Local Emergency Medical Services Research Articles

1610. Implementation of Clinical Care Pathway Reduces Measles Exposures During Outbreak in New York

BackgroundThe United States is currently experiencing the largest measles outbreak since 1994. The New York outbreak started in October 2018 in several communities with low immunization rates for measles. Our institution is a referral center for the Hudson Valley and New York City. Failure to immediately recognize the disease early in the outbreak resulted in several exposure investigations and significant expenditure of time and resources. With evidence of ongoing transmission in local communities, we initiated a multi-pronged approach to recognize and limit potential measles exposures.MethodsWe developed a clinical pathway to alert Emergency Department (ED) staff and local Emergency Medical Service (EMS) agencies to the signs and symptoms of measles and provided steps for isolation, care, and testing for patients with possible measles. The ED staff and EMS personnel were educated in meetings and by posters, emails, and huddles. Reports of cases were made to infection control in real time, and local Departments of Health (DOH) were subsequently notified of suspected cases and exposures. We describe data pre and post-intervention. Chi-square was used to compare the number of patients requiring contact investigations for staff and patient exposures pre- and post-pathway implementation.ResultsFrom October 2018 through April 2019, 31 patients were evaluated for measles. Measles was diagnosed in 15 patients (1 adult, 14 children). Eight patients were admitted to the hospital, 3 required Pediatric ICU care. Pre-pathway implementation, 2 out of 9 (22%) evaluated patients resulted in exposure investigations; post implementation, 1 out of 22 (4.5%) evaluated patients required an exposure investigation (P = 0.18). The investigations conducted by our infection control department included 153 patients, 141 pre-implementation vs. 12 post-implementation. Nine patients required prophylaxis with immunoglobulin, and 10 patients received MMR vaccine as prophylaxis. No exposures resulted in clinical cases of measles.ConclusionImplementation of a clinical pathway to recognize and isolate suspected measles patients with ED staff and EMS personnel resulted in reduced exposures and improvement in communication with Infection Control and local DOH.Disclosures All authors: No reported disclosures.

Addressing the EMS workforce shortage: How medical students can help bridge the gap.

The authors propose that, through innovative and mutually beneficial partnerships between medical schools and local Emergency Medical Services (EMS) agencies, medical students can help mitigate EMS shortages in areas across the country. These partnerships, which we have seen very early signs of in some places, would create channels by which medical students get their emergency medical technician certifications in the summer before matriculating and volunteer with the agency's ambulance service, either as an extracurricular clinical experience (which are very popular among medical students) or as a way to fulfill clinical or service requirements or earn elective credit. In the attached piece, the authors (1) establish, using data, that a key factor contributing to current and impending EMS shortages is a lack of certified personnel, and (2) propose why and how medical students could provide a novel source of additional volunteers for understaffed public ambulance services, explore some of the benefits and limitations of this proposal, and provide a road-map for how to form partnerships between medical schools and local EMS agencies.

P046: Students as first responders: A survey of Canadian campus emergency medical response teams

Introduction: Canadian post-secondary campuses are densely-populated communities and the first home-away-from-home to many students participating in various academic programs, new social activities, and on-campus athletic activities. The diversity of on-campus activities combined with the high-stress of academic programs results in illness and injury rates that may increase the strain on emergency medical systems. Existing on some campuses for more than 30 years, campus emergency medical response teams (CEMRTs) address the need for a local emergency medical service that can provide first-aid in low-acuity situations and rapid response to high-acuity emergencies. In Canada, many student-run volunteer-responder CEMRTs exist but the range of their service capabilities, operations, and their call-volumes have not been described previously. This study aims to fill this knowledge gap. Methods: We surveyed the 30 known campus emergency medical response teams identified through membership in the Canadian Association of Campus Emergency Response Teams. The 32-question survey asked information on their level of training (standard first aid [SFA], first responder [FR], emergency medical responder [EMR]), service operations including call volume, and funding model. This study was approved by the Western University Institutional Review Board. Results: Twenty-four teams completed the survey (80%); the majority of which are located in Ontario (70%, 16 teams). One team reported that they are no longer in operation. Eleven teams (48%) have medical directors. Nine teams (39%) reported responding to ≤100 calls/year, 11 teams (48%) reported 100-500 calls/year, and 3 teams (13%) reported >500 calls/year. Responders of two teams (9%) maintain training at SFA level; 14 teams (61%) have some or all responders with FR training; and 6 teams (26%) have some or all members certified at EMR level. Twenty-one teams (91%) are equipped with AEDs and 19 teams (83%) are equipped with oxygen. Common medications carried include epinephrine (13 teams, 57%), naloxone (12 teams, 52%), and acetylsalicylic acid (9 teams, 39%). Conclusion: Canadian post-secondary campuses have highly-active student-run volunteer CMERTs. Considerable variability in the services provided may reflect the unique needs of the campuses they serve. CEMRTs may reduce low-acuity case demand on local emergency medical response and emergency department services in some communities; their impact on system demand and costs is the subject of future work.

Lessons Learned in Helicopter Operations During a Large Multiagency Disaster Prevention Drill in Japan

ObjectiveIn 2018, the Cabinet Office executed a disaster prevention drill based on the scenario that Nankai had a megathrust earthquake and a large tsunami hit Tokushima Prefecture. The purpose of this study was to summarize the key lessons learned in the review of the Department of Aviation Operation for Tokushima Prefecture in this drill. MethodsThis report was based on a review using data from the Japan emergency medical information sharing system that can be accessed via the Internet. ResultsIn the disaster drill, the doctor helicopter (DH) headquarters of Tokushima Prefecture at Takamatsu Airport was able to procure 2 actual DHs and 2 mock DHs. The Department of Aviation Operation within the Tokushima Prefectural Government was able to procure 1 actual helicopter belonging to the Coast Guard and 8 mock helicopters (4 belonging to the military and 4 to the fire department). There were 29 flights, including actual and mock flights, and 44 victims were medically transported. ConclusionBy making flight plans with each organization concerned, we were able to share the basic rules, concepts, and management approaches of flights among the responding organizations. Disaster planners should have at least a passing familiarity with the aviation capabilities of the local helicopter emergency medical service and other helicopter operations.

Medical Control Decisions: When Does a Neonate Become a Separate Patient?

Patient refusal for care or transport is a common request to medical control physicians, and it is an especially challenging decision in the case of minors. Parents or guardians are able to refuse medical care for a minor if there is not an imminent threat of harm to the minor. However, if a minor patient is presumed to be in need of emergent medical care to prevent harm, medical personnel have the right to treat the minor, even if the parent or guardian objects. If the minor patient is a fetus or a neonate, it is not always clear when they are considered to be a separate patient. Apparently, there is no over-riding general rule or law and, consequently, Emergency Medical Services (EMS) protocols vary greatly from state to state. This case report describes one patient case that involved some of these unclear legal areas and how it fit with local EMS protocols. The legal question arose when a pregnant patient delivered her baby, but the umbilical cord was not cut. Are the mother's rights violated by cutting the umbilical cord if she objects to the procedure? How is the medical control physician to decide when to go beyond established EMS protocols to ensure that the safest and most ethical care is provided to a patient in the field? Does the care of the infant or the mother take precedence? Continued analyses of cases are required to ensure that protocols and guidelines are protecting both patients and providers.Venegas A, Ann Maggiore W, Wells R, Baker R, Watts S. Medical control decisions: when does a neonate become a separate patient? Prehosp Disaster Med. 2019;34(2):224-225.

Knowledge, attitude and practice of emergency medical care in Lima, Peru

Background: This study gauged public need and reception for a community-based first-aid and cardiopulmonary resuscitation (CPR) training program in Lima, Peru, to counteract predicted emergency medical service (EMS) deficits.Methods: The study population consisted of Lima households that were selected with a two-staged 30x7 cluster sampling method. An EMS and first-aid focused knowledge-attitude-practice (KAP) survey was administered by a joint academic-community interview team.Results: The study included 210 households from 30 districts within Lima. Among the participants, 61.4% were unable to provide an EMS number and only 24.8% would call an ambulance in case of a family emergency. Although 37.6% could provide first-aid, 99.5% would feel more comfortable if a neighbor were first-aid trained.Conclusions: The results indicated a lack of confidence in Lima’s EMS systems and awareness of EMS contact numbers, which possibly led community members to trust each other over their local EMS. The creation of a community-based first-aid and CPR training program can potentially take advantage of strong intra-community trust, mitigate first-aid deficits, and alleviate Lima’s injury burden by providing a buffer against barriers to effective EMS responses.

Abstract TP377: Routing for Rapid Results

Background: In 2016, the American Heart Association (AHA) published recommendations for emergent large vessel occlusion (ELVO) routing at the International Stroke Conference based on symptomatology and distance from a thrombectomy capable stroke center. Research has shown that a rapid door to puncture and reperfusion time leads to improved patient outcomes in large vessel occlusion patients who meet criteria for thrombectomy. The door to puncture (D2P) benchmark for the AHA Get with the Guidelines data registry and the local Emergency Medical Services (EMS) is 90 minutes. Purpose: The purpose of the project was to find a way to shorten the D2P time in ELVO patients in a 265 bed community hospital. Method: The solution to shortening the D2P time was to identify ELVO patients using an evidenced based stroke severity scale. Collaboration ensued between the thrombectomy capable stroke centers and local EMS to discuss ELVO routing. Previously, stroke patients were identified by EMS only using the Cincinnati Prehospital Stroke Scale (CPSS). The local EMS and the participating hospitals selected the Ventura ELVO Scale (VES), an evidenced based stroke severity scale, to assess positive CPSS patients in the field. Policies were developed, education was rolled out, and ELVO routing went live in October 2017 with two ELVO receiving centers. Our hospital, one of the receiving centers, collected data to follow the trend of D2P times. Results: D2P median prior to going live with ELVO routing was 127 minutes. Only one patient out of fifteen patients between December 2016 and August 2017 had a D2P less than 90 minutes. Between October 2017 and July 2018, after ELVO routing began, ten out of fourteen patients had D2P less than 90 minutes. The median improved to 89 minutes on these patients. All D2P times were then tabulated together to calculate a total median time of all cases. Conclusion: ELVO routing combined with the implementation of the VES enabled us to be successful in shortening our D2P to below the benchmark of 90 minutes. This method may be beneficial in other community based hospitals and counties looking to shorten their D2P.

Abstract WP497: And the Golden Lobe Award for Best Stroke Patient Outcomes Goes To

Background and Purpose: This process improvement project was conducted to improve the emergency department (ED) door to needle time (DTN) for intravenous (IV) alteplase times for stroke patients arriving both by local emergency medical services (EMS) and by private owned vehicles (POV). Ultimate goal was to meet American Heart Association (AHA) and American Stroke Association (ASA) Get With the Guidelines (GWTG) Target Stroke Honor Roll Elite Plus. Methods: A two-year nurse led multidisciplinary collaborative process improvement (PI) plan was designed to include local EMS, emergency department (ED) and radiology personnel. The patient workflow was streamlined allowing EMS Stroke Alert patients, as well as patients arriving in the ED in POV, with stroke symptoms, to go straight to the radiology department for immediate computed tomography (CT) scans. The PI plan was based on Six Sigma methodology and included a 90-day pilot data analysis led by Registered Nurse (RN) Directors, Neurologists, ED Physicians, Medical Imaging, Quality Improvement, and RN Stroke Coordinator. As part of the project design a recognition award was given to team mates with the best patient outcomes. The “Golden Lobe” award was awarded to EMS and ED team members for their significant improvement in stroke patient outcomes. Results: January 2016 to July 2018, a total of 79 were included. Average DTN times for EMS patients decreased 5.4 minutes, from 40.7 to 35.3. Average DTN times for POV patients decreased 17.8 minutes, from 51.8 to 34. Additional improvements were noted on transferring large vessel occlusion, drip and ship cases 81 minutes faster, from 196 to 115. Complication rates associated with IV alteplase decreased by 2.9% and stroke mimic rate reduced by 6.1%. Conclusion: In conclusion, nurse led multi-disciplinary collaborative PI project was successful in reducing DTN time for patients exhibiting stroke symptoms regardless if they arrived EMS or POV. Not only did the ED team improve DTN time, they also decreased IV alteplase complication rates, stroke mimic rates and stroke interventional transfer times.

Response time in the emergency services. Systematic review.

The growth of the urban population raises concern about municipal public managers in the sense of providing emergency medical services (EMS) that are aligned with the needs of prehospital emergency medical care demanded by the population. The literature review aims at presenting the response time of emergency medical services in several parts of the world and discussing some factors that interfere in the result of this indicator such as GDP (Gross Domestic Product) percentage spent on health and life expectancy of countries. The study will also show that in some of the consulted articles, authors suggest to EMS recommendations for decreasing the response time using simulations, heuristics and metaheuristics. Response time is a basic indicator of emergency medical services, in such a way that researchers use the descriptive statistics to evaluate this parameter. Europe and the USA outstand in the publication of studies that present this information. Some articles use stochastic and mathematical methods to suggest models that simulate scenarios of response time reduction and suggest such proposals to the local EMS. Countries in which the response time was identified have a high index of human development and life expectancy between 74.7 and 83.7 years.

The Digital EMS California Academy of Learning: One State's Innovative Approach to EMS Fellow Education.

Emergency medical services (EMS) fellowships are growing in significance within the United States prehospital health care system. While fellowships represent a cornerstone of EMS subspecialty education, an individual learner's experiences are limited by local resources and practices. California EMS fellowships have developed an innovative method for expanding fellows' educational experiences outside their immediate programs. Each month, fellows, fellowship directors, and local EMS medical directors from throughout the state participate in a video conference. This meeting is divided into four distinct components: book chapter presentation, board-style question review, call review, and an EMS literature review. The two-volume text Emergency Medical Services: Clinical Practice and Systems Oversight has been categorized into 12 modules, one for each month of the fellowship. Every meeting, one fellow prepares a didactic presentation summarizing the highlights from that month's chapters. Fellows each create five multiple-choice questions and answers, based on the section reading. Questions are assessed by the group, both for informational content and for appropriate formatting. After completion, these questions are submitted for future review for the EMS fellowship in-service examination. Based on that month's module topics, a call is chosen and reviewed. Regional protocol and practice differences from different systems are discussed. The online medical oversight provided and the prehospital provider performance are evaluated by the group. Fellows not assigned to present a call or didactic segment each choose one paper focusing on a subject relevant to the module or call. Strengths of the study design, analysis, outcomes, and relevance to EMS practice are discussed. Fellows and experienced EMS attendings are exposed to different protocol and system approaches in an interactive and accessible format. This partnership expands educational opportunities for fellows and promotes collaboration across EMS systems.

Abstract 170: Challenges in Implementing an ECPR Program for Out of Hospital Cardiac Arrest

Introduction: Extracorporeal cardiopulmonary resuscitation (ECPR) can treat cardiac arrest refractory to conventional therapy. Many institutions are interested in developing their own ECPR program. However, there are challenges in logistics and implementation. Hypothesis: Development of an ECPR team and identification of UPMC Presbyterian as a receiving center will increase recognition of potential ECPR candidates. Methods: We developed an infrastructure of Emergency Medical Services (EMS), Medic Command, and an in-hospital ECPR team. We identified inclusion criteria for patients with an out of hospital cardiac arrest (OHCA) likely to have a reversible arrest etiology and developed them into a simple checklist. These criteria were: witnessed arrest with bystander CPR, shockable rhythm, and ages 18 to 60. We trained local EMS crews to screen patients and review the checklist with a Command Physician prior to transport to our hospital. Results: From October 2015 to March 31 st 2018, there were 1165 dispatches for OHCA, of which 664 (57%) were treated and transported to the hospital and 120 to our institution. Of these, five patients underwent ECPR. Of the remaining cases, 64 (53%) had nonshockable rhythms, 48 (40%) were unwitnessed arrests, 50 (42%) were over age 60 and the remaining 20 (17%) had no documented reasons for exclusion. Prehospital CPR duration was 26 [IQR 25-40] min. Four patients (80%) underwent mechanical CPR with LUCAS device. Time from arrest to arrive on scene was 5 [IQR 4-6] min and time call MD command was 13 [IQR 7-21] min. Time to transport was 20 [IQR 19-21] min. Time from arrest to initiation of ECMO was 63 [IQR 59-69] min. Conclusions: ECPR is a relatively infrequent occurrence. Implementation challenges include prompt identification of patients with reversible OHCA causes, preferential transport to an ECPR capable facility and changing the focus of EMS in these select patients from a “stay and play” to a “load and go” mentality.

Botulism Outbreak in a Regional Community Hospital: Lessons Learned in Transfer and Transport Considerations

Botulism is a potentially lethal disease caused by a toxin released by Clostridium botulinum. Outbreaks of botulism from food sources can lead to a Mass Casualty Incident (MCI) involving sometimes hundreds of individuals. We report on a recent outbreak of botulism treated at a regional community hospital with a focus on emergency medical services (EMS) response and transport considerations. Case Presentation: There were 53 patient evaluated for botulism at the sending facility. In total, 11 botulism exposures required intubation at the sending facility. Twenty-four patients were ultimately transported by critical care capable ALS crews with the majority (16) of these transports occurred in the first 24 hours. There was one fatality in the first days of the outbreak and a second death that occurred in a patient who died after long-term acute care (LTAC) placement several months after hospital discharge. Conclusion: Local EMS providers and public safety officers have a critical role in identifying and following up on potentially exposed botulism cases. The organization of transporting agencies and the logistics of transfer turned out to be 2 opportunities for improvement in response to this mass casualty incident.

Achieving Health System Wide 90 Minute Door-to-balloon Times for STEMI Transfers

Introduction Most patients experiencing STEMI present to facilities that lack interventional cardiology services, thus requiring transport to a tertiary center. The national D2B goal time for patients requiring interfacility transfer is 120 minutes or less; our previous work achieved that goal by implementing an STEMI autolaunch process. To further improve D2B times for transfer patients we took a systems level approach to develop a high reliability STEMI transfer system. The primary interventions, system changes, and results are presented. Methods This was a quality improvement project that entailed a collaboration between the Emergency Services Institute, Heart and Vascular Institute, Critical Care Transport, health system community hospitals and local emergency medical services throughout our region. Over 18 months, system changes were developed by the interdisciplinary team (Table 1), implemented, and evaluated with feedback provided to all involved on a monthly basis. Results Patients presenting to community hospital ED's experienced a 16 minute reduction in door-in-door-out time (now 44 minutes versus 60 minutes). Additionally the mean D2B times for all patients requiring transfer in the health system reduced to and remained at 90 minutes for 12 consecutive months in 2017. Reported mortality at the project start was below the 50th percentile and now exceeds the 90th percentile nationally. Conclusion Our results show that improving and maintaining D2B times for patients needing interfacility transfer requires a systems level approach that must encompass the entire healthcare system from initial patient activation through to discharge. The interventions developed can be adapted and applied in other settings.

Challenges in Statewide Implementation of a Prehospital Evidence-Based Guideline: An Assessment of Barriers and Enablers in Five States

Background: Individual states, regions, and local emergency medical service (EMS) agencies are responsible for the development and implementation of prehospital patient care protocols. Many states lack model prehospital guidelines for managing common conditions. Recently developed national evidence-based guidelines (EBGs) may address this gap. Barriers to statewide dissemination and implementation of model guidelines have not been studied. The objective of this study was to examine barriers and enablers to dissemination and implementation of an evidence-based guideline for traumatic pain management across 5 states. Methods: This study used mixed methods to evaluate the statewide dissemination and implementation of a prehospital EBG. The guideline provided pain assessment tools, recommended opiate medication dosing, and indications and contraindications for analgesia. Participating states were provided an implementation toolkit, standardized training materials, and a state-specific implementation plan. Outcomes were assessed via an electronic self-assessment tool in which states reported barriers and enablers to dissemination and implementation and information about changes in pain management practices in their states after implementation of the EBG. Results: Of the 5 participating states, 3 reported dissemination of the guideline, one through a state model guideline process and 2 through regional EMS systems. Two states did not disseminate or implement the guideline. Of these, one state chose to utilize a locally developed guideline, and the other state did not perform guideline dissemination at the state level. Barriers to state implementation were the lack of authority at the state level to mandate protocols, technical challenges with learning management systems, and inability to track and monitor training and implementation at the agency level. Enablers included having a state/regional EMS office champion and the availability of an implementation toolkit. No participating states demonstrated an increase in opioid delivery to patients during the study period. Conclusion: Statewide dissemination and implementation of an EBG is complex with many challenges. Future efforts should consider the advantages of having statewide model or mandatory guidelines and the value of local champions and be aware of the challenges of a statewide learning management system and of tracking the success of implementation efforts.

Assessing the Prevalence and Predictors of Bullying Among Emergency Medical Service Providers

Background: Bullying as a stressor in the workplace has been evaluated in numerous settings. It has never been evaluated in the emergency medical service (EMS) environment where bullying can occur from many different sources. The Negative Acts Questionnaire-Revised (NAQ-R) is a 22-question validated tool for evaluating bullying. Our hypothesis was that we could identify a shortened version of the NAQ-R that identifies bullying as accurately as the full screening tool. Methods: This was a cross sectional study of EMS providers in our local EMS transport agency. The local EMS agency transports approximately 50,000 patients per year and is a paramedic level response system. Results on the NAQ-R were on a 5-point Likert scale for each of 22 different categories of bullying that were summed by adding each questions 1–5 response for the 22 questions. Respondents were also categorized as victims or non-victims of bullying based on being positive for any of the 22 types of bullying at least once a week. We performed a binomial decision tree analysis and a cross-validation. Results: Data were collected from 153 providers. Mean age was 33 ± 10 years and 50% were male. Total years in EMS were 8 ± 8 years. NAQ-R summed results in our group ranged between 22 and 88, with an average of 40 ± 15. A NAQ-R score of 33 or less was 91% accurate in identifying non-victims and a score of 45 or more was 94% accurate in identifying victims. The majority at 51% (77/152) of respondents were victims of one or more types of bullying. A combination of five questions was 94% accurate in identifying a victim of bullying among EMS providers. Cross validation resulted in a misclassification risk estimate of 0.12 ± .03. Conclusion: NAQ-R bullying scores in EMS are similar or higher than numbers in other fields. Five questions on the NAQ-R were 94% accurate in identifying victims of bullying in EMS providers.

BreathEZ: Using smartwatches to improve choking first aid

Choking first aid is an important tool for all individuals as choking is the cause of nearly 5000 deaths per year in the US. Normally for incidents like this, the local emergency medical services (EMS) could be relied up on to respond and provide necessary lifesaving aid. The average EMS response time is almost eight minutes and someone choking only has four to six minutes before permanent brain damage occurs. Cardiopulmonary resuscitation (CPR) trained individuals are often also trained in choking first aid for this very reason, though relying on bystanders presents its own problem. Many individuals assume others will be more qualified to help and therefore will not involve themselves, a psychological phenomenon known as the bystander effect. In order to combat this problem, we present BreathEZ, a smartwatch application that provides both choking first aid instruction and real-time tactile and visual feedback on the quality of the abdominal thrust compressions. To the best of our knowledge, prior to this there has been no feedback device developed that targets choking first aid. BreathEZ uses the onboard accelerometer on an Android smartwatch to identify an abdominal thrust and measure the peak acceleration. It then analyzes the data collected and provides feedback on the quality of the thrust to the user.

Implementation of a Regional Network for ST-Segment-Elevation Myocardial Infarction (STEMI) Care and 30-Day Mortality in a Low- to Middle-Income City in Brazil: Findings From Salvador's STEMI Registry (RESISST).

BackgroundFew data exist on regional systems of care for the treatment of ST‐segment–elevation myocardial infarction (STEMI) in developing countries. Our objective was to describe temporal trends in 30‐day mortality and identify predictors of mortality among STEMI patients enrolled in a prospective registry in Brazil.Methods and ResultsFrom January 2011 to June 2013, 520 patients who received initial STEMI care at 23 nonspecialized public health units or hospitals, some of whom were transferred to a public cardiology referral center, were identified through a regional STEMI network supported by telemedicine and the local prehospital emergency medical service. We stratified patients into five 6‐month periods based on presentation date. Mean age (±SD) of patients was 62.0 (±12.2) years, and 55.6% were men. The mean Global Registry of Acute Coronary Events (GRACE) score was 145 (±34). Overall mortality at 30 days was 15.0%. Use of dual antiplatelet therapy and statins increased significantly from baseline (January 2011) to period 5 (June 2013): 61.8% to 93.6% (P<0.001) and 60.4% to 79.7% (P<0.001), respectively. Rates of primary reperfusion also increased (29.1%–53.8%; P<0.001), and more patients were transferred to the referral center (44.7%–76.3%; P=0.001). Thirty‐day mortality rates decreased from 19.8% to 5.1% (P<0.001). In multivariable analysis, factors independently associated with 30‐day mortality were higher GRACE score, history of previous stroke, lack of transfer to the referral center, and lack of use of optimized medical therapy.ConclusionsImplementation of a regional STEMI system was associated with lower mortality and higher use of evidence‐based therapies.

Usefulness of Intravenous Sodium Nitrite During Resuscitation for the Treatment of Out-of-Hospital Cardiac Arrest

It is hypothesized that intravenous (IV) sodium nitrite given during resuscitation of out-of-hospital cardiac arrest (OHCA) will improve survival. We performed a phase 1 open-label study of IV sodium nitrite given during resuscitation of 120 patents with OHCA from ventricular fibrillation or nonventricular fibrillation initial rhythms by Seattle Fire Department paramedics. A total of 59 patients received 25 mg (low) and 61 patients received 60 mg (high) of sodium nitrite during resuscitation from OHCA. Treatment effects were compared between high- and low-dose nitrite groups, and all patients in a concurrent local Emergency Medical Services registry of OHCA. Whole blood nitrite levels were measured in 97 patients. The rate of return of spontaneous circulation (48% vs 49%), rearrest in the field (15% vs 25%), use of norepinephrine (12% vs 12%), first systolic blood pressure (124 ± 32 vs 125 ± 38 mm Hg), survival to discharge (23.7% vs 16.4%), and neurologically favorable survival (18.6% vs 11.5%) were not significantly different in the low and high nitrite groups. There were no significant differences in these outcomes among patients who received IV nitrite compared with concurrent registry controls. We estimate that 60 mg achieves whole blood nitrite levels of 22 to 38 μM 10 minutes after administration, whereas 25 mg achieves a level of 9 to 16 μM 10 minutes after delivery. In conclusion, administration of IV nitrite is feasible and appears to be safe in patients with OHCA, permitting subsequent evaluation of the effectiveness of IV nitrite for the treatment of OHCA.

MP10: Implementation of the PulsePoint mobile device application in Kingston, Ontario, Canada: a pilot study on crowdsourcing bystander CPR for victims of out-of-hospital cardiac arrest

Introduction: Every year 40,000 out-of-hospital cardiac arrests (OHCA) occur in Canada. Only 1 in 10 survive. Early bystander cardiopulmonary resuscitation (CPR) and defibrillation can triple odds of survival. PulsePoint is a mobile device application designed to crowdsource bystander CPR and public access defibrillation for victims of OHCA. Kingston, Ontario was the first Canadian city to launch PulsePoint. The objective of this project was to determine feasibility of PulsePoint implementation in a Canadian setting and to describe system performance. Methods: This was a descriptive observational study. We included all 9-1-1 incidents involving PulsePoint system activation in Kingston, Ontario and all confirmed, public location OHCAs assessed by local emergency medical services (EMS) between March 23, 2015 to January 23, 2017. By using time and location data from PulsePoint system alert notifications, we attempted to link each PulsePoint activation to de-identified ambulance call records. Results: Between March 23, 2015 to January 23, 2017, there were 258 PulsePoint system activations in Kingston and a total of 32 cases of confirmed OHCAs. Only 58 (22%) of PulsePoint activations could be linked to EMS records with high confidence. Of these linked cases, 10 were confirmed OHCAs, reflecting 17% (10/58) of all linked PulsePoint activations and 31% (10/32) of all confirmed OHCAs. Of the remaining 48 cases that triggered PulsePoint activation numerous final paramedic problem codes were assigned of which 14% (8/58) were deemed alcohol intoxication, 10% (6/58) were active seizures, 7% (4/58) were behavioural/psychiatric events, among others. 10 incidents (17%) that triggered PulsePoint activation did not have an assigned final paramedic problem code. Conclusion: Implementation of PulsePoint is feasible in Canadian communities. Improved capabilities for linking with local EMS data will improve data capture, program monitoring capacity, and opportunity for research. The impact of PulsePoint on clinical outcomes remains uncertain and should be determined in future research.

Are You Ready for Emergency Medical Services in Your Oral and Maxillofacial Surgery Office?

Efficient responses to emergencies in the oral and maxillofacial surgery office require preparation, communication, and thorough documentation of the event and response. The concept of team anesthesia is showcased with these efforts. Emergency medical services training and response times vary greatly. The oral and maxillofacial surgery office should be prepared to manage the patient for at least 15minutes after making the call to 911. Patient outcomes are optimized when providers work together to manage and transport the patient. Oral and maxillofacial surgery offices should develop and rehearse emergency plans and coordinate these protocols with local Emergency medical services teams.