Emergency Medical Services Encounters Research Articles

Pediatric Intubation by Paramedics in a Large Emergency Medical Services System: Process, Challenges, and Outcomes

Pediatric intubation is a core paramedic skill in some emergency medical services (EMS) systems. The literature lacks a detailed examination of the challenges and subsequent adjustments made by paramedics when intubating children in the out-of-hospital setting. We undertake a descriptive evaluation of the process of out-of-hospital pediatric intubation, focusing on challenges, adjustments, and outcomes. We performed a retrospective analysis of EMS responses between 2006 and 2012 that involved attempted intubation of children younger than 13 years by paramedics in a large, metropolitan EMS system. We calculated the incidence rate of attempted pediatric intubation with EMS and county census data. To summarize the intubation process, we linked a detailed out-of-hospital airway registry with clinical records from EMS, hospital, or autopsy encounters for each child. The main outcome measures were procedural challenges, procedural success, complications, and patient disposition. Paramedics attempted intubation in 299 cases during 6.3 years, with an incidence of 1 pediatric intubation per 2,198 EMS responses. Less than half of intubations (44%) were for patients in cardiac arrest. Two thirds of patients were intubated on the first attempt (66%), and overall success was 97%. The most prevalent challenge was body fluids obscuring the laryngeal view (33%). After a failed first intubation attempt, corrective actions taken by paramedics included changing equipment (33%), suctioning (32%), and repositioning the patient (27%). Six patients (2%) experienced peri-intubation cardiac arrest and 1 patient had an iatrogenic tracheal injury. No esophageal intubations were observed. Of patients transported to the hospital, 86% were admitted to intensive care and hospital mortality was 27%. Pediatric intubation by paramedics was performed infrequently in this EMS system. Although overall intubation success was high, a detailed evaluation of the process of intubation revealed specific challenges and adjustments that can be anticipated by paramedics to improve first-pass success, potentially reduce complications, and ultimately improve clinical outcomes.

Prehospital recognition of severe sepsis: development and validation of a novel EMS screening tool

ObjectiveTo derive and validate a predictive model and novel emergency medical services (EMS) screening tool for severe sepsis (SS). DesignRetrospective cohort study. SettingA single EMS system and an urban, public hospital. PatientsSequential adult, nontrauma, nonarrest, at-risk, EMS-transported patients between January 1, 2011, and December 31, 2012 were included in the study. At-risk patients were defined as having all 3 of the following criteria present in the EMS setting: (1) heart rate greater than 90 beats/min, (2) respiratory rate greater than 20 beats/min, and (3) systolic blood pressure less than 110 mm Hg. InterventionsNone. Measurements and Main ResultsAmong 66,439 EMS encounters, 555 met the criteria for analysis. Fourteen percent (n = 75) of patients had SS, of which 19% (n = 14) were identified by EMS clinical judgment. In-hospital mortality for patients with SS was 31% (n = 23). Six EMS characteristics were found to be predictors of SS: older age, transport from nursing home, Emergency Medical Dispatch (EMD) 9-1-1 chief concern category of “sick person,” hot tactile temperature assessment, low systolic blood pressure, and low oxygen saturation. The final predictive model showed good discrimination in derivation and validation subgroups (areas under curves, 0.843 and 0.820, respectively). Sensitivity of the final model was 91% in the derivation group and 78% in the validation group. At a predefined threshold of 2 or more points, prehospital severe sepsis (PRESS) score sensitivity was 86%. ConclusionsThe PRESS score is a novel EMS screening tool for SS that demonstrates a sensitivity of 86% and a specificity of 47%. Additional validation is needed before this tool can be recommended for widespread clinical use.

Prehospital intravenous access and fluid resuscitation in severe sepsis: an observational cohort study.

IntroductionPrompt treatment of severe sepsis in the Emergency Department reduces deaths, but the role of prehospital fluid resuscitation is unknown. We sought to determine the risk-adjusted association between prehospital fluid administration and hospital mortality among emergency medical services (EMS) patients admitted with severe sepsis.MethodsWe performed a prospective, observational study of patients hospitalized with severe sepsis on admission among 45,394 adult EMS encounters taken to 15 hospitals from 11/2009 to 12/2010 by a two-tier EMS system in King County, Washington. The region mandated recording of prehospital intravenous catheter and fluid administration in prehospital records, along with detailed demographic, incident, physiologic, and hospital adjustment variables. We determined the effect of prehospital intravenous catheter or fluid versus no catheter or fluid on all-cause mortality using multivariable logistic regression.ResultsOf all encounters, 1,350 met criteria for severe sepsis on admission, of whom 205 (15%) died by hospital discharge, 312 (23%) received prehospital intravenous fluid, 90 (7%) received a prehospital catheter alone and 948 (70%) did not receive catheter or fluid. EMS administered a median prehospital fluid volume of 500 mL (interquartile range (IQR): 200, 1000 mL). In adjusted models, the administration of any prehospital fluid was associated with reduced hospital mortality (Odds ratio =0.46; 95% Confidence interval: 0.23, 0.88; P =0.02) compared to no prehospital fluid. The odds of hospital mortality were also lower among severe sepsis patients treated with prehospital intravenous catheter alone (Odds ratio =0.3; 95% Confidence interval: 0.17 to 0.57; P <0.01).ConclusionsIn a population-based study, the administration of prehospital fluid and placement of intravenous access were associated with decreased odds of hospital mortality compared with no prehospital catheter or fluid.Electronic supplementary materialThe online version of this article (doi:10.1186/s13054-014-0533-x) contains supplementary material, which is available to authorized users.

EMS-STARS: Emergency Medical Services “Superuser” Transport Associations: An Adult Retrospective Study

Objective. Emergency medical services (EMS) "superusers" –those who use EMS services at extremely high rates –have not been well characterized. Recent interest in the small group of individuals who account for a disproportionate share of health-care expenditures has led to research on frequent users of emergency departments and other health services, but little research has been done regarding those who use EMS services. To inform policy and intervention implementation, we undertook a descriptive analysis of EMS superusers in a large urban community.In this paper we compare EMS superusers to low, moderate, and high users to characterize factors contributing to EMS use. We also estimate the financial impact of EMS superusers. Methods. We conducted a retrospective cross-sectional study based on 1 year of data from an urban EMS system. Data for all EMS encounters with patients age ≥18 years were extracted from electronic records generated on scene by paramedics. We identified demographic and clinical variables associated with levels of EMS use. EMS users were characterized by the annual number of EMS encounters: low (1), moderate (2–4), high (5–14), and superusers (≥15). In addition, we performed a financial analysis using San Francisco Fire Department (SFFD) 2009 charge and reimbursement data. Results. A total of 31,462 adults generated 43,559 EMS ambulance encounters, which resulted in 39,107 transports (a 90% transport rate). Encounters for general medical reasons were common among moderate and high users and less frequent among superusers and low users, while alcohol use was exponentially correlated with encounter frequency. Superusers were significantly younger than moderate EMS users, and more likely to be male. The superuser group created a significantly higher financial burden/person than any other group, comprising 0.3% of the study population, but over 6% of annual EMS charges and reimbursements. Conclusions. In this retrospective study, adult EMS "superusers" emerged as a distinct, predominantly male population and their EMS encounters were associated with alcohol use. Continued analysis of this unique, high-cost, and frequently transported population will likely illuminate specific intervention strategies.

The epidemiology and outcome of prehospital respiratory distress.

Patients with respiratory distress often seek emergency medical care and are transported by emergency medical services (EMS). EMS encounters with patients in respiratory distress have not been well described. The study objective was to characterize the epidemiology of prehospital respiratory distress and subsequent patient outcomes. This was a population-based cohort study of noninjured adults transported by EMS to any of 16 hospitals between 2002 and 2006. EMS records were linked to hospital administrative data for encounters categorized by EMS personnel as primarily "respiratory distress" in nature. The authors described prehospital patient and encounter characteristics, interventions, hospital discharge diagnoses (using ICD-9-CM codes), and patient outcomes. The association between prehospital variables, defined a priori, and hospital admission were described using multivariable logistic regression. There were 166,908 EMS encounters, of which 19,858 were for respiratory distress (11.9%, 95% confidence interval [CI] = 11.7% to 12.1%). Half of the patients were admitted to the hospital (n = 9,964), one-third of those required intensive care (n = 3,094), and 10% of hospitalized patients died prior to discharge (n = 948). Fifteen percent of hospitalized patients received invasive mechanical ventilation (n = 1,501), over half of whom were intubated during prehospital care (n = 896). The most common primary discharge diagnoses among prehospital respiratory distress patients admitted to the hospital were congestive heart failure (CHF; 16%), pneumonia (15%), chronic obstructive pulmonary disease (COPD; 13%), and acute respiratory failure (13%). Few EMS patients with respiratory distress were coded with a primary diagnosis of acute myocardial infarction (3.5%, n = 350) or underwent percutaneous coronary intervention (0.7%, n = 71). In a multivariable regression model, prehospital factors that were independently associated with hospital admission included initial respiratory rate (odds ratio [OR] = 1.29 for an increase in respiratory rate of five breaths/min, 95% CI = 1.24 to 1.35) and an encounter that originated at a nursing home (OR = 2.80, 95% CI = 2.28 to 3.43). In a population-based cohort, EMS personnel commonly encounter prehospital respiratory distress among medical patients, many of whom require hospital admission to the intensive care unit. These data may help to inform targeted therapy or more efficient triage and transport decisions.

Abstract 208: Emergency Medical Service Resuscitative Interventions in North-Central West Virginia Trauma Activation Criteria Patients: A Ten Year Experience

Introduction: West Virginia (WV) is the second most rural state, with 51.3% of the population living in a rural area and 97.3% of the land area considered rural by the US Census Bureau. West Virginia University (WVU) MedCom provides medical command for Emergency Medical Services (EMS) in 26 north-eastern WV counties. EMS transport times often exceed 20 minutes in rural counties. However, little is known about the specific provider capabilities and interventions that occur in the rural pre-hospital setting. Methods: This was a retrospective, observational review of EMS interventions for “trauma activation criteria patients” (based on CDC Field Triage Guidelines) in the WVU MedCom database. Trauma activation criteria EMS encounters from January 1, 2002 to December 31, 2011 were analyzed for EMS provider capability, receiving hospital capability, and pre-hospital resuscitative interventions. Results: There were 11,853 patients available for analysis in the time period. Basic Life Support (BLS) providers provided 21.0% of the care. The distribution of receiving Trauma Centers was as follows: 83.2% Level I, 4.7% Level II, 3.9% Level III, 5.0% Level IV; 3.2% were taken to a facility without trauma center designation. Airway intervention occurred in 7.5% of patients; 2.3% had endotracheal tube (ETT) placement (0.88% had failed ETT placement), 0.34% had King/Combi-tube placement, and 4.0% had positive pressure ventilation with bag valve mask. Vascular access was attempted in 78.7% of the patients; 73.0% had vascular access established (72.9% by IV and 0.08% by intra-osseous access) and 5.1% had an IV fluid bolus administered. CPR was performed on 1.0% of the patients and needle thoracostomy was performed on 0.32% of the patients. Discussion: In rural north-central WV, BLS responders provided the pre-hospital care to 1 in 5 patients. Although treatment at a Level I Trauma Center has been shown to decrease patient mortality by 25%, only 83.2% of trauma patients in rural north-central WV were initially treated at a Level I Trauma Center. Pre-hospital airway intervention was needed in 7.5% of patients. Vascular access was established in only 73.0%; 5.1% received a fluid bolus. Additional studies will be needed to assess the impact of these treatments on patient outcomes.

Severe Sepsis in Pre-Hospital Emergency Care

Severe sepsis is common and highly morbid, yet the epidemiology of severe sepsis at the frontier of the health care system-pre-hospital emergency care-is unknown. We examined the epidemiology of pre-hospital severe sepsis among emergency medical services (EMS) encounters, relative to acute myocardial infarction and stroke. Retrospective study using a community-based cohort of all nonarrest, nontrauma King County EMS encounters from 2000 to 2009 who were transported to a hospital. Overall incidence rate of hospitalization with severe sepsis among EMS encounters, as well as pre-hospital characteristics, admission diagnosis, and outcomes. Among 407,176 EMS encounters, we identified 13,249 hospitalizations for severe sepsis, of whom 2,596 died in the hospital (19.6%). The crude incidence rate of severe sepsis was 3.3 per 100 EMS encounters, greater than for acute myocardial infarction or stroke (2.3 per 100 and 2.2 per 100 EMS encounters, respectively). More than 40% of all severe sepsis hospitalizations arrived at the emergency department after EMS transport, and 80% of cases were diagnosed on admission. Pre-hospital care intervals, on average, exceeded 45 minutes for those hospitalized with severe sepsis. One-half or fewer of patients with severe sepsis were transported by paramedics (n = 7,114; 54%) or received pre-hospital intravenous access (n = 4,842; 37%). EMS personnel care for a substantial and increasing number of patients with severe sepsis, and spend considerable time on scene and during transport. Given the emphasis on rapid diagnosis and intervention for sepsis, the pre-hospital interval may represent an important opportunity for recognition and care of sepsis.

Effects of an Emergency Medical Services–based Resource Access Program on Frequent Users of Health Services

Background. A small group of adults disproportionately and ineffectively use acute services including emergency medical services (EMS) and emergency departments (EDs). The resulting episodic, uncoordinated care is of lower quality and higher cost and simultaneously consumes valuable public safety and acute care resources. Objective. To address this issue, we measured the impact of a pilot, EMS-based case management and referral intervention termed the San Diego Resource Access Program (RAP) to reduce EMS, ED, and inpatient (IP) visits. Methods. This was a historical cohort study of RAP records and billing data of EMS and one urban hospital for 51 individuals sequentially enrolled in the program. The study sample consisted of adults with ≥10 EMS transports within 12 months and others reported by prehospital personnel with significant recent increases in transports. Data were collected over a 31-month time period from December 2006 to June 2009. Data were collected for equal pre- and postenrollment time periods based on date of initial RAP contact, and comparisons were made using the Wilcoxon signed-rank test. Overall use for subjects is reported. Results. The majority of subjects were male (64.7%), homeless (58.8%), and 40 to 59 years of age (72.5%). Between the pre and post periods, EMS encounters declined 37.6% from 736 to 459 (p = 0.001), resulting in a 32.1% decrease in EMS charges from $689,743 to $468,394 (p = 0.004). The EMS task time and mileage decreased by 39.8% and 47.5%, respectively, accounting for 262 (p = 0.008) hours and 1,940 (p = 0.006) miles. The number of ED encounters at the one participating hospital declined 28.1% from 199 to 143, which correlated with a 12.7% decrease in charges from $413,410 to $360,779. The number of IP admissions declined by 9.1% from 33 to 30, corresponding to a 5.9% decrease in IP charges from $687,306 to $646,881. Hospital length of stay declined 27.9%, from 122 to 88 days. Across all services, total charges declined by $314,406. Conclusions. This pilot study demonstrated that an EMS-based case management and referral program was an effective means of decreasing EMS transports by frequent users, but had only a limited impact on use of hospital services.

A Statewide, Prehospital Emergency Medical Service Selective Patient Spine Immobilization Protocol

To evaluate the practices and outcomes associated with a statewide, emergency medical services (EMS) protocol for trauma patient spine assessment and selective patient immobilization. An EMS spine assessment protocol was instituted on July 1, 2002 for all EMS providers in the state of Maine. Spine immobilization decisions were prospectively collected with EMS encounter data. Prehospital patient data were linked to a statewide hospital database that included all patients treated for spine fracture during the 12-month period following the spine assessment protocol implementation. Incidence of spine fractures among EMS-assessed trauma patients and the correlation between EMS spine immobilization decisions and the presence of spine fractures-stable and unstable-were the primary investigational outcomes. There were 207,545 EMS encounters during the study period, including 31,885 transports to an emergency department for acute trauma-related illness. For this cohort, there were 12,988 (41%) patients transported with EMS spine immobilization. Linkage of EMS and hospital data revealed 154 acute spine fracture patients; 20 (13.0%) transported without EMS-reported spine immobilization interventions. This nonimmobilized group included 19 stable spine fractures and one unstable thoracic spine injury. The protocol sensitivity for immobilization of any acute spine fracture was 87.0% (95% confidence interval [CI], 81.7-92.3) with a negative predictive value of 99.9% (95% CI, 99.8-100). The use of this statewide EMS spine assessment protocol resulted in one nonimmobilized, unstable spine fracture patient in approximately 32,000 trauma encounters. Presence of the protocol affected a decision not to immobilize greater than half of all EMS-assessed trauma patients.

EMS Provider Findings andInterventions with a Statewide EMS Spine-Assessment Protocol

Objective. To describe the utilization andfindings with a statewide, prehospital spine-assessment protocol for emergency medical services (EMS) providers in a rural state. Methods. The study was a prospective sample of EMS patients evaluated by prehospital providers for trauma-related injury during a one-year investigation period. Prehospital providers prospectively completed supplementary spine data-collection forms that reported patient demographics andEMS provider findings with the spine-assessment protocol. Data were analyzed using descriptive statistics. Results. There were 207,545 EMS encounters during the study period, including 31,885 transports for acute trauma-related illness. Prehospital providers provided spine-assessment forms for 2,220 patient encounters. Providers reported a decision to immobilize 1,301 (59%) patients. For these immobilized patients, spine protocol findings included 416 (32%) patients deemed as unreliable, 358 (28%) with distracting injury, 80 (6%) with an abnormal neurologic examination, and709 (54%) with spine pain or tenderness. Linkage of EMS andhospital data revealed seven acute spine fracture patients among the 2,220 reported encounters, all of whom were immobilized by EMS providers. Conclusions. Use of this prehospital spine-assessment protocol resulted in an EMS provider decision not to immobilize approximately 40% of EMS trauma patients. Few spine fracture patients were encountered during the investigational period, though all were immobilized.

Suspected opioid-related emergency medical services encounters in a rural state, 1997–2002

Introduction News organizations and governmental agencies have reported substantial increases in the number of opioid-related overdose cases in recent years. Objective To describe the utilization of emergency medical services (EMS) for suspected opioid-related overdose cases in a rural state during the period 1997 through 2002. Methods Statewide EMS records were reviewed for 1997 through 2002. Data reviewed included prehospital diagnosis and medications given to all patients by prehospital providers. For cases with a prehospital diagnosis of poisoning or overdose, data reviewed included medications given to patients by prehospital providers, pupil size, and respiratory rate. All records were reviewed in a defined sequence. Results The study period encompassed 1,175,781 patient encounters. Poisoning or overdose patients accounted for 19,808 (1.7%) encounters. Naloxone was administered by the EMS provider to 2,668 (0.2%) patients. For all poisoning or overdose patients, 1,308 (6.6%) had miotic pupils, 450 (2.2%) had a respiratory rate of <12 breaths/min, and 1,569 (7.9%) received naloxone. During the investigation period, total EMS patient encounters increased 25%, while patients with a complaint of poisoning or overdose increased 47%. The incidences of EMS overdose patients with miotic pupils, respiratory rate <10 breaths/min, and naloxone administration increased 167%, 295%, and 154%, respectively. Conclusion In this rural state, prehospital patients with findings suspicious for opioid overdose disproportionately outpaced the growth of all EMS encounters as well as general overdose encounters during the defined investigation period.

SUSPECTED OPIOID-RELATED EMERGENCY MEDICAL SERVICES ENCOUNTERS IN A RURAL STATE, 1997–2002

Introduction. News organizations and governmental agencies have reported substantial increases in the number of opioid-related overdose cases in recent years. Objective. To describe the utilization of emergency medical services (EMS) for suspected opioid-related overdose cases in a rural state during the period 1997 through 2002. Methods. Statewide EMS records were reviewed for 1997 through 2002. Data reviewed included prehospital diagnosis and medications given to all patients by prehospital providers. For cases with a prehospital diagnosis of poisoning or overdose, data reviewed included medications given to patients by prehospital providers, pupil size, and respiratory rate. All records were reviewed in a defined sequence. Results. The study period encompassed 1,175,781 patient encounters. Poisoning or overdose patients accounted for 19,808 (1.7%) encounters. Naloxone was administered by the EMS provider to 2,668 (0.2%) patients. For all poisoning or overdose patients, 1,308 (6.6%) had miotic pupils, 450 (2.2%) had a respiratory rate of <12 breaths/min, and 1,569 (7.9%) received naloxone. During the investigation period, total EMS patient encounters increased 25%, while patients with a complaint of poisoning or overdose increased 47%. The incidences of EMS overdose patients with miotic pupils, respiratory rate <10 breaths/min, and naloxone administration increased 167%, 295%, and 154%, respectively. Conclusion. In this rural state, prehospital patients with findings suspicious for opioid overdose disproportionately outpaced the growth of all EMS encounters as well as general overdose encounters during the defined investigation period.

A N E MERGENCY M EDICAL S ERVICES P ROGRAM OF A LTERNATE D ESTINATION OF P ATIENT C ARE

Objective: The emergency department (ED) is ideally reserved for urgent health needs. The ED, however, is often the site of care for nonurgent conditions. The authors investigated whether emergency medical technicians could decrease ED use by patients with nonurgent concerns who use 911 by appropriately identifying and triaging them to alternate care destinations. Methods: From August 2000 through January 2001, two King County fire-based emergency medical services (EMS) agencies participated in an alternate care destination program for patients with specific low-acuity diagnosis codes (intervention group). Eligible patients were offered care at a clinic-based destination as an alternate to the ED (n = 1,016). The frequency of the destination of care (ED, clinic, or home) for the intervention group was compared with a matched control group that was comprised of a preintervention historical cohort of EMS encounters from the same two fire-based agencies and with the same acuity and diagnosis criteria and seasonal interval (n = 2,617). Results: Compared with the preintervention group, a smaller proportion of patients in the intervention group received care in the ED (44.6% vs. 51.8%, p = 0.001), while a greater proportion of patients in the intervention group received clinic care (8.0% vs. 4.5%, p = 0.001) or home care (no transport) (47.4 vs. 43.7%, p = 0.043). Results were comparable when adjusted for other patient characteristics. Similar relationships were not evident among nonparticipating King County EMS agencies. Based on physician review and patient interview, the alternate care intervention appeared to be safe and satisfactory. Conclusion: An EMS-based program may represent one approach to limiting nonurgent ED use.