EMS Crews Research Articles

Reliability of Wearable Technology to Monitor Core Temperature Among Helicopter-Based EMS Crews.

Excessive heat stress led to more than 400 deaths in the United States from 2011 to 2021. Common methods for heat injury prevention revolve around measurements of the environment and fail to account for the unique individual response to stressors. An observational approach was utilized with nine helicopter-based emergency medical services personnel during emergency flights to compare core temperature readings obtained from an ingestible temperature monitoring pill and the estimated core temperature reading of the Slate Safety Band V2 wearable device. Comparison of data was conducted within Microsoft Excel programming to determine the mean square error (MSE), root mean square error (RMSE), mean absolute error (MAE), mean biased error (MBE), and Bland-Altman plot development. A significant bias (t = 17.58, p < .001) toward the Slate Safety device reading higher with an average difference of -0.48°C (-0.86°F) was found, meaning the average temperature reading is 0.48°C (-0.86°F) higher with the Slate Safety device. A significant correlation of .26 (p < .001) was noted between the ingestible pill and the wearable device with a 95% confidence interval of 0.23 to 0.29. Aggregate core temperature data demonstrated an MSE of 0.43, an RMSE of 0.65, an MAE of 0.54, and an MBE of -0.48. The ability to monitor the physiological parameters of a worker remotely adds safety tools relative to the risks of heat stress. The slightly higher reading associated with the Slate Safety wearable device provides an added safety margin to protect our workers.

Prehospital Extended FAST Exams Improve Clinical Decision Making by Helicopter EMS Crews: A Retrospective Case Series

Point of Care Ultrasound (POCUS) has seen increasing use in the prehospital environment over the last decade, primarily with the extended focused assessment with sonography in trauma (eFAST) exam. Previous studies have shown prehospital eFAST exams are feasible in the helicopter transport environment but have yet to demonstrate effects on clinical care. This retrospective case series identified 655 patients with blunt thoraco-abdominal trauma or concern for pneumothorax due to penetrating injury transported by a single helicopter EMS (HEMS) program over a two-year period after introducing POCUS. Of those patients, 258 received prehospital ultrasound which was reported to change clinical care in seven cases (2.7%, 95%-CI [1.1–5.5]). This was primarily through preventing unnecessary needle thoracostomy and initiating blood transfusion for treatment of hemorrhagic shock in cases where the degree of shock was unclear due to inconsistent vital signs. This study highlights the improvements in clinical care that may result from the introduction of eFAST exams in the prehospital environment.

10: PROFOUND INCREASES IN NEUROINTACT PATIENT SURVIVAL FOR NONSHOCKABLE (ASYSTOLE/PEA) CARDIAC ARRESTS

Introduction: The neuroprotective approach to basic CPR (NPCPR) using adjuncts to lower ICP and enhance cardiac venous return (including gradual head/torso-up positioning [HTup]), has significantly improved overall neuro-intact survival (SURVni) for out-of-hospital cardiac arrest (OHCA) patients (Resuscitation 2022). However, as ~80% of OHCA cases have non-shockable (asystole/PEA) presentations (N-Sh) and attendant grim prognoses, the specific aim was to confirm if (and by how much) NPCPR-improved SURVni applies to N-Sh OHCA cases. Methods: Five U.S. EMS agencies using NPCPR prospectively tracked SURVni and all known SURVni related factors: age; sex; witnessed arrest; bystander CPR; T-CPR (time from 9-1-1 call to EMS crews starting CPR); initial ECG; and T-htup (9-1-1 call to HTup start). An automated HTup device (occiput raised to 22cm over several mins) was combined with active compression-decompression and impedance threshold devices (all FDA-cleared). For rigorous comparisons, conventional CPR (C-CPR) controls were derived from 2 large (n=10,053) published NIH trials involving (criteria-compliant) high-performance EMS systems (eg, recorded /monitored /reported CPR quality). Using propensity scoring for the pivotal SURVni factors, 353 N-Sh NPCPR patients were well-matched with 353 N-Sh C-CPR patients and compared for SURVni (mRS < or =3 or CPC 1 or 2). Results: For both 353 NPCPR patients and 353 controls: 2/3 were in asystole; mean ages 66; 8 min median T-CPR (IQR 6-10). Median T-htup = 11 min (IQR 9-15). Before propensity matching, the overall unadjusted OR [95%CI] for NPCPR SURVni (vs C-CPR) was 3.09 [1.64-5.81] and 3.87 [1.27-11.78] after matching (incl. responses >20 min). Analogous to AEDs in shockable OHCA, the earlier NPCPR was applied, SURVni improved: NPCPR SURVni was >10-fold higher, 6.1% v 0.6% (10/165 v 1/165) when T-htup < 11 mins [OR 10.59;1.34-83.63] or (cumulatively) 4.6% v 0.4% (13/281 v 1/281) if < 16 mins [OR 13.58;1.76-104.54]. Conclusions: Even compared to top-performing EMS systems, NPCPR, especially applied early, was associated with markedly-improved SURVni odds for asystole/PEA patients, with or without propensity score matching. As most EMS systems can initiate CPR for the majority of patients in < 12 min, NPCPR may potentially salvage many more lives than previously projected.

Employee Dilemmas from Competing Organizational Goals: Insights from Emergency Medical Services

Organizations face unique challenges when simultaneously pursuing conflicting organization-level objectives. We study how frontline employees deal with competing financial and social objectives within the context of Emergency Medical Services. Using data from 31 US states, we find that even in the absence of direct financial incentives, emergency crews are responsive to the financial objective of their agencies by providing differential service to patients based on their ability to pay. Private insurance and Medicare patients receive more procedures (6.1% and 1.9%) and have longer transport times (5.3% and 4.0%) than Medicaid patients after controlling for call and patient characteristics. Importantly, we also find evidence suggesting that EMS crews vacillate between the financial and social objectives between calls, depending on the relative salience of the objective.

Abstract P144: Successful Regional Implementation of a Large Vessel Occlusion Screening Tool: An Interdisciplinary Process Improvement Project

Introduction: Recommendations have recently been updated to support use of an LVO screening tool to assist in the identification and routing of eligible patients to endovascular stroke centers. Despite the recommendations for the use of an LVO screening tool, the general adoption and implementation is incomplete amongst many stroke systems nationwide. Methods: An interdisciplinary team selected the Vision, Aphasia, Neglect (VAN) tool for use amongst a series of Primary Stroke Centers and freestanding emergency departments. Educational plans surrounding the tool were developed and disseminated to prehospital EMS crews, Emergency Department nurses, and specialty transport crews. Staff education was bolstered utilizing existing EMR-based tools and the development of quick access materials for all personnel. Over a 12-month period, a combination of real time feedback and retrospective chart review were performed to ensure staff compliance and accuracy of LVO evaluations. Results: A total of 687 stroke alert patient were reviewed over a 12-month period—339 were triage arrivals and 348 were EMS arrivals. Initial compliance was low across both EMS and nursing, with only 23% of patients being screened for LVO status during the initial 6 months of implementation but increased to 66% compliance over the last 6 months. Sensitivity of VAN assessments increased from 88% to 93% and specificity increased from 80% to 86% over the same one-year period. Conclusions: Successful implementation of an LVO screening tool requires an interdisciplinary team to adopt a tool that is both user-friendly and validated for detection of LVO. Initial staff education and continuous feedback are essential elements to ensure the overall compliance and accuracy of assessments. Ongoing efforts are underway with a one-year goal of 80% compliance of screening while maintaining a high-level of accuracy. Additional staff education directed at the most common reason for a false positive screening, mistaking dysarthria for aphasia.

Employee Dilemmas from Competing Organizational Objectives: Insights from Emergency Medical Services

Organizations face unique challenges when simultaneously pursuing conflicting organization-level objectives. We study how frontline employees deal with competing financial and social objectives within the context of Emergency Medical Services. Using data from 31 US states, we find that even in the absence of direct financial incentives, emergency crews are responsive to the financial objective of their agencies by providing differential service to patients based on their ability to pay. Private insurance and Medicare patients receive more procedures (6.1% and 1.9%) and have longer transport times (5.3% and 4.0%) than Medicaid patients after controlling for call and patient characteristics. Importantly, we also find evidence suggesting that EMS crews vacillate between the financial and social objectives between calls, depending on the relative salience of the objective.

Abstract TMP67: Prehospital Cath Lab Activation Based on EMS Large Vessel Occlusion Screen Cancelled

Background: Current guidelines indicate reduced time to reperfusion with thrombectomy is strongly associated with better outcomes. Validated screening tools for large vessel occlusions are available for the prehospital setting. Objective: To reduce door to access times for patients arriving by EMS to an urban 487 bed quaternary hospital. Methods: Starting in January of 2016, EMS crews screened all stroke patients with the Cincinnati - Stroke Triage Assessment Tool (C-STAT) and communicated results to the ED prior to arrival (PTA). In 2017, a team consisting of Neurology, ED, Cath Lab, Neuro Interventional leadership and stroke coordinator agreed to a 6-month pilot project of activating the Cath Lab when EMS radioed a patient was C-STAT positive. Any ED staff who might take EMS radio report were educated on the new process. Instructions were added to the existing Stroke Patient Checklist. Cath Lab and EMS staff were notified of the pilot project. During the pilot period, feedback was provided to EMS and ED leadership if an issue was identified for a specific case and trends were discussed. Results: During the pilot period, median door to access time for C-STAT positive patients who had Cath Lab activated PTA was 66 minutes compared to the 104 minutes the previous year (37% reduction). Unexpectedly, the median door to needle time for these patients also improved from 45 minutes the previous year to 28 minutes (38% reduction). The Cath Lab was activated PTA 16 times for patients EMS reported as C-STAT positive; Only 5 went on to have a thrombectomy. Overcalls were due to lack of C-STAT specificity (n=6) or C-STAT not scored correctly (n=5). In practice as well as when cases associated with assessment errors are removed, C-STAT demonstrated a low specificity for LVO (37.5% and 40% respectively). Lastly, internal process issues lead to 5 additional PTA Cath Lab activations for patients EMS did not report as being C-STAT positive. Conclusions: It was felt additional education would not be enough to make this initiative sustainable given the low specificity. In conclusion, despite marked improvement in door to access and door to needle times, the overactivation of Cath Lab lead to the initiative being cancelled.

Dosing Errors Made by Paramedics During Pediatric Patient Simulations After Implementation of a State-Wide Pediatric Drug Dosing Reference

Background: Drug dosing errors occur at a high rate for prehospital pediatric patients. To reduce errors, Michigan implemented a state-wide pediatric dosing reference (PDR), with doses listed in milliliters, the requirement that doses be drawn into a smaller syringe from a pre-loaded syringe using a stopcock, and dilution of certain drugs to different concentrations.Purpose: To evaluate the rate of medication errors, including errors of omission and commission, after implementation of a state-wide PDR.Methods: EMS crews from 15 agencies completed 4 validated, simulation scenarios: an infant seizing, an infant cardiac arrest, an 18-month-old with a burn, and 5-year-old with anaphylactic shock. Agencies were private, public, not-for-profit, for-profit, urban, rural, fire-based, and third service. EMS crews used their regular equipment and were required to carry out all the steps to administer a drug dose. Two evaluators scored crew performance via direct observation and video review. An error was defined as 20% difference compared to the weight-appropriate dose. Descriptive statistics were utilized.Results: A total of 142 simulations were completed. The majority of crews were (58.3%) Emergency Medical Technician-Paramedic (EMTP)/EMTP. For the cardiac arrest scenario, 51/70 (72.9%; 95% CI: 60.9%, 82.8%) epinephrine doses were correct. There were 6 (8.6%, 95% CI: 2.0%, 15.1%) 10-fold overdoses and one (1.4%; 95% CI: –1.4%, 4.2%), 10-fold under dose. In the seizure scenario, 28/50 (56.0%; 95% CI: 42.2%, 69.8%) benzodiazepine doses were correct; 6/18 (33.3%; 95% CI: 11.5%, 55.1%) drug dilutions were incorrect resulting in dosing errors. Unrecognized air was frequently entrained into the administration syringe resulting in under doses. Overall, 31.2% (95% CI: 25.5%, 36.6%) of drug doses were incorrect. Obtaining an incorrect weight led to a drug dosing error in 18/142 (12.7%, 95% CI: 7.2%, 18.2%) cases. Errors of omission included failure to check blood sugar in the seizure scenario and failure to administer epinephrine and a fluid bolus in anaphylactic shock.Conclusion: Despite implementation of a PDR, dosing errors, including 10-fold errors, still occur at a high rate. Errors occur with dilution and length-based tape use. Further error reduction strategies, beyond a PDR and that target errors of omission, are needed for pediatric prehospital drug administration.

Statewide Method of Measuring Ambulance Patient Offload Times

Objective: Ambulance patient offload time (APOT) also known colloquially as “Wall time” has been described in various jurisdictions but seems to be highly variable. Any attempt to improve APOT requires the use of common definitions and standard methodology to measure the extent of the problem. Methods: An Ambulance Offload Delay Task Force in California developed a set of standard definitions and methodology to measure APOT for transported 9-1-1 patients. It is defined as the time “interval between the arrival of an ambulance at an emergency department and the time that the patient is transferred to an ED gurney, bed, chair or other acceptable location and the ED assumes responsibility for care of the patient.” Local EMS agencies voluntarily reported data according to the standard methodology to the California EMS Authority (State agency). Results: Data were reported for 9-1-1 transports during 2017 from 9 of 33 local EMS Agencies in California that comprise 37 percent of the state population. These represent 830,637 ambulance transports to 126 hospitals. APOT shows significant variation by EMS agency with half of the agencies demonstrating significant delays. Offload times vary markedly by hospital as well as by region. Three-fourths of hospitals detained EMS crews more than one hour, 40% more than two hours, and one-third delayed EMS return to service by more than three hours. Conclusion: This first step to address offload delays in California consists of standardized definitions for data collection to address the significant variability inherent in obtaining data from 33 local agencies, hundreds of EMS provider agencies, and 320 acute care hospital Emergency Departments that receive 9-1-1 ambulance transports. The first year of standardized data collection of ambulance patient offload times revealed significant ambulance patient offload time delays that are not distributed uniformly, resulting in a substantial financial burden for some EMS providers in California.

Abstract 47: Impact of EMS Field-telestroke With Hand-held Ipads on IV-tpa Therapy for Stroke

Introduction: Reducing the Door-to-Needle (D2N) time to IV-tPA has been shown to improve outcomes after acute ischemic stroke. Pre-hospital Telestroke using Mobile Stroke Units has been shown to reduce D2N times but the number of patients treated are underpowered to show improvement in stroke outcome. With deployment in urban areas near multiple comprehensive stroke centers and costs averaging $1M to purchase and $1M to operate annually, it is unlikely that Mobile Stroke Units will exert a major impact on the broader population of stroke victims. Hypothesis: Bringing Telestroke expertise to the patient by utilizing Advance Stroke Life Support (ASLS)- trained EMS crews equipped with hand-held iPADS for videoconferencing in the field with their Medical Control could enhance patient assessment and reduce D2N times for IV-tPA in acute stroke. Methods: Field-Telestroke training of 243 EMS personnel from 6 community squads associated with a 332-bed acute care Primary Stroke Center was conducted in 2q 2016 and included ASLS Certification, education on Stroke Protocols and videoconferencing in the field with the hospital’s Medical Control, and the use of HIPPA-compliant hand-held iPADs. A retrospective analysis of transports from July 2014- July 2016 pre-implementation and July 2016-June 2017 post-implementation included Stroke Alert process times of Door-to-CT completion (DCT) and D2N. Results: Pre-hospital use of Field-Telestroke from July 2016-June 2017 was associated with a shorter average DCT of 10.7 vs 34.5 minutes and shorter D2N time for IV-tPA therapy of 41 minutes vs 50 minutes with standard pre-hospital notification. Overall IV-tPA utilization from July 2016-June 2017 (12.7%, 26/204) was non-significantly increased from baseline July 2014- June 2016 (10.6%, 50/473, p=0.43). Conclusions: The use of Field- Telestroke was associated with faster DCT and D2N times for IV-tPA therapy. Field-Telestroke by ASLS-trained EMS squads is a promising low-cost approach to deliver high quality pre-hospital stroke care to communities.

LO70: Do automatic external defibrillators improve rates of return of spontaneous circulation, survival to hospital discharge and favourable neurological survival in Canada?

Introduction: Survival for victims of out-of-hospital cardiac arrest (OHCA) is typically 8-12%. Recent evidence has shown that public access automatic external defibrillators (AED) may improve survival. The objectives of this study were to determine whether AEDs improve rates of return of spontaneous circulation (ROSC), overall survival, and favourable neurological survival (FNS) in Canada. Methods: The BC Resuscitation Outcomes Consortium prospectively collected detailed prehospital and hospital data on consecutive non-traumatic OHCAs from 2011-2015 within BC’s four metropolitan areas. We included all EMS-treated adult patients. Data were collected in accordance with recognized Utstein criteria. We described frequencies with counts, means and medians where appropriate, and the Z-test was used to compare population proportions. Results: We examined 7577 OHCAs from 2011-2015. AEDs were deployed on 223 patients in this period (mean age 60.4 yrs [95% CI 45.7-75.1] and 83.9% male; non-AED OHCAs mean age 66.2 yrs [48.4-83.8] and 67.3% male). Seventy seven percent of AED deployments occurred in public locations, 69.1% were witnessed by bystanders and CPR was initiated in 98.7% of these cases. Fifteen percent of non-AED OHCAs occurred in public locations, 38.3% were bystander witnessed, and 45.4% received bystander CPR. AEDs delivered shocks to 61.4% of patients, and EMS crews found an initial shockable rhythm upon scene arrival in 60.5% of AED deployments (22.9% for non-AED cases). AED OHCA patients had higher rates of ROSC at any time (67.2% vs 47.6%; difference of 19.6% [12.9-26.2 p&amp;lt;0.01]), and ROSC at ED arrival (61% vs 35.4%; difference of 25.6% [19.2-32.0 p&amp;lt;0.01]). AED OHCA patients had higher rates of survival to hospital discharge (23.8% vs 8.5%; difference 15.3% [11.5-19.1 p&amp;lt;0.01]). Detailed neurologic outcome data was not available for all patients, yet for those which it was available AED OHCA patients had improved outcomes (modified Rankin score&amp;lt;2) compared to non-AED OHCA patients (9.0% vs 5.4%; difference 3.6% [0.6-6.6 p&amp;lt;0.02]. Conclusion: Automatic external defibrillators markedly improve rates of ROSC at any time, sustained ROSC at ED arrival, survival to hospital discharge, and FNS in Canada. Continued support for public access AED programs is essential to improve patient outcomes.

LO32: Are EMS offload delay patients at increased risk of adverse outcomes?

Introduction: ED and hospital overcrowding cause offload delays that remove EMS crews from service and compromise care delivery to patients. Prolonged ED boarding times are associated with increased hospital LOS and patient mortality, but the impact of offload delays has not been studied. Our objective was to determine whether offload delays are associated with adverse system and patient outcomes. Methods: From July 2013 to June 2016, administrative data was collated from four Calgary adult EDs. All CTAS 2 and 3 EMS arrivals were studied. Those assigned an ED care space within 15 minutes were considered controls while those with delays of ≥60-minutes were considered ‘delayed’. Multivariable logistic regression was used to determine propensity scores, which were used to match delayed patients to nearest neighbor controls. Matching variables for propensity modeling included age, sex, CTAS level, ED site, arrival day and time, living situation (homecare/facility vs. independent), complaint category (medical, cardiovascular, mental health/neuro, GI, trauma/MS, other) and previous ED use (visits within 1 year). The primary outcome was 7-day mortality. Secondary outcomes included hospital LOS and 30-day mortality. Results: A total of 111,743 patients were studied: 70711 controls and 41032 delayed (median time to stretcher of 8 vs. 109 minutes). There was significant baseline covariate imbalance: Delayed patients were more likely to be female, older, have lower CTAS acuity, arrive on weekdays and evenings, to have general medical complaints, and to arrive at the slowest offload site. In the unmatched analysis, delayed patients had lower 7-day mortality (2.1% vs. 2.6%), similar 30-day mortality (3.5% vs. 3.6%), and longer hospital LOS (10.3 vs. 9.8 days). In the propensity-matched analysis (41016 patients per group), covariate balance was substantially improved and outcomes differed slightly. Seven and 30-day mortality were essentially unchanged, but between group differences for hospital LOS disappeared (10.3 vs. 10.2 days). Conclusion: Propensity analysis suggests that EMS patients exposed to offload delays have similar 30-day mortality and slightly lower 7-day mortality than patients who receive timely ED access. While offload delays lead to substandard hallway care, patient dissatisfaction, and remove EMS crews from service, the levels of offload delay studied here were not associated with higher mortality or prolonged hospital LOS.

Abstract TP367: Decreasing Decision to Transfer Times

Novant Health Greater Charlotte market is comprised of three advanced primary stroke care centers; one providing 24/7 stroke interventional radiology coverage. To expedite the transfer of patients meeting criteria for mechanical thrombectomy, the stroke best practice teams in the two community primary stroke centers collaborated to develop a protocol to improve the decision to transfer time to meet a goal of 120 minutes from door to skin puncture time, regardless of original transport destination. The Novant Health Charlotte market teams realize the benefit of cohesive physician coverage among the Emergency Department, Radiology and Inpatient Neurology physician providers. CTA scans performed in the non-interventional facilities are readily available to Neuro-Endovascular Radiologists, allowing for prompt interpretation and mobilization of the IR team to prepare for patient arrival. Recognizing internal critical care transport resources are limited and may not be available, the process was facilitated by the development of an activase transport protocol implemented by Mecklenburg County EMS in June of 2016. Since actual transport time is affected by traffic patterns in urban areas, the controllable measure selected by the teams was decision to transfer time. Prior to the initiation of the protocol, the median decision to transfer time for ischemic stroke patients requiring tertiary care was 66.5 minutes. Post protocol implementation the median time was reduced 32% to 44.5 minutes. Across the market, median door to skin puncture time in 2016 is 131.5 minutes. Ongoing evaluation of the transfer process, and multidisciplinary IR case review with identification of process variation is key to the success of this initiative. The Emergency Department at the tertiary care facility has been an instrumental partner in identifying issues that are barriers to timely throughput of these patients. A consistent feedback process informs all team members regarding patient outcomes. Individual case feedback is provided to all direct care givers, EMS crews and stroke team leaders, usually within 24 to 48 hours of the intervention. This data is shared monthly with the stroke best practice teams at the transferring facilities.

Abstract TP243: Evaluation of Transfer Time for Trauma, Stroke and Cardiac Patients

Introduction: Since the 1960’s, the “Golden Hour” has been a phrase well known in trauma circles- the sooner patients reached definitive care, the better their outcomes. In light of the positive endovascular stroke treatment trials we looked to evaluate the time EMS spends at the bedside before transferring a patient. We sought to understand the delays that occur after a diagnosis is made, after a hospital is selected, and after EMS arrives- what happens? Methods: We evaluated trauma, stroke, and cardiac patients who were transferred via helicopter from either the scene or a referring hospital. An air ambulance was requested for all of these patients either by EMS crews at the scene or by physicians in the referring hospital. We measured time to departure as the length of time between the Air crew arriving at the patient and the crew departing with the patient for the definitive care hospital. Results: We evaluated patients in 2015 and 2016 who were transferred via air ambulance for trauma, cardiac, and stroke. There were 749 trauma flights from the scene and 337 interfacility transfers (IFC). For cardiac, there were 38 from the scene and 178 IFC transfers. Finally, for stroke there were 338 from the scene and 301 IFC transfers. Cardiac had the most interesting results with the shortest IFC time at 8 minutes , but the longest IFC time at 22 minutes. Stroke and Trauma were similar at 17 and 16 minutes with no difference between scene and IFC. Conclusions: Acute Stroke patients are delayed in arriving at definitive care. The lack of a national goal for stroke patients is a current impediment leading change. Based on this data though, it is possible to move more efficiently in the transport of critically ill patients.

Emergency Medical Dispatchers Can Obtain Accurate Pediatric Weights from 9-1-1 Callers

Background: Prehospital pediatric drug dosing errors affect 56,000 U.S. children annually. An accurate weight is the first step in accurate dosing. To date, the accuracy of Emergency Medical Dispatcher (EMD) obtained weights has not been evaluated. We hypothesized that EMD could obtain accurate pediatric weights. Methods: We used a convenience sample of patients 12 years and younger that were transported by EMS to one children's hospital. EMD obtained patient weight (DW) from the 9-1-1 caller. Paramedics reported their estimate of the patient's weight on arrival to the hospital (PW). The DW and PW were compared to the hospital scale weight (HW) for accuracy. Results: A total of 197 patients were included. Parent/guardians were the most frequent 9-1-1 callers (74%). The most frequent method utilized by paramedics to obtain patient weight was to ask a family member. For 0–2 year olds, the mean differences between HW and DW/PW were 0.239kg (SD 3.117)/ -0.374 (SD 2.528). For 3–7 year olds, the mean differences between HW and DW/PW were 0.041kg (SD 4.684)/1.007 (SD 2.466). For 8–11 year olds the mean difference between HW and DW/PW was 2.768 kg (SD 10.926)/ 1.919 (SD 6.909). Conclusion: EMD were able to obtain pediatric patient weights with relative accuracy for patients 0–7 year old. Using this EMD-obtained weight to carry out a drug dose calculation would be unlikely to result in a clinically significant dose error in the vast majority of cases. Communicating an EMD-obtained weight to EMS crews en route to a pediatric patient offers additional preparation time for drug calculations, which could improve accuracy.

P075: Impact of pit-crew CPR following out-of-hospital cardiac arrest in Saskatoon

Introduction: Between 1980 and 2008, survival rates following an out-of-hospital cardiac arrest (OHCA) have remained unchanged, averaging 7.6%. Despite the use of new and emerging technologies, new medications, and automated external defibrillators, survival remains low. Recently, a new focus in cardiopulmonary resuscitation (CPR) has shown dramatic improvements in survival post OHCA. This new model, called pit-crew CPR, focuses on minimizing interruptions in chest compressions and has each team member playing a specific role in the resuscitation, akin to the pit-crew of a car race. Certain districts in the United States and Canada have adopted the pit-crew, or a similar, high quality, maximum time-on-chest CPR model, with much success. We aim to determine whether the pit-crew model of CPR improves survival following OHCA in Saskatoon, SK. Methods: In Saskatoon, EMS and Fire crews respond to OHCAs and have been exclusively using the pit-crew model of CPR since Jan 1st, 2015. This study is a before and after retrospective chart analysis, comparing two groups - pre and post implementation of the pit-crew CPR model. The primary outcome is survival to hospital discharge post OHCA. Secondary outcomes include survival to admission and any return of spontaneous circulation (as per the Utstein definition). The inclusion criteria are patients &gt;18 years old with a witnessed OHCA of presumed cardiac origin who receive CPR by EMS/Fire within the Saskatoon Ambulance service (MD Ambulance) catchment area. Patients were excluded if the OHCA was unwitnessed, or if there was a presumed non-cardiac cause for the arrest, e.g. trauma. Results: In the pre-pit-crew model cohort, between Jan 1st, 2011 and Sept 31st, 2014, 455 OHCAs were analyzed. In this cohort 10.5% survived to discharge, 31.9% survived to admission and ROSC was achieved in 39% of cases. The percentage of patients with initial rhythms of VF/VT, asystole or PEA were 28.5% (26%), 41.5% (1%) and 23.6% (10%) respectively, with survival to discharge shown in parentheses. The post-pit-crew cohort is still in the data collection phase. Conclusion: Our pre-pit crew cohort data has been collected and analyzed. With ongoing data acquisition for the post-pit crew cohort, we hope to have the full data set complete by the end of 2018. It will be at that time when we are able to determine whether the pit-crew model of CPR improves survival to discharge following OHCA in Saskatoon.

Abstract TMP81: Stroke Systems of Care: EMS Partnerships and Feedback

Background and Purpose: In 2014, Novant Health Presbyterian Medical Center (NHPMC) and Mecklenburg EMS Agency (MEDIC) launched a collaborative project to improve stroke care in our community. The goals of the project were to: Improve the efficiency of the Code Stroke process Determine the accuracy of priority one stroke calls from EMS to the Emergency Department Identify areas of the community with greatest numbers of stroke calls Provide individual case feedback to EMS colleagues Method: MEDIC crews call in priority one suspected acute stroke patients prior to emergency arrival. Unless stabilization is required, MEDIC takes the patient directly to the CT scanner, located in the emergency room, and assists with transferring the patient to the scanner. The accuracy of priority one calls is shared monthly and quarterly with MEDIC and the NHPMC Stroke Best Practice Team.If the patient receives t-PA, the NHPMC Clinical Analyst sends the MEDIC Quality Specialist a feedback sheet within 24-48 hours which includes dispatch to arrival and dispatch to drug time parameters and initial patient outcomes. The feedback sheets are sent via the supervisors, who also send a letter of commendation to the responding crew members. Results: In 2013 the door to CT report time averaged 27 minutes, 2014 average was 20 minutes or a 26% reduction. In 2014, NHPMC received 80 priority one stroke calls from MEDIC crews. Of these 80 patients, 71 were coded at discharge as either strokes or stroke mimics. This number reflects 89% stroke identification accuracy. Ischemic stroke patients who received t-PA at NHPMC had a median door to drug time of 40 minutes and a median dispatch to drug time of 68.5 minutes. Density of stroke calls assisted in identification of target areas and populations for community awareness education. Conclusion: Having a strong collaborative relationships with EMS agencies, together both EMS and hospitals can positively impact the quality of stroke care within a community. As first responders, EMS crews have a unique perspective that can improve processes and decrease time to treatment. Providing feedback information to our EMS partners helps them understand their impact on stroke patient outcomes.

Abstract WMP62: Achieving Ultra-Fast Door-to-Needle Times With a “Treat-in-CT” Acute Stroke Protocol

Background: Ultra-early thrombolysis [onset-to-treatment time (OTT) &lt; 90 min], leads to better clinical outcomes. We utilized lean manufacturing principles to re-choreograph patient flow such that tPA was delivered in the CT scanner rather than moving the patient to a separate treatment room. We tested the efficiency and safety of a “Treat-in-CT” protocol comparing metrics and outcomes before and after implementation. Methods: In July 2014, a LEAN rapid improvement event was conducted to design a “Treat-in-CT” stroke protocol. Several changes included: (1) Vital signs monitors and point of care glucose and INR were placed near the scanner. (2) Computer monitors were placed in the scanner to allow for rapid charting and order entry. (3) Local EMS crews, physicians, nursing staff, and CT technicians were trained on parallel work-flow in the scanner. The “Treat-in-CT” protocol went live 10/1/2014. We directly compared the “Pre” and “Post” Treat-in-CT epochs (1/2013-9/2014 and 10/2014-8/2015, respectively) with regard to baseline variables, metrics, and outcomes. Non-parametric statistics were used with p&lt;0.05 required for significance. Results: In the Pre- and Post-Treat-in-CT epochs, 139 and 74 patients were treated with IV tPA, respectively. Baseline variables were similar between the two epochs. Median door-to-needle time was lower in the Post-Treat-in-CT epoch: 38 min pre vs. 29 min post (p=0.002) with a trend towards lower OTT: 131 min pre vs. 100 min post (p=0.07). To ensure that efficiency did not impact safety, favorable discharge location (87% pre vs. 81% post, p=0.3), symptomatic hemorrhage rate (2.9% pre vs. 1.5% post, p=1.0), stroke mimic rate, and 90 day mRS were compared and did not differ. Conclusions: The AHA Target: Stroke-Phase II guidelines recommend administration of tPA bolus while in the CT scanner. A “Treat-in-CT” acute stroke protocol using efficient choreography and parallel processing expedited tPA delivery without compromising safety.

Ability of a diabetic problems protocol to predict patient severity indicators determined by on-scene EMS crews

Purpose: Diabetes mellitus is a leading cause of human disease, with 25.8 million Americans affected. Diabetes can cause chronic or sudden signs and symptoms, which often result in observers calling 911 for assistance. The Emergency Dispatcher's Interpretation of these calls affects dispatch triage and pre-arrival patient care. The purpose of this study is to determine the relationship between the EMDs’ assigned Medical Priority Dispatch System (MPDS) determinant codes and patient severity indicators as determined by paramedic (or EMT) on-scene findings and treatments.

Abstract P313: Using In-Situ Simulation to Reduce Door-to-Balloon Times in ST-Elevation Myocardial Infarction

BACKGROUND: Sixteen hospitals from across the United States participated in a high-fidelity teamwork simulation exercise, which was designed to identify and resolve factors that adversely affect door-to-balloon (D2B) times. METHODS: The simulation scenario was the same at each participating hospital: EMS crews transported a simulated patient who was complaining of chest pain. The patient was transferred to either the ED or the cardiac catheterization laboratory, where a simulated angioplasty was performed. All of the simulations were videotaped using high-definition video cameras, and were scored by three trained raters at 7 specific “events” during the simulation. During each event, measures of team performance and D2B times were collected. RESULTS: The results were analyzed using hierarchical multiple regression. After statistically controlling for historical data concerning D2B performance across the 16 hospitals, the observed teamwork ratings accounted for 10-50% of the criterion variance in relevant D2B measures, depending on the specific simulation event. Despite the limited sample size, all but one of the analyses reached standard levels of statistical significance. Qualitative observations also identified several systemic problems that occurred across hospital sites: inconsistent rules which resulted in the ED team needlessly repeating time-critical behaviors that were already performed by the EMS crews; how failing to register the patient while en route led to needless delays upon arriving at the cardiac catheterization laboratory; and the lack of well-defined handoff procedures between EMS crews and their counterparts in both the ED and cardiac catheterization lab. DISCUSSION: Although the findings from this pilot test need to be cross-validated with a much larger sample, the preliminary results are clear: improved teamwork behaviors can result in both practically and statistically significant reductions in D2B times, and by extension, patient care. These findings complement recent research conducted with OB teams, which have shown that our research team's “in-situ” simulation method is particularly well-suited to addressing organizational challenges that compromise patient safety and quality of care.