Emergency Medical Services Transport Research Articles

Assessment of the Safety and Effectiveness of Emergency Department STEMI Bypass by Defibrillation-only Emergency Medical Technicians/Primary Care Paramedics

Introduction. The American Heart Association (AHA) suggests emergency medical service (EMS) providers transporting ST-segment elevation myocardial infarction (STEMI) patients to a percutaneous coronary intervention (PCI) center require advanced life support (ALS) skills. Objectives. To evaluate the potential safety and time savings effectiveness of defibrillation-only emergency medical technician/primary care paramedic (EMT-D/PCP) EMS transport to a PCI center in a system where only emergency medical technician-paramedics/advanced care paramedics (EMT-Ps/ACPs) are authorized to bypass non-PCI hospitals. Methods. We reviewed 89 consecutive patients meeting STEMI criteria transported by EMT-Ds/PCPs per protocol by one of three paths: 1) closest non-PCI center emergency department (ED) with secondary transfer by EMT-Ps/ACPs to a PCI lab, 2) rendezvous with EMT-Ps/ACPs and diversion to a PCI lab, and 3) PCI center ED if it was closest. Actual transport times to the PCI center ED were compared to predicted transport times determined by mapping software had EMT-Ds/PCPs followed a direct path. Lastly, we recorded predefined clinically important events and advanced care interventions. Results. Twenty-seven, 51, and 11 patients followed paths 1, 2, and 3 respectively. Median transport times for path 1 were 6 (IQR 5) minutes to reach the nearest non-PCI center ED and 66 (IQR 45) minutes to the PCI center ED compared to a median predicted 13 (IQR 7) minutes to a PCI center ED had EMT-Ds/PCPs followed a direct path. Median transport time for path 2 was 12 (IQR 8) minutes compared to a median predicted time of 11 (IQR 6) minutes had no EMT-P/ACP rendezvous occurred. Median transport time for path 3 was 7 minutes (IQR 5). Three patients experienced prehospital cardiac arrest; 1 required dopamine, and 4 others received a saline bolus for hypotension. Conclusions. Substantial time savings may occur if EMT-Ds/PCPs bypass non-PCI center EDs with only a small predicted increase (about 7 minutes) in the transport time to the PCI center ED. EMT-P/ACP rendezvous does not appear to substantially increase transport time. Given the relatively low occurrence of clinically important events, our findings suggest that EMT-D/PCP bypass to a PCI center ED may be safe and effective for selected STEMI patients.

Septic patients arriving with emergency medical services

Sepsis is a serious condition with high mortality. Early treatment improves outcome and can be initiated by emergency medical services (EMS) personnel.The primary aim of our study was to investigate how many sepsis patients are transported by EMS to the internist at the emergency department (ED). The secondary aims were to compare these EMS patients with patients who arrived at the ED otherwise and to investigate how these patients were managed. We further investigated how often the diagnosis sepsis/infection was documented by EMS. We retrospectively retrieved all ED and EMS data of patients with sepsis who were assessed by the internist between March 2011 and March 2012. Half (48.0%) of 654 sepsis patients were transported by EMS. These patients were more seriously ill (more severe grades of sepsis, more admittances to the hospital/ICU) than patients who were transported otherwise. Mortality within 28 days was 19.4% compared with 6.5% in the other patients. Nevertheless, half of the EMS transports were considered not urgent, even in 34.6% of the patients with septic shock. Assessment of vital signs was not routinely performed and treatment was started in only 43.6%. The diagnosis sepsis/infection was documented in 63.4% of patients. Half of the patients with sepsis arrive at the ED by EMS. These patients are seriously ill, and although these patients are likely to benefit from early treatment, they are often transported with nonurgent rides and both assessment of vital signs and early start of treatment are not routinely performed.

142 Emergency Medical Services, Injury, and Illness at the 2013 Boy Scout Jamboree

The 2013 Boy Scouts of America (BSA) National Jamboree attracted 36,261 youth, staff, and volunteers to 11,000 acres of West Virginia, a new permanent home for the BSA. All attendees camped and participated in events including mountain biking, BMX biking, skateboarding, climbing and other activities. The environment, length of event and the fact that all attendees were participants makes the Jamboree a unique challenge for Emergency Medical Services (EMS). The EMS plan involved a coordinated effort by BSA volunteers, US military, and private local EMS and air medical providers. A licensed EMS provider was established for the site: Summit EMS. State regulations were established to allow ambulance transport to temporary on-site medical facilities and to allow volunteers to practice in West Virginia. Non emergent transport capability was also provided. There were 13 Jamboree medical facilities, 2 with X-ray capability. To quantify the volume, chief complaint and destination of EMS transports at the 2013 BSA Jamboree and gain an understanding of illness and injury patterns for future events. A unified dispatch system was used to manage and track EMS resources. A combination of paper patient care reports (for military and volunteer units) and electronic run reports (for private EMS) were used. All reports were scanned into the Jamboree medical record system and a data registry was created. During 12 days of activity on the site there were 883 emergency medical services transports. Private, locally based EMS handled all off-site transports. There were 757 on site transports, 148 were by BSA EMS utility vehicle (UTV), 483 were by military field litter ambulance (FLA), 126 were by private EMS provider. There were 121 patients transported off site by ground to local hospitals. and 5 patients were transported to an on-site landing zone for helicopter transport to hospital facilities. 468 transports were related to injuries (238 extremity injuries, 230 injuries to other site), 415 transports were for medical complaints (150 heat related, 21 suspected cardiac complaints, 244 assorted medical complaints and 1 cardiac arrest). There were 347 non-emergent patients transported by van. Coordination of services between private, military and volunteer services permitted all areas to be covered with multiple possible transport methods depending on the nature and severity of complaints. There were a large percentage of non-emergent transports likely due to the terrain and geography of the site. A change in regulations permitted ambulance resources to be available for onsite and off-site transports, making more effective use of available resources and limiting the number of transports to local hospitals. There were a large number of heat-related complaints, the role and effectiveness of prevention strategies should be examined. A review of injury prevention methods should also be reviewed.

When birds can't fly: an analysis of interfacility ground transport using advanced life support when helicopter emergency medical service is unavailable.

Helicopter emergency medical service (HEMS) transport of trauma patients is costly and of unproven benefit. Recent retrospective studies fail to control for crew expertise and therefore compare highly trained advance life support with less-trained basic life support crews. The purpose of our study was to compare HEMS with ground, interfacility transport while controlling for crew training. We hypothesized that patients transported by HEMS would experience shorter interhospital transport time and reduced mortality. Our National Trauma Registry of the American College of Surgeons database was retrospectively queried to identify consecutive interfacility, hospital transfers (January 1, 2008, to November 1, 2012) to our Level I trauma center. Transfers were stratified by transportation vehicle (i.e., HEMS vs. ground transport). Cohorts were compared across standard demographic and clinical variables using univariate analysis. Multivariate logistic regression was performed to determine the association of these variables with mortality. The HEMS (n = 2,190) and ground (n = 223) cohorts were well matched overall, with no significant differences for demographics, injury severity, physiology, hospital length of stay, or complications. Median (interquartile range) time to definitive care was significantly lower for HEMS (150 [114] minutes vs. 255 [157] minutes, p < 0.001), without change in mortality (9.0% vs. 8.1%, p = 0.71). Multivariate logistic regression did not identify an association between transport mode and mortality. Despite faster interfacility transport times, HEMS offered no mortality benefit compared with ground when crew expertise was controlled for, contradicting recent large, retrospective National Trauma Data Bank studies. Our study may represent the best approximation of a prospective study by focusing on patients deemed worthy of HEMS by referring providers. Although HEMS may seem intuitively beneficial for time-dependent injuries, larger studies with a similar methodology are warranted to justify the cost and risk of HEMS and identify subsets of patients who may benefit. Prognostic/epidemiologic study, level III.

Statewide Regionalization of Postarrest Care for Out-of-Hospital Cardiac Arrest: Association With Survival and Neurologic Outcome

For out-of-hospital cardiac arrest, authoritative, evidence-based recommendations have been made for regionalization of postarrest care. However, system-wide implementation of these guidelines has not been evaluated. Our hypothesis is that statewide regionalization of postarrest interventions, combined with emergency medical services (EMS) triage bypass, is associated with improved survival and neurologic outcome. This was a prospective before-after observational study comparing patients admitted to cardiac receiving centers before implementation of the interventions ("before") versus those admitted after ("after"). In December 2007, the Arizona Department of Health Services began officially recognizing cardiac receiving centers according to commitment to provide specified postarrest care. Subsequently, the State EMS Council approved protocols allowing preferential EMS transport to these centers. Participants were adults (≥ 18 years) experiencing out-of-hospital cardiac arrest of presumed cardiac cause who were transported to a cardiac receiving center. Interventions included (1) implementation of postarrest care at cardiac receiving centers focusing on provision of therapeutic hypothermia and coronary angiography or percutaneous coronary interventions (catheterization/PCI); and (2) implementation of EMS bypass triage protocols. Main outcomes included discharged alive from the hospital and cerebral performance category score at discharge. During the study (December 1, 2007, to December 31, 2010), 31 hospitals were recognized as cardiac receiving centers statewide. Four hundred forty patients were transported to cardiac receiving centers before and 1,737 after. Provision of therapeutic hypothermia among patients with return of spontaneous circulation increased from 0% (before: 0/145; 95% confidence interval [CI] 0% to 2.5%) to 44.0% (after: 300/682; 95% CI 40.2, 47.8). The post return of spontaneous circulation catheterization PCI rate increased from 11.7% (17/145; 95% CI 7.0, 18.1) before to 30.7% (210/684; 95% CI 27.3, 34.3) after. All-rhythm survival increased from 8.9% (39/440) to 14.4% (250/1,734; adjusted odds ratio [aOR] = 2.22; 95% CI 1.47 to 3.34). Survival with favorable neurologic outcome (cerebral performance category score = 1 or 2) increased from 5.9% (26/439) to 8.9% (153/1,727; aOR = 2.26 [95% CI 1.37, 3.73]). For witnessed shockable rhythms, survival increased from 21.4% (21/98) to 39.2% (115/293; aOR = 2.96 [95% CI 1.63, 5.38]) and cerebral performance category score = 1 or 2 increased from 19.4% (19/98) to 29.8% (87/292; aOR = 2.12 [95% CI 1.14, 3.93]). Implementation of a statewide system of cardiac receiving centers and EMS bypass was independently associated with increased overall survival and favorable neurologic outcome. In addition, these outcomes improved among patients with witnessed shockable rhythms.

3 Echo: concept of operations for early care and evacuation of victims of mass violence.

This report describes the successful use of a simple 3-phase approach that guides the initial 30 minutes of a response to blast and active shooter events with casualties: Enter, Evaluate, and Evacuate (3 Echo) in a mass-shooting event occurring in Minneapolis, Minnesota USA, on September 27, 2012. Early coordination between law enforcement (LE) and rescue was emphasized, including establishment of unified command, a common operating picture, determination of evacuation corridors, swift victim evaluation, basic treatment, and rapid evacuation utilizing an approach developed collaboratively over the four years prior to the event. Field implementation of 3 Echo requires multi-disciplinary (Emergency Medical Services (EMS), fire and LE) training to optimize performance. This report details the mass-shooting event, the framework created to support the response, and also describes important aspects of the concepts of operation and curriculum evolved through years of collaboration between multiple disciplines to arrive at unprecedented EMS transport times in response to the event.

Increased mortality associated with EMS transport of gunshot wound victims when compared to private vehicle transport

BackgroundRecent studies suggest that mode of transport affects survival in penetrating trauma patients. We hypothesised that there is wide variation in transport mode for patients with gunshot wounds (GSW) and there may be a mortality difference for GSW patients transported by emergency medical services (EMS) vs. private vehicle (PV). Study designWe studied adult (≥16 years) GSW patients in the National Trauma Data Bank (2007–2010). Level 1 and 2 trauma centres (TC) receiving ≥50 GSW patients per year were included. Proportions of patients arriving by each transport mode for each TC were examined. In-hospital mortality was compared between the two groups, PV and EMS, using multivariable regression analyses. Models were adjusted for patient demographics, injury severity, and were adjusted for clustering by facility. Results74,187 GSW patients were treated at 182 TCs. The majority (76%) were transported by EMS while 12.6% were transported by PV. By individual TC, the proportion of patients transported by each category varied widely: EMS (median 78%, interquartile range (IQR) 66–85%), PV (median 11%, IQR 7–17%), or others (median 7%, IQR 2–18%). Unadjusted mortality was significantly different between PV and EMS (2.1% vs. 9.7%, p<0.001). Multivariable analysis demonstrated that EMS transported patients had a greater than twofold odds of dying when compared to PV (OR=2.0, 95% CI 1.73–2.35). ConclusionsWide variation exists in transport mode for GSW patients across the United States. Mortality may be higher for GSW patients transported by EMS when compared to private vehicle transport. Further studies should be performed to examine this question.

Pediatric Prehospital Pain Management: Impact of Advocacy and Research

Painful conditions are a common cause for emergency medical services transport. Adequate and appropriate treatment for pain in the prehospital setting is considered an essential part of care. Despite this, several studies have identified that pain in the prehospital setting is often undertreated with even greater disparities in the pediatric population. As a result, several organizations have written policy statements surrounding this issue advocating for better treatment of pain and further research into barriers and disparities in care. The aim of this article is to review the current state of prehospital pain management in children and adolescents and to highlight advances made in this area with a look toward future directions of care.

Effects of emergency medical service transport on acute stroke care

Since early treatment of acute stroke is associated with an improved outcome, emergency medical service (EMS) transport of stroke patients is recommended. It remains unclear, however, whether EMS transport leads to faster treatment. The impact of the transport mode on pre- and in-hospital processes of care was therefore investigated. The present study was based on a prospective database of 158 hospitals of the Stroke Register of Northwestern Germany, which included 162,511 stroke patients admitted between January 2010 and December 2011. Main outcome measures were the baseline characteristics associated with EMS transport and process-of-care indicators according to the transport mode. Overall, 101,850 (72.0%) patients were transported by EMS and 39,324 (28.0%) by self-transport. The baseline characteristics showing the strongest associations with EMS use were the care situation [institutional care, adjusted odds ratio (OR) 7.81; 95% CI 6.86-8.90], a disturbed level of consciousness (adjusted OR 3.00; 95% CI 2.59-3.48) and having a subarachnoid (adjusted OR 2.79; 95% CI 2.24-3.49) or intracerebral hemorrhage (adjusted OR 2.26; 95% CI 1.92-2.67). For self-transport patients the probability of being in a higher onset-to-door time category was 4.36 (95% CI 4.26-4.47) and the probability of being in a higher door-to-imaging time category was 1.32 (95% CI 1.28-1.36). Compared with self-transport, EMS transport was independently associated with thrombolysis (adjusted OR 1.95, 95% CI 1.77-2.15). Patient transport with EMS was independently associated with faster hospital arrival and shorter time periods from hospital admission to brain imaging and to the frequency of thrombolysis.

Impact of transport pathways on the time from symptom onset of ST-segment elevation myocardial infarction to door of coronary intervention facility

BackgroundReducing total ischemic time is important in achieving better outcome in ST-segment elevation myocardial infarction (STEMI). Although the onset-to-door (OTD) time accounts for a large portion of the total ischemic time, factors affecting prolongation of the OTD time are not established. PurposeThe purpose of this study was to determine the impact of transport pathways on OTD time in patients with STEMI. Methods and subjectsWe retrospectively studied 416 STEMI patients who were divided into 4 groups according to their transport pathways; Group 1 (n=41): self-transportation to percutaneous coronary intervention (PCI) facility; Group 2 (n=215): emergency medical service (EMS) transportation to PCI facility; Group 3 (n=103): self-transportation to non-PCI facility; and Group 4 (n=57): EMS transportation to non-PCI facility. OTD time was compared among the 4 groups. Essential resultsMedian OTD time for all groups combined was 113 (63–228.8)min [Group 1, 145 (70–256.5); Group 2, 71 (49–108); Group 3, 260 (142–433); and Group 4, 184 (130–256)min]. OTD time for EMS users (Groups 2 and 4) was 138min shorter than non-EMS users (Groups 1 and 3). Inter-hospital transportation (Groups 3 and 4) prolonged OTD by a median of 132min compared with direct transportation to PCI facility (Groups 1 and 2). Older age, history of myocardial infarction, prior PCI, shock at onset, high Killip classification, and high GRACE Risk Score were significantly more frequent in EMS users. Principal conclusionsSelf-transportation without EMS and inter-hospital transportation were significant factors causing prolongation of the OTD time. Approximately 35% of STEMI patients did not use EMS and 21% of patients were transported to non-PCI facilities even though they called EMS. Awareness in the community as well as among medical professionals to reduce total ischemic time of STEMI is necessary; this involves educating the general public and EMS crews.

Importance of Hospital Entry: Walk-in STEMI and Primary Percutaneous Coronary Intervention

IntroductionPatients with ST elevation myocardial infarction (STEMI) require rapid identification and triage to initiate reperfusion therapy. Walk-in STEMI patients have longer treatment times compared to emergency medical service (EMS) transported patients. While effective triage of large numbers of critically ill patients in the emergency department is often cited as the reason for treatment delays, additional factors have not been explored. The purpose of this study was to evaluate baseline demographic and clinical differences between walk-in and EMS-transported STEMI patients and identify factors associated with prolonged door to balloon (D2B) time in walk-in STEMI patients.MethodsWe performed a retrospective review of 136 STEMI patients presenting to an urban academic teaching center from January 2009 through December 2010. Baseline demographics, mode of hospital entry (walk-in versus EMS transport), treatment times, angiographic findings, procedures performed and in-hospital clinical events were collected. We compared walk-in and EMS-transported STEMI patients and identified independent factors of prolonged D2B time for walk-in patients using stepwise logistic regression analysis.ResultsWalk-in patients (n=51) were more likely to be Latino and presented with a higher heart rate, higher systolic blood pressure, prior history of diabetes mellitus and were more likely to have an elevated initial troponin value, compared to EMS-transported patients. EMS-transported patients (n=64) were more likely to be white and had a higher prevalence of left main coronary artery disease, compared to walk-in patients. Door to electrocardiogram (ECG), ECG to catheterization laboratory (CL) activation and D2B times were significantly longer for walk-in patients. Walk-in patients were more likely to have D2B time >90 minutes, compared to EMS- transported patients; odds ratio 3.53 (95% CI 1.03, 12.07), p=0.04. Stepwise logistic regression identified hospital entry mode as the only independent predictor for prolonged D2B time.ConclusionBaseline differences exist between walk-in and EMS-transported STEMI patients undergoing primary percutaneous coronary intervention (PCI). Hospital entry mode was the most important predictor for prolonged treatment times for primary PCI, independent of age, Latino ethnicity, heart rate, systolic blood pressure and initial troponin value. Prolonged door to ECG and ECG to CL activation times are modifiable factors associated with prolonged treatment times in walk-in STEMI patients. In addition to promoting the use of EMS transport, efforts are needed to rapidly identify and expedite the triage of walk-in STEMI patients.

Comparison of Outcomes for Children With Cervical Spine Injury Based on Destination Hospital From Scene of Injury

Pediatric cervical spine injury is rare. As a result, evidence-based guidance for prehospital triage of children with suspected cervical spine injuries is limited. The effects of transport time and secondary transfer for specialty care have not previously been examined in the subset of children with cervical spine injuries. The primary objective was to determine if prehospital destination choice affects outcomes for children with cervical spine injuries. The secondary objectives were to describe prehospital and local hospital interventions for children ultimately transferred to pediatric trauma centers for definitive care of cervical spine injuries. The authors searched the Pediatric Emergency Care Applied Research Network (PECARN) cervical spine injury data set for children transported by emergency medical services (EMS) from scene of injury. Neurologic outcomes in children with cervical spine injuries transported directly to pediatric trauma centers were compared with those transported to local hospitals and later transferred to pediatric trauma centers, adjusting for injury severity, indicated by altered mental status, focal neurologic deficits, and substantial comorbid injuries. In addition, transport times and interventions provided in the prehospital, local hospital, and pediatric trauma center settings were compared. Multiple imputation was used to handle missing data. The PECARN cervical spine injury cohort contains 364 patients transported from scene of injury by EMS. A total of 321 met our inclusion criteria. Of these, 180 were transported directly to pediatric trauma centers, and 141 were transported to local hospitals and later transferred. After adjustments for injury severity, odds of a normal outcome versus death or persistent neurologic deficit were higher for patients transported directly to pediatric trauma centers (odds ratio [OR]= 1.89, 95% confidence interval [CI]=1.03 to 3.47). EMS transport times to first hospital did not differ and did not affect outcomes. Prehospital analgesia was very infrequent. Initial destination from scene (pediatric trauma center vs. local hospital) appears to be associated with neurologic outcome of children with cervical spine injuries. Markers of injury severity (altered mental status and focal neurologic findings) are important predictors of poor outcome in children with cervical spine injuries and should remain the primary guide for prehospital triage to designated trauma centers.

An Emergency Department Paramedic Staffing Model Significantly Improves EMS Transport Unit Offload Time – A Novel Approach to an ED Crowding Challenge

Objective: We assessed the impact of emergency department (ED) paramedic staffing on emergency medical services (EMS) unit offload time, an intervention designed to assist with EMS unit patient offload when the ED is at full bed capacity. Methods: This prospective pre/post intervention study assessed patients offloaded via the regional EMS system at an urban tertiary care teaching hospital. Three groups were compared: 1) a pre-paramedic group with data obtained prior to any paramedics staffing the ED; 2) a transition (control) group with data obtained during paramedic orientation; and 3) a post-paramedic group with data measured after paramedics were staffing the ED. Research assistants stationed in the ambulance bay of the ED enrolled a convenience sample of patients for seven consecutive days and recorded offload time as patients were brought in by EMS. The primary outcome measure was offload time (the interval between patient arrival via EMS and transfer of patient care to an ED stretcher). Results: A total of 519 offloaded patients were assessed: 207 in the pre-paramedic period, 93 in the transition (control) period and 219 in the post-paramedic period. Overall median offload times (in minutes) in the preparamedic and post-paramedic groups were 10 [IQR 4-32] versus 4 [IQR 1-16] respectively (p<0.001). In those who were triaged directly to an ED bed the median offload times were 14 [IQR 3-40] and 4 [IQR 1-16] respectively (p<0.001). The proportion of patients offloaded within 5 minutes went from 29% before the paramedic intervention to 53% after (p<0.001). The proportion of patients offloaded within 30 minutes went from 66% before paramedics to 83% (p<0.001) after and those offloaded within 60 minutes went from 87% to almost 100% (p<0.001). Conclusion: An ED paramedic-staffing model focused on receiving EMS-arrived patients at times when the ED is at full bed capacity significantly reduced the offload time for EMS units.

Giving EMS Flexibility In Transporting Low-Acuity Patients Could Generate Substantial Medicare Savings

Some Medicare beneficiaries who place 911 calls to request an ambulance might safely be cared for in settings other than the emergency department (ED) at lower cost. Using 2005-09 Medicare claims data and a validated algorithm, we estimated that 12.9-16.2percent of Medicare-covered 911 emergency medical services (EMS) transports involved conditions that were probably nonemergent or primary care treatable. Among beneficiaries not admitted to the hospital, about 34.5percent had a low-acuity diagnosis that might have been managed outside the ED. Annual Medicare EMS and ED payments for these patients were approximately $1billion per year. If Medicare had the flexibility to reimburse EMS for managing selected 911 calls in ways other than transport to an ED, we estimate that the federal government could save $283-$560million or more per year, while improving the continuity of patient care. If private insurance companies followed suit, overall societal savings could be twice as large.

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.

Abstract 205: Termination of Resuscitation Rules for Traumatic Cardiopulmonary Arrest: Old Dogma, New Validation

Introduction: Pre-hospital terminations of resuscitation (TOR) rules for traumatic cardiopulmonary arrest (TCPA) have been proposed by the National Association Emergency Medical Physicians (NAEMSP) and the American College of Surgeons Committee on Trauma (ACSCOT) for a decade. However, validation studies from United Kingdom and Australia produced conflicting results. This study aimed to evaluate the performance of TOR rules for TCPA in an Asian metropolitan area. Methods: We analyzed data from an Utstein registry system of adult patients with TCPA in Taipei to test the performance of the first guiding criteria of TOR for TCPA: blunt trauma patient found in asystole upon the arrival of emergency medical service (EMS) at the scene. Predictive outcome was in-hospital death. Test statistics including sensitivity, specificity, positive predictive value (PPV), negative predictive values (NPV), and decreased transport rate (DTR) were calculated. Results: From Jan 1, 2008 to Dec 31, 2009, there were 328 adult patients with TCPA. The mechanism was blunt trauma in 155 (47.3%), penetrating trauma in 106 (32.3%) and uncertain in 106 (32.3%), and mechanisms were 155 (47.3%), 106 (32.3%), and 67 (20.4%). The presenting rhythm was asystole in 54/155 (34.8%) of blunt trauma, 57/107(53.3%) of penetrating trauma, and 28/67 (41.8%) of uncertain mechanism. Overall survival rate of TCPA (to hospital discharge) were 11/328 (3.4%). For those with blunt trauma, only 4 survived to hospital discharge (2.6%). The test statistics of the first guiding criteria (i.e. patients with blunt trauma and asystole) and sensitivity analysis by categorizing uncertain mechanism as blunt trauma were presented in the Table. Conclusion: Application of the first rule of thumb proposed by NAEMSP and ACSCOT for adult patients with TCPA can accurately identify non-survivors (100% PPV and 100% specificity) and decrease unnecessary EMS transports (16.5%~25.0%) in an Asian Metropolitan area.

Thrombolysis in Acute Ischemic Stroke: A Simulation Study to Improve Pre- and in-Hospital Delays in Community Hospitals

BackgroundVarious studies demonstrate better patient outcome and higher thrombolysis rates achieved by centralized stroke care compared to decentralized care, i.e. community hospitals. It remains largely unclear how to improve thrombolysis rate in decentralized care. The aim of this simulation study was to assess the impact of previously identified success factors in a central model on thrombolysis rates and patient outcome when implemented for a decentral model.MethodsBased on a prospectively collected dataset of 1084 ischemic stroke patients, simulation was used to replicate current practice and estimate the effect of re-organizing decentralized stroke care to resemble a centralized model. Factors simulated included symptom onset call to help, emergency medical services transportation, and in-hospital diagnostic workup delays. Primary outcome was proportion of patients treated with thrombolysis; secondary endpoints were good functional outcome at 90 days, Onset-Treatment-Time (OTT), and OTT intervals, respectively.ResultsCombining all factors might increase thrombolysis rate by 7.9%, of which 6.6% ascribed to pre-hospital and 1.3% to in-hospital factors. Good functional outcome increased by 11.4%, 8.7% ascribed to pre-hospital and 2.7% to in-hospital factors. The OTT decreased 17 minutes, 7 minutes ascribed to pre-hospital and 10 minutes to in-hospital factors. An increase was observed in the proportion thrombolyzed within 1.5 hours; increasing by 14.1%, of which 5.6% ascribed to pre-hospital and 8.5% to in-hospital factors.ConclusionsSimulation technique may target opportunities for improving thrombolysis rates in acute stroke. Pre-hospital factors proved to be the most promising for improving thrombolysis rates in an implementation study.

Assessing Satisfaction and Quality in the EMS/HEMS Working Relationship

Background/ObjectiveTreatment provided to critically ill and injured patients during air medical transport bridges initial local emergency medical service (EMS) treatment and the care provided upon arrival to the emergency department. Transition of care from EMS to air medical service includes multiple elements, many of which have been previously undefined. These include operational details surrounding the handoff and attention to issues of continuity in patient care. The purpose of this study is to pilot the development of survey instrumentation to measure key elements of quality in the interaction between EMS and air medical crews. MethodsA focus group of 12 individuals, including rural and urban EMS providers, medical directors, administrators, and air medical transport providers, defined the activities involved in the working relationship between EMS and air medical transport. Ideas were refined into statements and placed into a 16-item Likert scale questionnaire distributed to EMS agencies throughout Ohio. Exploratory factor analysis was performed to identify subscales within the questionnaire. Results380 questionnaires were returned over 2009, 2010, and 2011. Factor analysis of the initial responses from 2009 revealed themes similar to those identified by the focus group: patient care, user-friendly helicopter EMS (HEMS) operations, response time accuracy, operational feedback, and general system issues. The measure had good internal reliability, with alphas for subscales in the 0.85–0.88 range. A modified questionnaire used in 2010 and 2011 actually performed as a single scale. ConclusionUsing qualitative and quantitative approaches, a survey instrument was developed to assess satisfaction with HEMS care from the EMS provider's perspective. Evaluating the EMS perspective on the working relationship with HEMS is a new field of discovery for the air medical transport industry and process improvement activities.

Should Payment Policy Be Changed to Allow a Wider Range of EMS Transport Options?

The Institute of Medicine and other national organizations have asserted that current payment policies strongly discourage emergency medical services (EMS) providers from transporting selected patients who call 911 to non-ED settings (eg, primary care clinics, mental health centers, dialysis centers) or from treating patients on scene. The limited literature available is consistent with the view that current payment policies incentivize transport of all 911 callers to a hospital ED, even those who might be better managed elsewhere. However, the potential benefits and risks of altering existing policy have not been adequately explored. There are theoretical benefits to encouraging EMS personnel to transport selected patients to alternate settings or even to provide definitive treatment on scene; however, existing evidence is insufficient to confirm the feasibility or safety of such a policy. In light of growing concerns about the high cost of emergency care and heavy use of EDs, assessing EMS transport options should be a high-priority topic for outcomes research.

The Impact of Heat Waves on Transport Volumes in an Urban Emergency Medical Services System: A Retrospective Review

Heat waves pose a serious public health risk to particular patient populations, especially in urban areas. Emergency Medical Services (EMS) in many urban areas constitute the first line of regional preparation and response to major heat wave events; however, little is known on heat wave operational impact to the EMS system, such as call volume or demand. To examine the effect of heat wave periods on overall urban EMS system call volume and transport volume as well as the nature of the call types. Retrospective review of all emergency medical calls to an urban, two-tiered EMS system performed over a 5-year period from 2006-2010. Heat wave days (HWD) defined as two or more consecutive days of hot weather >32.2°C (90°F) were compared with similar non-heat wave days (nHWD) of the previous year to also include two calendar days prior to and after the heat wave. National Weather Service (NWS) temperature data, daily EMS call volume data, and call type codes were collected and underwent descriptive analysis. Thirty-one HWD were identified and compared with 93 nHWD. The mean maximum temperature for HWD was 34°C (93.2°F) compared with 25.3°C (77.6°F) for nHWD (P < .001). Average daily medical emergency calls (318.4 vs 296.3, P < .001) and actual patients transported per day (247.5 vs 198.3, P < .001) were significantly higher during HWD. There was no difference in daily medical emergency call volume or EMS transports between weekdays or weekend days. No significant differences on various call types were observed between HWD and nHWD except for "heat" related calls (7.7 vs 0.5, P < .001). Emergency Medical Services call volumes were significantly increased during heat waves, however there was minimal change in the types of calls received.