EMS Community Research Articles

Recommendations for Improving the Quality of Prehospital Evidence-Based Guidelines

Evidence-based guidelines that provide recommendations for clinical care or operations are increasingly being published to inform the EMS community. The quality of evidence evaluation and methodological rigor undertaken to develop and publish these recommendations vary. This can negatively affect dissemination, education, and implementation efforts. Guideline developers and end users could be better informed by efforts across medical specialties to improve the quality of guidelines, including the use of specific criteria that have been identified within the highest quality guidelines. In this special contribution, we aim to describe the current state of published guidelines available to the EMS community informed by two recent systematic reviews of existing prehospital evidenced based guidelines (EBGs). We further aim to provide a description of key elements of EBGs, methods that can be used to assess their quality, and concrete recommendations for guideline developers to improve the quality of evidence evaluation, guideline development, and reporting. Finally, we outline six key recommendations for improving prehospital EBGs, informed by systematic reviews of prehospital guidelines performed by the Prehospital Guidelines Consortium.

New Jersey's EMS response to Superstorm Sandy: a case study of the emergency management assistance compact.

In the United States, understanding the Emergency Management Assistance Compact (EMAC) is critical to responding to a natural disaster or manmade event. Recently, the State of New Jersey responded to Superstorm Sandy and implemented the EMAC system by requesting ambulances to aid in the Emergency Medical Services response. New Jersey's response to Superstorm Sandy was unprecedented in that this storm affected the entire state and EMS community. New Jersey's EMS community and infrastructure were impacted greatly, despite years of planning and preparation for such an event. Once received, out-of-state EMS resources were integrated into New Jersey's emergency management and EMS systems. In this report, each phase of the EMAC in New Jersey is explored, from how the response was coordinated to how it ultimately was executed. The state coordinated its response on multiple levels and, as such, tested the practical applicability of the EMAC process and employed best practices and solutions to issues that arose. These best practices and solutions may prove invaluable for any state or territory that may activate the EMAC system for emergency medical service resources.

The shootings in Oslo and Utøya island July 22, 2011: Lessons for the International EMS community

SJTREM has published an account by Sollid and colleagues of the pre-hospital medical response to the major incidents, which occurred in Oslo and Utoya island on July 22, 2011 [1]. Although very similar incidents have occurred in Europe and elsewhere, this terrible day saw the greatest loss of life recorded in this type of incident in recent times. Internationally EMS providers looked on with the certain knowledge that this type of incident is sadly one that we all have to prepare for. It is unrelated to national foreign policy, religious extremism or the existence of known terrorist activity. In short this type of incident is unpredictable and has the potential to happen in any community at any time. The aftermath of this type of incident is complex. Initially public and private grief dominates. There is then an attempt to comprehend the motives and background to apparently senseless acts that led to the tragic loss of innocent lives. Usually there is intense scrutiny of the perpetrator in an attempt to identify something in his or her background which might have predicted the incident. Inevitably the emergency response to the incidents is examined sometimes objectively and sometimes less so. The families of the victims and the public want to be reassured that everything possible was done to prevent the loss of life. Government legislation may result from incidents - the Dunblane school killings in Scotland in 1996 which resulted in the death of fifteen small children and their teacher led to rigorous controls on gun ownership in the UK. Later the emergency services can be subject to further scrutiny at inquests or public inquiries. These can be months or years after the event (the inquests into the London bombings in 2005 were only completed five years later). The motivations behind requests for information about the emergency response are varied. However, placing objective information about the emergency service response in the public domain is a responsible act. It allows other EMS services nationally and internationally to analyse and exercise their emergency responses to similar incidents with credible background information. This may allow improved emergency responses to future incidents which may occur before the conclusions of lengthy public or legal investigations. The authors of this paper are to be commended for bringing objective information into the medical literature in a timely manner after managing a difficult incident with great skill. Although all major incidents are unique they all have common elements. The incidents in July in Norway can be usefully categorised to analyse the challenges faced by the regional EMS system.

(A78) EMS System Assessment & Gap Analysis

PurposeThe World Health Organization Model Trauma System Policy suggests that Governments should undertake systematic reviews of the de facto prehospital transport systems for severely ill and injured persons. These systems, be they formal or informal, should be designed to optimize local resources with emphasis on standards of training, equipment, infrastructure and communications so as to assure delivery of prompt, quality, and equitable prehospital care. Scope of Review and Assessment a System Assessment and Gap Analysis (SAGA) tool has been developed to measure 127 key components of a high performance emergency transport system within the realms of Clinical, Organizational and Logistical functionality. The evaluation compares the current status of the specific components with those commonly expected to be seen in a formal international accredited EMS organization.MethodologyThe tool utilizes a thorough investigative process sufficient to produce credible and practical data which can be used to form a “System Improvement Plan.” While the scope of the project can be seen as relatively broad, the assessment process allows for adaptation to a wide variety of EMS system models which bring specific focus to the greatest areas of improvement opportunity with practical applications and alignment with those resources which are available to a given governmental entity.PresentationThis abstract, (in both oral and poster presentation format), demonstrates a portional mock evaluation with focus on those components often overlooked by both evolving and mature formal system designs by the international EMS community. The SAGA approach is an invaluable tool for those responsible for integrating the functionality and needs of a broad range of stake holders into the overarching prehospital delivery system in building support for qualitative improvements.

The Trauma Charge Nurse in the Pediatric Emergency Department

Introduction: The trauma charge nurse role at a Level 1 Pediatric Hospital benefits the emergency department, the trauma patients, the trauma service, the hospital itself and the community. Methods: The trauma charge nurses (TCN) are emergency department (ED) nurses who have passed off a trauma module which is made up of individual learning units, simulated skills pass-off stations and hands-on bedside nursing care of trauma patients. The TCNs are staffed 24/7 in the ED to insure that there is an RN with a high level of clinical expertise available to take care of patients at all times. In addition to being a clinical resource to the ED, the TCN is the bedside nurse for all high acuity trauma patients and coordinates the mobilization and response of the hospital trauma team to care for all trauma patients in the ED. The TCN also acts as a liaison for the ED with the hospital trauma team for communicating changes in procedures, process improvement, etc. In addition to their duties in the hospital, the TCNs provide pediatric trauma education to EMS agencies and community safety fairs throughout the state. Results: The trauma charge nurse role in the emergency department has helped to improve the care of the trauma patients in this Level 1 Trauma Center since the roles inception 12 years ago. Although the TCN role was initially set up to give the trauma team a consistent core group of nurses in the ED caring for the trauma patients, the TCN role has benefitted the ED, the hospital and the community. Conclusion: The TCN role has strengthened the trauma program and the ED at this Level 1 Trauma Center. Rhonda Carter, J Nurs Care 2013, 2:3 http://dx.doi.org/10.4172/2167-1168.S1.002

High Yield Polymer MEMS Process for CMOS/MEMS Integration

ABSTRACTMEMS community is increasingly using SU-8 as a structural material because it is self-patternable, compliant and needs a low thermal budget. While the exposed layers act as the structural layers, the unexposed SU-8 layers can act as the sacrificial layers, thus making it similar to a surface micromachining process. A sequence of exposed and unexposed SU-8 layers should lead to the development of a SU-8 based MEMS chip integrated with a pre-processed CMOS wafer. A process consisting of optical lithography to obtain SU-8 structures on a CMOS wafer is described in this paper.

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AMTC 2004 Cincinnati

AMTC 2004 Cincinnati

M EDICAL D IRECTOR FOR A IR M EDICAL T RANSPORT P ROGRAMS

The NAEMSP recognizes the multifaceted and integral position of a medical director for an air medical transport program and the EMS community at large.

New Vision for the Role of Emergency Medical Services

Thirty years ago, the National Academy of Science paper, Accidental Death and Disability: The Neglected Disease of Modern Society, created EMS as we know it today. The document has served us well, but recent shifts in health care require new insights, goals, skills, and resources for continued success in EMS. The 1996 document EMS: Agenda for the Future merges the many facets of EMS into a common vision and lays out 3 areas for change—building bridges, creating infrastructure, and developing new tools and resources. Emergency physicians’ leadership is essential to steer the EMS community toward a productive future that will strengthen the nation’s emergency medical safety net for the next 30 years. [Martinez R: New vision for the role of emergency medical services. Ann Emerg Med November 1998;32:594-599.]

An Eight-Year Review of Legal Cases Related to an Urban 9-1-1 Paramedic Service

An eight year retrospective analysis was conducted to determine the type and outcome of lawsuits related to the provision of 9-1-1 paramedic service in an urban environment. For the evaluation period of May 1986 to March 1994, all litigation cases related to Ambulance Service or paramedics were collected and analyzed. This urban 9-1-1 Paramedic Service has an estimated call volume of > 60,000 assignments resulting in > 30,000 patient encounters during the evaluation period. Seven lawsuits were filed against the service. No lawsuits were related to tardy response, failure to transport, or patient care negligence of any kind. All of the litigation was related to motor vehicle collisions (MVC). The data suggest that motor vehicle collisions are a significant medical-legal risk to the EMS community. In addition, it was found that the use and lack of use of seatbelts was an important component in many of the suits.

Implementation of an out-of-hospital termination of resucitation policy

Objective. To evaluate the implementation of an out-of-hospital termination of resuscitation policy in an urban EMS setting.Methods. A descriptive study characterizing the implementation of an out-of-hospital termination of resuscitation policy in the Chicago EMS system. It includes a retrospective telemetry record review analyzing the utilization and compliance with the policy. The newly implemented policy involved field termination of resuscitation for all nontraumatic, adult cardiac arrest victims presenting in asystole who were not responsive to a standard trial of resuscitation.Results. Over the three-month study period, 228 resuscitations of adult, nontraumatic cardiac arrest victims were identified and submitted for review. The group of 142 cardiac arrest victims who presented in asystole and received resuscitative efforts were categorized into four groups. Group I included 34 cardiac arrests for which resuscitation was terminated in the field following policy criteria. Group II included eight cardiac arrests for which resuscitation was terminated but the patients did not meet criteria for termination of resuscitation. Group III included 84 cardiac arrests for which resuscitation was not terminated because the patients did not meet criteria for out-of-hospital termination. Group IV included 16 cardiac arrests for which resuscitative efforts were continued, although the patients met indications for field termination.Conclusions. Field termination of resuscitation is practical in the setting of asystole unresponsive to aggressive resuscitative efforts. The implementation of such an out-of-hospital termination of resuscitation policy is complicated by many problems and is best accomplished by a gradual implementation process. Through this process all members of the EMS community can address practical and ethical issues and grow comfortable with the ongoing evolution of out-of-hospital therapy.

Medical Anti-Shock Trousers: Blind Faith, Poor Judgment and Patient Jeopardy

The oft-repeated historic development of the pneumatic lower body compression suit (MAST, PASG) for the presumed treatment of hypotension has been well-documented by McSwain(l). While the experimental and anecdotal clinical observations of Crile, Gardner, Wangenstein and Kaplan are interesting, they are not prospective, controlled, randomized clinical trials in humans(2,3,4,5). In the early 1970s, the EMS community was ripe for the bandwagon reflex to grasp at any and all gimmicks and gadgets which became available, regardless of a lack of evidence regarding their safety or danger to patients. Inventions such as the esophageal obturator airway, various darts, MAST, external cardiac bumpers, percutaneous trachea obturators, and many others simultaneously were thrust upon the unsuspecting and unprotected patient community. Some of these innovations may have been beneficial but others were dangerous. Contending that some intervention in a “life threatening, good Samaritan situation” was better than no interventional treatment or “stabilization” at all, the paramedics' blind faith in these modalities persisted. The Medical Device Amendment of 1976 (6), which requires safety and efficacy for devices, similar to that long in effect for new drugs, had not yet been enacted into law to require premarketing clearance of new medical devices. Building on blind faith and premature recommendations regarding in the unproven concept of MAST, the EMS community exercised poor judgment in recommending to state legislators that this unproven device be “required equipment” on board ambulances. Furthermore, this small cadre of “special interest groups” lobbied to have the MAST mandated as essential equipment in trauma centers(7,8). Although the minutes of the trauma planning meetings do not reflect the debate at the American College of Surgeons Committee on Trauma, numerous voices of advised constraint, said “go slow” on including the MAST as part of the ATLS course and the ACS optimal resources document.

National EMS standards: The ASTM process

Summary In recognizing the need for national EMS standards, DOT/NHTSA has set the stage for participation by all sectors of the EMS community in formulating these standards. The ASTM process was selected as a means of achieving national EMS standards using a management organization with a reputation for excellence. The participation of NFNA and ASHBEAMS members in the national EMS standards effort has already resulted in a draft entitled “Standard of Practice for Establishing the Qualifications of EMS Aeromedical Personnel” being placed in ASTM subcommittee letter ballot form. The opportunity for contributing to the effort to establish national standards for EMS is here. Your participation in this process is important to achieving standards that reflect our commitment to high quality emergency medical services throughout the country.