptors are to feel safe and secure in their role as assessor, teacher and ambulance nurse. ConclusionsPreceptors need to develop a didactic flexibility through preceptor courses adapted to the complex premises found in the EMS. Ambulance services and universities should recognize the importance of preceptors´ colleagues, student continuity, university support and cooperation for improving quality and clarity in supervision during clinical placements.

Understanding system-focused barriers to the identification and reporting of medication errors and adverse drug events in emergency medical services

Emergency medical services (EMS) represent an important and increasingly used entry point into the healthcare system. These services are often provided in the backdrop of challenging environments, with few diagnostic resources available, and for patients of varying acuity. As a result, the potential for medication errors (MEs) and adverse drug events (ADEs) is significant. However, the identification and reporting of these occurrences is poorly understood. A healthcare failure mode and effects analysis was conducted at the Hamad Medical Corporation Ambulance Service, Qatar, to identify and mitigate potential system-focused barriers to the identification and reporting of ADEs and MEs in the EMS setting. Between May 2018 and July 2018, a process map and potential failure points were developed and identified. Probabilities, severity, and hazard scores were calculated for each failure point, and action items were developed to address these. In total, 110 potential failure points were identified among 22 sub-processes, divided between six major processes. In terms of severity, most were classified as either ‘moderate’ [n = 90 (80%)] or ‘major’ [n = 14 (13%)]. In terms of probability, failure points classified as ‘frequent’ [n = 39 (35%)] and ‘occasional’ [n = 38 (35%)] made up the majority. Through consensus, 76 failure points (69%) were deemed necessary for action. Five strategic-level, system-focused action items were identified to mitigate against the failure points meeting the criteria for action. The unique circumstances that occur within the EMS setting dictate that bespoke solutions be developed to allow for ease of implementation and ongoing success of use. Strategies that also take advantage of mobile technology are crucial for a service that has mobility as one of its core functions.

Performance of the RACE Score for the Prehospital Identification of Large Vessel Occlusion Stroke in a Suburban/Rural EMS Service

Introduction: Emergency Medical Services (EMS) providers may identify and preferentially transport patients experiencing large vessel occlusion (LVO) stroke to appropriate treatment centers. The Rapid Arterial oCclusion Evaluation (RACE) scale was created for prehospital LVO detection, yet few studies have evaluated its function in real-world EMS settings. Our objective was to assess the prehospital performance of the RACE scale for detecting LVO stroke following implementation at a large suburban/rural agency in the United States. Methods: In this retrospective analysis, all 9-1-1 patients with an EMS provider primary or secondary impression of stroke treated by the agency between June 1, 2016 and November 1, 2017 were eligible for inclusion. Patient data were abstracted using a standardized form completed by receiving hospitals. Performance for LVO detection at each RACE cutoff value was evaluated using sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). A receiver operating characteristic (ROC) curve was used to evaluate the discrimination of the RACE scale overall. A secondary analysis of RACE for patients experiencing strokes best treated at comprehensive stroke centers (LVO and intracerebral hemorrhage [ICH]) was conducted. Results: There were 440 patients with a documented RACE score and hospital outcome data included in the analysis. About half (51%, n = 220) were female and the median age was 70 years (IQR: 59–81). Last known well time was under 4.5 hours for 76% of patients (n = 261). Over half (61%, n = 269) had a hospital discharge diagnosis of stroke and 64/440 (15%) were classified as LVO. The ROC curve demonstrated adequate discrimination with a c-statistic of 0.72. Performance for identifying LVO in the prehospital setting was greatest for RACE scores ≥5 with a sensitivity of 66% and specificity of 72%, PPV of 29%, and NPV of 93%. A RACE score ≥5 for both LVO and ICH demonstrated sensitivity: 63%, specificity: 77%, PPV: 47% and NPV: 86%. Conclusion: The RACE scale demonstrated acceptable discrimination, yet the sensitivity and positive predictive value were lower in this cohort of EMS professionals in the United States than in the original validation study conducted in Spain. Further work is needed to determine the optimal prehospital screening tool for identification of LVO.

Evaluating the Usefulness of Translation Technologies for Emergency Response Communication: A Scenario-Based Study

BackgroundIn the United States, language barriers pose challenges to communication in emergency response and impact emergency care delivery and quality for individuals who are limited English proficient (LEP). There is a growing interest among Emergency Medical Services (EMS) personnel in using automated translation tools to improve communications with LEP individuals in the field. However, little is known about whether automated translation software can be used successfully in EMS settings to improve communication with LEP individuals.ObjectiveThe objective of this work is to use scenario-based methods with EMS providers and nonnative English-speaking users who identified themselves as LEP (henceforth referred to as LEP participants) to evaluate the potential of two automated translation technologies in improving emergency communication.MethodsWe developed mock emergency scenarios and enacted them in simulation sessions with EMS personnel and Spanish-speaking and Chinese-speaking (Mandarin) LEP participants using two automated language translation tools: an EMS domain-specific fixed-sentence translation tool (QuickSpeak) and a statistical machine translation tool (Google Translate). At the end of the sessions, we gathered feedback from both groups through a postsession questionnaire. EMS participants also completed the System Usability Scale (SUS).ResultsWe conducted a total of 5 group sessions (3 Chinese and 2 Spanish) with 12 Chinese-speaking LEP participants, 14 Spanish-speaking LEP participants, and 17 EMS personnel. Overall, communications between EMS and LEP participants remained limited, even with the use of the two translation tools. QuickSpeak had higher mean SUS scores than Google Translate (65.3 vs 48.4; P=.04). Although both tools were deemed less than satisfactory, LEP participants showed preference toward the domain-specific system with fixed questions (QuickSpeak) over the free-text translation tool (Google Translate) in terms of understanding the EMS personnel’s questions (Chinese 11/12, 92% vs 3/12, 25%; Spanish 12/14, 86% vs 4/14, 29%). While both EMS and LEP participants appreciated the flexibility of the free-text tool, multiple translation errors and difficulty responding to questions limited its usefulness.ConclusionsTechnologies are emerging that have the potential to assist with language translation in emergency response; however, improvements in accuracy and usability are needed before these technologies can be used safely in the field.

Peer-support: a coping strategy for nurses working at the Emergency Ambulance Service.

Background and aim of the study: Working in the emergency medical service often exposes nurses to highly stressful situations and can impact their quality of life. Among the strategies aimed at mitigating the effects of this phenomenon, peer-supporting represents an emerging model used in the emergency medical service setting. The aim of the study is to explore the experiences, the opinions and feelings of emergency medical service nursing staff in relation to the use of the peer supporting model. Methods: A semi-structured interview was carried out. Participants were recruited on a voluntary basis from an emergency medical service in the north of Italy. Interviews were audio-recorded and the data extracted were anonymised. Results: 14 nurses participated in the study. The totality of the participants recognized that their daily clinical practice, especially when involving paediatric patients, can have a profound emotional impact on their life in general. Furthermore, interviewees admitted that their personal copying mechanisms did not seem to be entirely effective when processing their painful experiences. The majority of the participants were in favour of introducing a peer-supporter in the ambulance service. Conclusions: This study emphasises the need to implement emotional support tools for non-hospital emergency nurses in daily clinical practice, in order to facilitate emotional decompression secondary to particularly stressful interventions as soon as possible. The peer-supporting strategy could represent, in this direction, a valid and shared model. (www.actabiomedica.it)

Psychometric properties of the Norwegian version of the hospital survey on patient safety culture in a prehospital environment

BackgroundTo develop a culture of patient safety in a regime that strongly focuses on saving patients from emergencies may seem counter-intuitive and challenging. Little research exists on patient safety culture in the context of Emergency Medical Services (EMS), and the use of survey tools represents an appropriate approach to improve patient safety. Research indicates that safety climate studies may predict safety behavior and safety-related outcomes. In this study we apply the Norwegian versions of Hospital Survey on Patient Safety Culture (HSOPSC) and assess the psychometric properties when tested on a national sample from the EMS.MethodsThis study adopted a web based survey design. The Norwegian HSOPSC has 13 dimensions, consisting of 46 items, in addition to two single-item outcome variables. SPSS (version 21) was used for descriptive data analysis, estimating internal consistency, and performing exploratory factor analysis. Confirmatory factor analysis (CFA) was applied to test the dimensional structure of the instruments using Amos (version 21).ResultsN = 1387 (27%) EMS employees participated in the survey. Overall, acceptable psychometric properties were observed, i.e. acceptable internal consistencies and construct validity. The patient safety climate dimensions with highest scores (number of positive answers) were “teamwork within units” and “manager expectations & actions promoting patient safety”. The dimension “hospital management support for patient safety” had the lowest score.ConclusionsThe results provided a validated instrument, the Prehospital Survey on Patient Safety Culture (PreHSOPSC), for measuring patient safety climate in an EMS setting. In addition, the explanatory power was strong for several of the outcome dimensions; i.e., several of the safety climate dimensions have a strong predictive effect on outcome variables related to employees’ perceptions on patient safety and safety-related attitude.

Direct vs. Video Laryngoscopy in a Helicopter Emergency Medical Service (HEMS) Setting: A Retrospective Comparison

Introduction In the prehospital setting, when caring for critically ill patients, the ability to quickly and effectively secure a definitive airway can be a matter of life of death. As such, all helicopter emergency medical service (HEMS) providers must be able to safely perform this procedure with speed and efficacy. Video laryngoscopy (VL) was invented and introduced as an improved technique for performing orotracheal intubation, and its use has become widespread amongst pre-hospital and HEMS organizations. Despite this, little information is available regarding the efficacy of VL when compared to standard direct laryngoscopy (DL) in this pre-hospital setting. As such, there is sparse evidence to guide the HEMS provider's decision on which to use when attempting to secure the airway of a critically ill patient. Provider preference often comes into play in this situation. In a preliminary survey, Nolen and Pokorney found that while the majority of Wisconsin Flight For Life (FFL) HEMS providers choose VL, variation does exist between providers in regards to VL vs DL preference. Self-reported success rates by providers suggested 100% first pass success with DL and 87.5 success with VL. This survey relied on provider recall, and further review of records is required to evaluate the accuracy of these reports. Currently, there is no protocol regarding which laryngoscopy modality to employ in the HEMS setting. This research aims to improving the quality of care received by patients who require orotracheal intubation by HEMS providers. To do this, we investigate whether the use of VL or DL increases successful orotracheal intubations by HEMS providers. We hypothesized that the first pass and overall success would be greater with VL and the overall complications would be less with VL when compared to DL. Methods A retrospective chart review was performed of all intubated patients transported by HEMS providers from January 2015 to July 2017. Inclusion Criteria Adult patients transported by HEMS providers that required orotracheal intubation and underwent at least one attempt at orotracheal intubation. Results When comparing the survey results, we found similar rates of DL vs VL attempts (15/21 vs 104/120). First pass success rates were overestimated for both modalities (100%/90.5% vs 87.5%/84.8%). First Pass Success Rate No statistically significant difference was found in 1st pass success rate. The top reported reason for failed DL attempts was inability to pass tube, while the top reported reason for failed VL attempts include blood/secretions on camera, followed by inability to pass tube. Overall Success Rate No statistically significant difference was found between the two modalities. However, there was notably no difference between 1st pass and overall success rate in the DL group, while the overall success improved over fist pass in the VL group. While not statistically significant, this trend results from more attempts and alterations by those performing VL prior to resorting to a rescue airway. The most common alteration made was change in VL blade, followed by changing from VL to DL. Complications DL and VL groups had nearly identical complication rates. In both groups, the primary complication was hypoxia, so BVM ventilation was utilized. There was one cardiac arrest in the DL group. Influencing Factors Overwhelmingly, the method of intubation favored by HEMS providers is video laryngoscopy (VL). In the survey by Pokorney and Nolan, provider preference was the most common reason for choosing a modality. Of the patient characteristics observed, no significant differences were found. Initial GCS showed near statistical significance, with lower initial GCS trending to VL. Perhaps VL is more utilized when indication for intubation is apparent immediately upon arrival on scene. Unresponsiveness as reason for intubation, however, did not vary significantly. Respiratory failure alone demonstrated a statistically significant difference with proportionally more VL intubations in these patients. No definition for what constitutes respiratory failure was present in the charts and the reason for this variance between modality used is unknown. Conclusion In the data reviewed, no significant differences were found in first pass or overall success rates for direct and video laryngoscopy. Additionally no significant difference was observed in the complication rates and no factors were found that influenced the decision to perform DL vs VL.

Factors influencing the decision to convey or not to convey elderly people to the emergency department after emergency ambulance attendance: a systematic mixed studies review

BackgroundThe decision over whether to convey after emergency ambulance attendance plays a vital role in preventing avoidable admissions to a hospital’s emergency department (ED). This is especially important with the...

Safety and Feasibility of Telestroke in the Prehospital Emergency Medical Services Setting – The REACHOUT Project (P2.251)

Safety and Feasibility of Telestroke in the Prehospital Emergency Medical Services Setting – The REACHOUT Project (P2.251)

Systematic Review Methodology for the Fatigue in Emergency Medical Services Project

Background: Guidance for managing fatigue in the Emergency Medical Services (EMS) setting is limited. The Fatigue in EMS Project sought to complete multiple systematic reviews guided by seven explicit research questions, assemble the best available evidence, and rate the quality of that evidence for purposes of producing an Evidence Based Guideline (EBG) for fatigue risk management in EMS operations. Methods: We completed seven systematic reviews that involved searches of six databases for literature relevant to seven research questions. These questions were developed a priori by an expert panel and framed in the Population, Intervention, Comparison, and Outcome (PICO) format and pre-registered with PROSPERO. Our target population was defined as persons 18 years of age and older classified as EMS personnel or similar shift worker groups. A panel of experts selected outcomes for each PICO question as prescribed by the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. We pooled findings, stratified by study design (experimental vs. observational) and presented results of each systematic review in narrative and quantitative form. We used meta-analyses of select outcomes to generate pooled effects. We used the GRADE methodology and the GRADEpro software to designate a quality of evidence rating for each outcome. Results: We present the results for each systematic review in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA). More than 38,000 records were screened across seven systematic reviews. The median, minimum, and maximum inter-rater agreements (Kappa) between screeners for our seven systematic reviews were 0.66, 0.49, and 0.88, respectively. The median, minimum, and maximum number of records retained for the seven systematic reviews was 13, 1, and 100, respectively. We present key findings in GRADE Evidence Profile Tables in separate publications for each systematic review. Conclusions: We describe a protocol for conducting multiple, simultaneous systematic reviews connected to fatigue with the goal of creating an EBG for fatigue risk management in the EMS setting. Our approach may be informative to others challenged with the creation of EBGs that address multiple, inter-related systematic reviews with overlapping outcomes.

Proposed Performance Measures and Strategies for Implementation of the Fatigue Risk Management Guidelines for Emergency Medical Services

Background: Performance measures are a key component of implementation, dissemination, and evaluation of evidence-based guidelines (EBGs). We developed performance measures for Emergency Medical Services (EMS) stakeholders to enable the implementation of guidelines for fatigue risk management in the EMS setting. Methods: Panelists associated with the Fatigue in EMS Project, which was supported by the National Highway Traffic Safety Administration (NHTSA), used an iterative process to develop a draft set of performance measures linked to 5 recommendations for fatigue risk management in EMS. We used a cross-sectional survey design and the Content Validity Index (CVI) to quantify agreement among panelists on the wording and content of draft measures. An anonymous web-based tool was used to solicit the panelists' perceptions of clarity and relevance of draft measures. Panelists rated the clarity and relevance separately for each draft measure on a 4-point scale. CVI scores ≥0.78 for clarity and relevance were specified a priori to signify agreement and completion of measurement development. Results: Panelists judged 5 performance measures for fatigue risk management as clear and relevant. These measures address use of fatigue and/or sleepiness survey instruments, optimal duration of shifts, access to caffeine as a fatigue countermeasure, use of napping during shift work, and the delivery of education and training on fatigue risk management for EMS personnel. Panelists complemented performance measures with suggestions for implementation by EMS agencies. Conclusions: Performance measures for fatigue risk management in the EMS setting will facilitate the implementation and evaluation of the EBG for Fatigue in EMS.

Reliability and Validity of Survey Instruments to Measure Work-Related Fatigue in the Emergency Medical Services Setting: A Systematic Review

Background: This study sought to systematically search the literature to identify reliable and valid survey instruments for fatigue measurement in the Emergency Medical Services (EMS) occupational setting. Methods: A systematic review study design was used and searched six databases, including one website. The research question guiding the search was developed a priori and registered with the PROSPERO database of systematic reviews: “Are there reliable and valid instruments for measuring fatigue among EMS personnel?” (2016:CRD42016040097). The primary outcome of interest was criterion-related validity. Important outcomes of interest included reliability (e.g., internal consistency), and indicators of sensitivity and specificity. Members of the research team independently screened records from the databases. Full-text articles were evaluated by adapting the Bolster and Rourke system for categorizing findings of systematic reviews, and the rated data abstracted from the body of literature as favorable, unfavorable, mixed/inconclusive, or no impact. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology was used to evaluate the quality of evidence. Results: The search strategy yielded 1,257 unique records. Thirty-four unique experimental and non-experimental studies were determined relevant following full-text review. Nineteen studies reported on the reliability and/or validity of ten different fatigue survey instruments. Eighteen different studies evaluated the reliability and/or validity of four different sleepiness survey instruments. None of the retained studies reported sensitivity or specificity. Evidence quality was rated as very low across all outcomes. Conclusions: In this systematic review, limited evidence of the reliability and validity of 14 different survey instruments to assess the fatigue and/or sleepiness status of EMS personnel and related shift worker groups was identified.

Impact of non-guideline-based treatment of status epilepticus

BackgroundThis retrospective study analyzed benzodiazepine usage patterns in relation to guideline recommendations for the treatment of generalized convulsive status epilepticus (GCSE) as practiced by emergency medical services (EMS) and the emergency department (ED) of an inner-city hospital. Secondary outcomes of interest were adverse events and admission/discharge outcomes. MethodsRecords of all patients≥18years old diagnosed with GCSE between June 2012 and September 2015 and transported by EMS to our hospital ED were reviewed. ResultsOf 44 patients analyzed, 43 (98%) had a history of epilepsy. Benzodiazepine utilization varied; EMS preferred midazolam (69% of cases) while the ED utilized lorazepam (91% of cases). Benzodiazepine dosages used were lower than guideline recommendations. Seizure activity was aborted with benzodiazepines alone in 22 (50%) patients. Twelve patients (27%) experienced seizure recurrence following SE treatment and achievement of seizure cessation. Twenty-three (52%) patients required intubation after arrival to ED. All 44 patients were admitted; 30 (68%) required admission to the intensive care unit. ConclusionsThere was consistent underdosing of benzodiazepines in treatment of GCSE in both EMS and ED settings likely resulting in underachievement of seizure cessation, while intubation rates were higher than reported when compared to previous studies. Prospective studies are needed to identify barriers to optimal benzodiazepine usage in GCSE patients.

Development of a trigger tool to identify adverse events and harm in Emergency Medical Services

BackgroundAdverse event(AE) detection in healthcare has traditionally relied upon several methods including: patient care documentation review, mortality and morbidity review, voluntary reporting, direct observation and complaint systems. A novel sampling...