Emergency Medical Services Interventions Research Articles

Patient Safety in Emergency Medical Services: A Systematic Review of the Literature

Background. Preventable harm from medical care has been extensively documented in the inpatient setting. Emergency medical services (EMS) providers care for patients in dynamic and challenging environments; prehospital emergency care is a field that represents an area of high risk for errors and harm, but has received relatively little attention in the patient safety literature. Objective. To identify the threats to patient safety unique to the EMS environment and interventions that mitigate those threats, we completed a systematic review of the literature. Methods. We searched MEDLINE, EMBASE, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) for combinations of key EMS and patient safety terms composed by a pan-canadian expert panel using a year limit of 1999 to 2011. We excluded commentaries, opinions, letters, abstracts, and non-english publications. Two investigators performed an independent hierarchical screening of titles, abstracts, and full-text articles blinded to source. We used the kappa statistic to examine interrater agreement. Any differences were resolved by consensus. Results. We retrieved 5,959 titles, and 88 publications met the inclusion criteria and were categorized into seven themes: adverse events and medication errors (22 articles), clinical judgment (13), communication (6), ground vehicle safety (9), aircraft safety (6), interfacility transport (16), and intubation (16). Two articles were randomized controlled trials; the remainder were systematic reviews, prospective observational studies, retrospective database/chart reviews, qualitative interviews, or surveys. The kappa statistics for titles, abstracts, and full-text articles were 0.65, 0.79, and 0.87, respectively, for the first search and 0.60, 0.74, and 0.85 for the second. Conclusions. We found a paucity of scientific literature exploring patient safety in EMS. Research is needed to improve our understanding of problem magnitude and threats to patient safety and to guide interventions. Key words: emergency medical services; ambulance; prehospital; patient safety; medication error; adverse event; systematic review

First responder performance in pediatric trauma: A comparison with an adult cohort*

Is the prehospital care of injured children comparable with adult standards? This question has been asked repeatedly by many clinicians, yet there are no definite answers. To evaluate the prehospital care provided by first responders to pediatric patients (<12 yrs of age) with head injury compared with the adult group (>12 yrs of age) to determine whether the emergency medical services providers are able to adequately assess the children and provide emergency services comparable with adult standards. A retrospective 4-yr review of pediatric (n = 102) and adult (n = 99) patients with head injury and Glasgow coma scale score <15 who were treated at a level 1 trauma center. Emergency medical service interventions such as intravenous access, endotracheal intubation, and fluid resuscitation were reviewed. Patients who required further intervention on arrival at the trauma center either from nonperformance of a required procedure or complications arising from such procedures were documented. There were 102 pediatric and 99 adult patients included in the final analysis. Injury severity based on Glasgow coma scale score was not different between the groups. A total of 91 patients, 52 adults (52.5%) and 39 children (38.2%), needed endotracheal intubation at the scene. Significantly more pediatric patients had problems with intubation, 27 children (69.2%) vs. 11 adults (21.2%), p < .001.Intravenous access was successfully established in 85.9% of adults compared to 65.7% in children at the scene (p = .001). Consequently, on arrival at the trauma center, more children required intravenous access, 80.4% compared with 63.6% for adults (p = .011). As a result, more children (25.5%) required initial or additional fluid bolus at the trauma center compared with adults (9.1%, p = .003). Prehospital care of children is suboptimal compared with adults in areas of endotracheal intubation, establishment of peripheral intravenous access, and fluid resuscitation.

Have We Killed the Golden Hour of Trauma?

Have We Killed the Golden Hour of Trauma?

Glasgow coma scale in acute poisonings before and after use of antidote in patients with history of use of psychotropic agents

Data on emergency interventions in poisonings are scarce. Objective To determine the effectiveness of antidote therapy in acute poisoning-related emergency medical services (EMS) interventions. A prospective observational study included all poisoning-related intervention cases over 3 years (1999-2001) in the Celje region, Slovenia, covering 125,000 inhabitants. Data were recorded on an EMS form. Psychoactive agents were present in 56.5% out of 244 poisoning-related EMS interventions. Prescription drugs were a cause of intoxication in 93 (39.2%) cases alone or in combination with alcohol or illegal drugs. More than one fifth of poisonings were due to the use of illegal drugs in 52 (21.9%) cases, 43 (18.1%) out of them heroin related. At the time of EMS arrival, more patients who ingested illegal drugs were in coma or comatose than the rest. 24 (45.3%) vs. 32 (17.3%) of poisoned patients were in coma (p < 0.001). Glasgow Coma Scale (GCS) at the first contact was lower in patients who ingested illegal drugs than in the remaining patients (9.0 vs. 11.6, p = 0.001). In 23.2% of the cases, an antidote was administered. In 29 (12.2%) naloxone and in 16 (6.7%) flumazenil was administered. Mean GCS after intervention was higher in all cases but significantly higher in illegal drug cases, 13.4 vs. 12.2 (p = 0.001), with a mean positive change in GCS of 4.5 vs. 0.6 (p < 0.001). In illegal drug users, mean change after antidote administration was 8.2 vs. 0.5 without antidote administration (p < 0.001). High rate of successful antidote use during the intervention indicated the importance of good EMS protocols and the presence of a skilled doctor in the EMS team.

Aetiological and demographical characteristics of acute poisoning in the Celje region, Slovenia

Data on emergency treatment of poisonings are scarce. To determine the annual rate of poisoning-related emergency medical services (EMS) interventions and to determine the aetiology and demographic characteristics of poisoning cases. A prospective observational study included all poisoning-related intervention cases over 3 years (1999-2001) in the Celje region, Slovenia, covering 125 000 inhabitants. Data were recorded on an EMS form. Two hundred and forty-four poisoning-related EMS interventions were recorded among a total of 4486 interventions (5.4%) corresponding to an average annual rate of 0.56 poisonings per 1000 inhabitants per year. Psychoactive agents were detected in 56.5% of the cases. Two-thirds of the poisonings took place outside patients' home. In 30% of the cases, the administration of poison was because of suicidal intentions. The most common substance ingested was alcohol alone or in combination with prescription or illegal drugs in 42.6% of cases, followed by drugs alone or in combination with alcohol in 39.2% cases. More than one-fifth of the poisonings were because of the use of illegal drugs. At the time of the arrival of EMS 23.5% of the patients were in coma. EMS applied antidote in 23.2% of the patients. After emergency care, 9.3% of the patients were still in coma, 15.6% were comatose, 26.6% were somnolent, 18.6% were disoriented and 30% had complete consciousness. Of these, 84.4% of the patients were admitted to hospital or specialized care and 15.6% were sent back home. The pattern of poisoning is contrasted with that in other countries. The EMS proved to be a valuable resource for treatment of acute poisoning.

Emergency Medical Services-Based Community Stroke Education

Although previous studies using mass media have demonstrated successful public stroke awareness campaigns, they may have been too costly for smaller communities to implement. The goal of this study was to investigate if a novel emergency medical services (EMS) -sponsored community awareness campaign could increase public stroke awareness. This was a pre- and postintervention study with 2 phases conducted between August 2005 and July 2007. During Phase I, strategic placement of stroke education media by EMS personnel was implemented in one county over a 2-year period. Five random-digit, standardized phone surveys measuring stroke awareness were conducted with county residents to assess the campaign's impact. In Phase II, EMS interventions and random-digit measurements were conducted in 4 additional counties with 4 counties randomly selected as controls. A pattern of increasing stroke knowledge after exposure to the EMS intervention followed by declines in the absence of the intervention was observed during Phase I. EMS interventions also demonstrated a positive effect on the stroke knowledge of residents who lived in counties exposed to the intervention during Phase II with a statistically significant (P<0.05) increase observed in the proportion of respondents that named 2 stroke risk factors and 3 symptoms in comparison to either no changes or declines in the control counties. No evidence of a positive impact on knowledge of calling 911 for stroke was observed. Results of this study suggest that the public's knowledge of stroke signs and symptoms was increased using communitywide EMS-based programs. Additional studies are needed to determine optimal methods for educating the public regarding the need to call 911 for stroke and to confirm these results in other locales.

The Resuscitation Outcomes Consortium Epistry-Trauma: Design, development, and implementation of a North American Epidemiologic Prehospital Trauma Registry

Injury is a major public health problem generating substantial morbidity, mortality, and economic burden on society. The majority of seriously injured persons are initially evaluated and cared for by prehospital providers, however the effect of emergency medical services (EMS) systems, EMS clinical care, and EMS interventions on trauma patient outcomes is largely unknown. Outcome-based information to guide future EMS care has been hampered by the lack of comprehensive, standardized, multi-center prehospital data resources that include meaningful patient outcomes. In this paper, we describe the background, design, development, implementation, content, and potential uses of the first North American comprehensive epidemiologic prehospital data registry for injured persons. This data registry samples patients from 264 EMS agencies transporting to 287 acute care hospitals in both the United States and Canada.

Evidence-Based Performance Measures for Emergency Medical Services Systems: A Model for Expanded EMS Benchmarking

There are few evidence-based measures of emergency medical services (EMS) system performance. In many jurisdictions, response-time intervals for advanced life support units andresuscitation rates for victims of cardiac arrest are the primary measures of EMS system performance. The association of the former with patient outcomes is not supported explicitly by the medical literature, while the latter focuses on a very small proportion of the EMS patient population andthus does not represent a sufficiently broad selection of patients. While these metrics have their place in performance measurement, a more robust method to measure andbenchmark EMS performance is needed. The 2007 U.S. Metropolitan Municipalties' EMS Medical Directors' Consortium has developed the following model that encompasses a broader range of clinical situations, including myocardial infarction, pulmonary edema, bronchospasm, status epilepticus, andtrauma. Where possible, the benefit conferred by EMS interventions is presented in the number needed to treat format. It is hoped that utilization of this model will serve to improve EMS system design anddeployment strategies while enhancing the benchmarking andsharing of best practices among EMS systems.

Prehospital neurologic deterioration in patients with intracerebral hemorrhage

Early neurologic deterioration has been studied in patients with intracerebral hemorrhage during hospitalization, but rates and factors associated with prehospital neurologic deterioration (PND) are unknown. We sought to determine the prevalence of PND among patients with intracerebral hemorrhage during Emergency Medical Services transportation to the hospital. Historical cohort study. U.S. acute care hospital from 2000 to 2004. Hospitalized patients with a diagnosis of spontaneous intracerebral hemorrhage were identified by codes of the International Statistical Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). The initial Glasgow Coma Scale score ascertained at the scene by the Emergency Medical Services was compared with the subsequent evaluation in the emergency department to identify neurologic deterioration (defined as a decrease in Glasgow Coma Scale of > or = 2 points). None. Of the 98 patients with acute intracerebral hemorrhage, 22 patients (22%) showed PND during Emergency Medical Services transport, with a mean decrease in the Glasgow Coma Scale score during transport of 6 points. The patients who demonstrated neurologic deterioration tended to have higher diastolic blood pressure at the scene (p = .045), greater rates of intraventricular extension (p < .0001), and radiologic signs of herniation (p < .0001) on initial computed tomographic scan. There was a statistically significant decrease in diastolic blood pressure between the evaluations of the Emergency Medical Services and the emergency department among both patients with and without PND. PND occurs in nearly one fifth of patients with intracerebral hemorrhage. Higher diastolic blood pressure at the scene, intraventricular extension, and radiologically evident herniation seem to be associated with PND. Prospective studies are needed to evaluate the efficacy of Emergency Medical Services interventions to reduce this early clinical deterioration.

Reasons Why Patients Choose an Ambulance and Willingness to Consider Alternatives

To test a hypothesis that patients would accept alternatives to transport to an emergency department (ED) by ambulance and to evaluate factors related to patient willingness to consider alternatives. Concerns about resource utilization have prompted emergency medical services (EMS) systems to explore alternatives to ambulance transport to an ED, but studies have evaluated the safety of alternatives, not patient preferences. Trained research assistants surveyed patients transported by ambulance to a university ED. Interfacility transfers, trauma patients, and critically ill patients were excluded. The primary outcome was willingness to accept one of several presented alternatives to ambulance transport to the ED for that visit. Demographic and clinical factors were evaluated for association with willingness to consider alternatives. Relative risks (RR) and 95% confidence intervals (95% CI) were determined by using Mantel-Haenszel stratified methods. Three hundred fifteen subjects completed the survey. Two hundred forty-seven (78.4%) were willing to consider at least one alternative. One hundred ninety-four (61.6%) were willing to consider transportation by car, and 177 (56.2%) were willing to consider transportation by taxi. Factors associated with willingness to consider alternatives included the following: age 18-65 years (RR, 1.25; 95% CI = 1.03 to 1.49), being unemployed (RR, 1.08; 95% CI = 1.08 to 1.33), use of the ED for routine care (RR, 1.25; 95% CI = 1.17 to 1.35), and not being admitted to the hospital (RR, 1.19; 95% CI = 1.04 to 1.40). Race, gender, health insurance status, and EMS interventions en route were not associated with willingness to consider transportation alternatives. Many patients transported by ambulance to an ED would have considered an alternative, if one were offered.

Reasons Why Patients Choose an Ambulance and Willingness to Consider Alternatives

Objectives: To test a hypothesis that patients would accept alternatives to transport to an emergency department (ED) by ambulance and to evaluate factors related to patient willingness to consider alternatives. Concerns about resource utilization have prompted emergency medical services (EMS) systems to explore alternatives to ambulance transport to an ED, but studies have evaluated the safety of alternatives, not patient preferences. Methods: Trained research assistants surveyed patients transported by ambulance to a university ED. Interfacility transfers, trauma patients, and critically ill patients were excluded. The primary outcome was willingness to accept one of several presented alternatives to ambulance transport to the ED for that visit. Demographic and clinical factors were evaluated for association with willingness to consider alternatives. Relative risks (RR) and 95% confidence intervals (95% CI) were determined by using Mantel-Haenszel stratified methods. Results: Three hundred fifteen subjects completed the survey. Two hundred forty-seven (78.4%) were willing to consider at least one alternative. One hundred ninety-four (61.6%) were willing to consider transportation by car, and 177 (56.2%) were willing to consider transportation by taxi. Factors associated with willingness to consider alternatives included the following: age 18–65 years (RR, 1.25; 95% CI = 1.03 to 1.49), being unemployed (RR, 1.08; 95% CI = 1.08 to 1.33), use of the ED for routine care (RR, 1.25; 95% CI = 1.17 to 1.35), and not being admitted to the hospital (RR, 1.19; 95% CI = 1.04 to 1.40). Race, gender, health insurance status, and EMS interventions en route were not associated with willingness to consider transportation alternatives. Conclusions: Many patients transported by ambulance to an ED would have considered an alternative, if one were offered.

Inadequate hemodynamic management in patients undergoing interfacility transfer for suspected aortic dissection

The study goal was the analysis of effectiveness of hemodynamic management of patients undergoing interfacility transport for suspected acute aortic dissection (SAAD). Our retrospective, consecutive-case review examined 62 nonhypotensive patients transported by an air emergency medical services (EMS) service during 1998 to 2002, with referral hospital diagnosis of SAAD. Of patients with systolic blood pressure (SBP) less than 120 upon air EMS arrival, antihypertensives had been given in only 23/42 (54.8%). In 19 cases where pretransport SBP is less than 120, with no referral hospital antihypertensive therapy given, median pretransport SBP was 158 (range, 122-212). In 20/62 cases (32.3%), the air EMS agency instituted antihypertensive therapy, which was successful; of 42 cases with pretransport SBP less than 120, mean intratransport SBP decrement was 24 (95% confidence interval, 16-32). In patients undergoing transport for SAAD, pretransport hemodynamic therapy was frequently omitted and often inadequate, generating an opportunity for air EMS intervention. Education to improve SAAD care should focus upon both referral hospitals and transport services.

Prehospital EMS Treatment of Pediatric Asthma and What Happens Before Help Arrives?

Many asthmatic children require assistance by emergency medical services (EMS) secondary to an acute asthma episode. What medication interventions are being utilized by EMS when responding to an asthma call for a child, and how does EMS management compare to home management given before ambulance arrival (pre-EMS)? Sixty-one ambulance reports pertaining to acute asthma episodes in children aged 1 month to 15 years were collected and analyzed. There was no significant difference between likelihood to receive a beta2-agonist nebulizer treatment pre-EMS arrival or by EMS. Oxygen was the most common EMS intervention.