Mean Scene Time Research Articles

EMS Calls for Service at Adult Detention Centers–A Descriptive Study

Introduction:Incarcerated individuals represent a particularly vulnerable sector of society, with a disproportionate burden of drug use, mental health problems, and chronic illness. The purpose of this study was to perform a descriptive analysis of EMS response to detention facilities.Method:Retrospective review of EMS calls to detention facilities between 1/1/2002 and 12/31/2021 within our EMS system. Data were analyzed using descriptive statistics and Student’s t-test. This study was deemed exempt by the Institutional Review Board.Results:3,126 requests for service occurred during the study period. Average patient age was 40.2 ± 13.3 years, compared with 54.0 ± 25.9 years for non-detention center calls (p < 0.001). The majority (80.8%) of patients were male. Mean scene time was 14:13 ± 7:49 minutes, compared with 12:04 ± 12:27 minutes (p < 0.01) for non-detention center calls. The most common complaints were chest pain (15.6%), trauma (13.6%), seizure (11.7%), behavioral (9.2%), and overdose (4.7%); OB requests accounted for 5.8% of calls for female patients. Most calls (86.0%) to detention centers involved incarcerated individuals. Four percent of patients refused treatment; 27.8% of these patients were still transported. One hundred and eight patients were identified by EMS as not needing transport. Consent for treatment/transport by the patient was documented in 5.2% of charts.Conclusion:Within our 911 service area, calls to detention facilities are not uncommon, predominantly involve incarcerated individuals, and are primarily due to chest pain, trauma, or seizures. Consent for treatment/transport was not documented in most EMS encounters. Further study is needed to better understand the health care needs of these patients, including ability to consent and access to chronic medications.

Comparing Emergency Medical Services Processing Times for Stroke Patients Before and During COVID-19 Pandemic; A Cross-sectional Study.

Coronavirus disease 2019 (COVID-19) has directly affected global healthcare, especially the front-line of healthcare provision, including emergency medical services (EMS). The present study aimed to compare EMS processing times and the number of acute stroke patients serviced by EMS before and during COVID-19 pandemic. This is a retrospective observational review of Bangkok Surgico Medical Ambulance and Rescue Team (S.M.A.R.T.) EMS data from 2018 to 2021. The EMS processing times and the number of acute strokes were compared between pre-COVID-19 era (January 1st, 2018, and December 31st, 2019) and during COVID-19 pandemic (January 1st, 2020, and December 31st, 2021). The number of stroke patients transported by EMS in one year, before and during COVID-19 pandemic was 128 and 150 cases, respectively (Change difference = 17.2%, 95% CI: 11.1-24.9). However, the average number of acute stroke patients per week was not significantly different (p = 0.386). The mean total EMS processing times before and during COVID-19 era were 25.59 ± 11.12 and 45.47 ± 14.61 minutes, respectively (mean difference of 19.88 (95% CI: 16.77-22.99) minutes; p < 0.001). The mean time from symptom onset to EMS arrival (p < 0.001), the mean call time (p < 0.001), the mean response time (p < 0.001), and the mean scene time (p < 0.001) were significantly higher during COVID-19 period. The mean transportation times for stroke patients was similar before and during COVID-19 pandemic (10.14 ± 6.28 and 9.41 ± 6.31 minutes, respectively; p = 0.338). During COVID-19 pandemic, the number of acute stroke patients serviced by EMS increased substantially, but there was no difference in the average number of patients per week. During the pandemic, EMS processing times markedly increased.

Pre-hospital emergency anaesthesia in trauma patients treated by anaesthesiologist and nurse anaesthetist staffed critical care teams.

BackgroundPre‐hospital tracheal intubation in trauma patients has recently been questioned. However, not only the trauma and patient characteristics but also airway provider competence differ between systems making simplified statements difficult.MethodThe study is a subgroup analysis of trauma patients included in the PHAST study. PHAST was a prospective, observational, multicentre study on pre‐hospital advanced airway management by anaesthesiologist and nurse anaesthetist manned pre‐hospital critical care teams in the Nordic countries May 2015‐November 2016. Endpoints include intubation success rate, complication rate (airway‐related complication according to Utstein Airway Template by Sollid et al), scene time (time from arrival of the critical care team to departure of the patient) and pre‐hospital mortality.ResultThe critical care teams intubated 385 trauma patients, of which 65 were in shock (SBP <90 mm Hg), during the study. Of the trauma patients, 93% suffered from blunt trauma, the mean GCS was 6 and 75% were intubated by an experienced provider who had performed >2500 tracheal intubations. The pre‐hospital tracheal intubation overall success rate was 98.6% and the complication rate was 13.6%, with no difference between patients with or without shock. The mean scene time was significantly shorter in trauma patients with shock (21.4 min) compared to without shock (21.4 vs 25.1 min). Following pre‐hospital tracheal intubation, 97% of trauma patients without shock and 91% of the patients in shock with measurable blood pressure were alive upon arrival to the ED.ConclusionPre‐hospital tracheal intubation success and complication rates in trauma patients were comparable with in‐hospital rates in a system with very experienced airway providers. Whether the short scene times contributed to a low pre‐hospital mortality needs further investigation in future studies.

Prehospital Trauma Scene and Transport Times for Pediatric and Adult Patients

IntroductionIncreased out-of-hospital time is associated with worse outcomes in trauma. Sparse literature exists comparing prehospital scene and transport time management intervals between adult and pediatric trauma patients. National Emergency Medical Services guidelines recommend that trauma scene time be less than 10 minutes. The objective of this study was to examine prehospital time intervals in adult and pediatric trauma patients.MethodsWe performed a retrospective cohort study of blunt and penetrating trauma patients in a five-county region in North Carolina using prehospital records. We included patients who were transported emergency traffic directly from the scene by ground ambulance to a Level I or Level II trauma center between 2013–2018. We defined pediatric patients as those less than 16 years old. Urbanicity was controlled for using the Centers for Medicare and Medicaid’s Ambulance Fee Schedule. We performed descriptive statistics and linear mixed-effects regression modeling.ResultsA total of 2179 records met the study criteria, of which 2077 were used in the analysis. Mean scene time was 14.2 minutes (95% confidence interval [CI], 13.9–14.5) and 35.3% (n = 733) of encounters had a scene time of 10 minutes or less. Mean transport time was 17.5 minutes (95% CI, 17.0–17.9). Linear mixed-effects regression revealed that scene times were shorter for pediatric patients (p<0.0001), males (p=0.0016), penetrating injury (p<0.0001), and patients with blunt trauma in rural settings (p=0.005), and that transport times were shorter for males (p = 0.02), non-White patients (p<0.0001), and patients in urban areas (p<0.0001).ConclusionThis study population largely missed the 10-minute scene time goal. Demographic and patient factors were associated with scene and transport times. Shorter scene times occurred with pediatric patients, males, and among those with penetrating trauma. Additionally, suffering blunt trauma while in a rural environment was associated with shorter scene time. Males, non-White patients, and patients in urban environments tended to have shorter transport times. Future studies with outcomes data are needed to identify factors that prolong out-of-hospital time and to assess the impact of out-of-hospital time on patient outcomes.

Abstract WP295: Factors Influencing Ems Transport Time for Patients After Stroke in San Diego County

Background: Emergency Medical Services (EMS) play an important role as initial providers to stroke patients. Data of on scene and transport times for stroke patients with unbiased populations are rare. We explored the range of times for stroke patients to receive care on scene and transport to a stroke receiving center (SRC) in a region with 3.3 million residents, 18 SRCs and 19 ground transport advanced life support EMS agencies. This will inform researchers on prehospital stroke invervention and policy makers deliberating triage and stroke center designation. Methods: We included all patients with final hospital diagnosis of AIS, ICH, SAH, or TIA transported by EMS to a San Diego County SRC between July 2017 and December 2018 with computer automated dispatch record and base hospital record. Records were linked on EMS incident number, reviewed for accuracy. We analyzed scene and transport time, weekday vs. weekend, last known normal (LKN) to EMS enroute &lt; 6 hours (approximation of LKN to 911 call), EMS recognition of stroke, and final hospital diagnosis. Results: In total, 2,376 patients with final stroke diagnosis were transported between July 2017 and December 2018. In 1,514 (63.7%) cases, EMS recognized stroke. In these cases mean (±SD) scene time was 12.0 (±4.6) minutes and transport time 12.4 (±7.2). In stroke patients without EMS stroke recognition the mean (±SD) scene time was 14.8 (±5.7) (p=.0001) and transport time of 16.2 (±8.1) (p=.0001). Scene time (p=.002), EMS stroke recognition (p=.00001), weekend vs. weekday (p=.013), LKN to enroute &lt; 6 hours (p=.00001) were all correlated with shorter transport time; hospital stroke diagnosis (p=.56) was not. Linear regression indicated LKN to enroute &lt; 6 hours (p=.001) and EMS stroke recognition (p=.00001) were significant in determining shorter transport time. Conclusion: EMS transport time of stroke patients varies across our system. However, when EMS providers recognize a stroke patient, scene time decreases by nearly 3 minutes and transport time decreases by nearly 4 minutes compared with patients with stroke undetected until after hospital arrival. Additionally, patients with a shorter LKN to EMS enroute time have a shorter transport time, which may be clinically important for this time-sensitive condition.

Abstract TP245: Variance in Ems Run Times by Receiving Hospital for Stroke Patients in San Diego County

Background: Emergency Medical Services (EMS) play an important role as initial providers after stroke. Few data are available that capture Stroke Receiving System and EMS response and transport data. We used a stroke registry from a community of 3.3 million residents, 18 stroke receiving centers, and 19 ground transporting advanced life support EMS agencies to evaluate EMS response time, scene time, and transport times. Our aim was to inform the stroke community about duration of EMS care and guide future prehospital interventions. Methods: We included all cases from the San Diego County Stroke Registry arriving by EMS with associated computer automated dispatch (CAD) record and base hospital record (BHR) from July 2017 through December 2018. Records were linked on the EMS incident number, reviewed for accuracy. We analyzed EMS response, scene, transport and total run times (enroute to arrival) by receiving hospital. Results: Between July 2017 and December 2018 2,376 EMS patients were transported to 18 hospitals. Volume per hospital ranged from 11 to 483 patients over the study period. Mean (±SD) response time was 7.0 (±3.7) minutes, range: 5.3 to 9.3 minutes between hospitals. Mean (±SD) scene time was 13.1 (±5.2) minutes, range: 10.5 to 15.0 minutes between hospitals. Transport time averaged 13.8 (±7.7) minutes, range: 8.3 to 23.8 minutes between hospitals (IQR=8.5-17.9). The mean (±SD) total EMS run time was 33.8 (±10.8) minutes, range: 26.4 to 44.9 minutes between hospitals (IQR=26.4-39.9). Conclusion: Only minor variations in EMS response and scene times were observed across the Stroke Receiving Centers. However, transport time showed greater variation and contributed to the differences in total EMS run times. Many systems had short transport times, limiting prehospital interventions. Next steps include studying factors contributing to transport time variation to inform prehospital care and triage decisions of possible stroke patients to optimize transport times.

Endotracheal intubation by a specialised paediatric retrieval team.

Intubation of critically ill children is an infrequent procedure, and is associated with significant risk. We set out to describe intubations carried out by the Children's Health Queensland Retrieval Service (CHQRS), with the intention to identify areas for improvement in the performance of intubation in the retrieval setting. Paediatric patients undergoing transport while intubated were identified, and cases where intubation occurred after the arrival of the CHQRS team were examined. Over the study period of January 2015 to September 2018, 498 intubated retrievals were undertaken; 85 patients were intubated after the arrival of CHQRS; the age range was 1 day to 16.5 years (median 0.5, interquartile range [IQR] 0.11-3 years). The median weight was 6.2 kg (IQR 3.7-16.5 kg). The pathology requiring intubation included respiratory 36 (42.3%), sepsis 21 (24.7%), neurological 11 (12.9%) and trauma 7 (8.2%). A total of 470 of 498 (94.4%) of intubated patients were from regional referral or tertiary hospitals, 28 of 498 (5.6%) were from rural and remote facilities. Of 85 patients, 57 (67.1%) were intubated by CHQRS and 28 (32.9%) were intubated by a doctor from the referring facility. The CHQRS team was more likely to perform the intubation in smaller children (median weight 5.0 vs 9.9 kg, P = 0.03). The mean scene time was 2.8 h. The scene time was shorter if the intubation was performed by CHQRS (mean 2.6 h, median 2.5, IQR 1.8-3.3; median 3, IQR 2.2-3.9; P = 0.048). The scene time was shorter when the intubation was predicted from tasking information (2.6 vs 3.1 h; P = 0.03). Paediatric endotracheal intubation is an infrequent procedure in our service. An airway registry could improve documentation and gather information to identify specific training requirements and areas for practice improvement.

Analysis of Prehospital Scene Times and Interventions on Mortality Outcomes in a National Cohort of Penetrating and Blunt Trauma Patients

Background: Recent studies have suggested improved outcomes in victims of penetrating trauma managed with shorter prehospital times and limited interventions. The purpose of the current study was to perform an outcome analysis of patients transported following penetrating and blunt traumatic injuries. Methods: We performed a descriptive retrospective analysis of the 2014 National Emergency Medical Services Information System (NEMSIS) public release research data set for patients presenting after acute traumatic injury. Results: A total of 2,018,141 patient encounters met criteria, of which 3.9% were penetrating trauma. Prehospital cardiac arrest occurred in 0.5% blunt and 4.2% penetrating trauma patients. Emergency department (ED) mortality was higher in penetrating than blunt trauma patients (4.1% vs. 0.8%). Scene times were 18.1 ± 36.5 minutes for blunt and 16.0 ± 45.3 minutes for penetrating trauma. Mean scene time for blunt trauma patients who died in the ED was 24.9 ± 58.0 minutes compared with 18.8 ± 38.5 minutes for those admitted; for penetrating trauma, scene times were 17.9 ± 23.5 and 13.4 ± 11.6 minutes, respectively. Mean number of procedures performed for blunt trauma patients who died in the ED was 6.5 ± 4.3 compared with 3.1 ± 2.3 for those who survived until admission; for penetrating trauma, the numbers of procedures performed were 5.7 ± 3.4 and 2.6 ± 2.0, respectively. Conclusions: Although less frequent than blunt trauma, penetrating trauma is associated with significantly higher prehospital and ED mortality. Increased scene time and number of procedures was associated with greater mortality for both blunt and penetrating trauma. Further study is required to better understand any causal relationships between prehospital times and interventions and patient outcomes.

The Association of Prehospital Intravenous Fluids and Mortality in Patients with Penetrating Trauma

BackgroundThe optimal approach to prehospital care of trauma patients is controversial, and thought to require balancing advanced field interventions with rapid transport to definitive care. ObjectiveWe sought principally to examine any association between the amount of prehospital IV fluid (IVF) administered and mortality. MethodsWe conducted a retrospective cohort analysis of trauma registry data patients who sustained penetrating trauma between January 2008 and February 2011, as identified in the Pennsylvania Trauma Systems Foundation registry with corresponding prehospital records from the Philadelphia Fire Department. Analyses were conducted with logistic regression models and instrumental variable analysis, adjusted for injury severity using scene vital signs before the intervention was delivered. ResultsThere were 1966 patients identified. Overall mortality was 22.60%. Approximately two-thirds received fluids and one-third did not. Both cohorts had similar Trauma and Injury Severity Score−predicted mortality. Mortality was similar in those who received IVF (23.43%) and those who did not (21.30%) (p = 0.212). Patients who received IVF had longer mean scene times (10.82 min) than those who did not (9.18 min) (p < 0.0001), although call times were similar in those who received IVF (24.14 min) and those who did not (23.83 min) (p = 0.637). Adjusted analysis of 1722 patients demonstrated no benefit or harm associated with prehospital fluid (odds ratio [OR] 0.905, 95% confidence interval [CI] 0.47–1.75). Instrumental variable analysis utilizing variations in use of IVF across different Emergency Medical Services (EMS) units also found no association between the unit's percentage of patients that were provided fluids and mortality (OR 1.02, 95% CI 0.96–1.08). ConclusionsWe found no significant difference in mortality or EMS call time between patients who did or did not receive prehospital IVF after penetrating trauma.

Utilization of Intravenous Catheters by Prehospital Providers during Pediatric Transports

Introduction: Prehospital intravenous (IV) access in children may be difficult and time-consuming. Emergency Medical Service (EMS) protocols often dictate IV placement; however, some IV catheters may not be needed. The scene and transport time associated with attempting IV access in children is unknown. The objective of this study is to examine differences in scene and transport times associated with prehospital IV catheter attempt and utilization patterns of these catheters during pediatric prehospital encounters. Methods: Three non-blinded investigators abstracted EMS and hospital records of children 0–18 years of age transported by EMS to a pediatric emergency department (ED). We compared patients in which prehospital IV access was attempted to those with no documented attempt. Our primary outcome was scene time. Secondary outcomes include utilization of the IV catheter in the prehospital and ED settings and a determination of whether the catheter was indicated based on a priori established criteria (prehospital IV medication administration, hypotension, GCS < 13, and ICU admission). Results: We reviewed 1,138 records, 545 meeting inclusion criteria. IV catheter placement was attempted in 27% (n = 149) with success in 77% (n = 111). There was no difference in the presence of hypotension or median GCS between groups. Mean scene time (12.5 vs. 11.8 minutes) and transport time (16.9 vs. 14.6 minutes) were similar. Prehospital IV medications were given in 38.7% (43/111). One patient received a prehospital IV medication with no alternative route of administration. Among patients with a prehospital IV attempt, 31% (46/149) received IV medications in the ED and 23% (34/396) received IV fluids in the ED. Mean time to use of the IV in the ED was 70 minutes after arrival. Patients with prehospital IV attempt were more likely to receive IV medication within 30 minutes of ED arrival (39.1% vs. 19.0%, p = 0.04). Overall, 34.2% of IV attempts were indicated. Conclusions: Prehospital IV catheter placement in children is not associated with an increase in scene or transport time. Prehospital IV catheters were used in approximately one-third of patients. Further study is needed to determine which children may benefit most from IV access in the prehospital setting.

PL03: Implementation of the Canadian C-Spine Rule by paramedics: a safety evaluation

Introduction: The Canadian C-Spine Rule (CCR) was validated by emergency physicians and triage nurses to determine the need for radiography in alert and stable Emergency Department trauma patients. It was modified and validated for use by paramedics in 1,949 patients. The prehospital CCR calls for evaluation of active neck rotation if patients have none of 3 high-risk criteria and at least 1 of 4 low-risk criteria. This study evaluated the impact and safety of the implementation of the CCR by paramedics. Methods: This single-centre prospective cohort implementation study took place in Ottawa, Canada. Advanced and primary care paramedics received on-line and in-person training on the CCR, allowing them to use the CCR to evaluate eligible patients and selectively transport them without immobilization. We evaluated all consecutive eligible adult patients (GCS 15, stable vital signs) at risk for neck injury. Paramedics were required to complete a standardized study data form for each eligible patient evaluated. Study staff reviewed paramedic documentation and corresponding hospital records and diagnostic imaging reports. We followed all patients without initial radiologic evaluation for 30 days for referral to our spine service, or subsequent visit with radiologic evaluation. Analyses included sensitivity, specificity, kappa coefficient, t-test, and descriptive statistics with 95% CIs. Results: The 4,034 patients enrolled between Jan. 2011 and Aug. 2015 were: mean age 43 (range 16-99), female 53.3%, motor vehicle collision 51.9%, fall 23.8%, admitted to hospital 7.0%, acute c-spine injury 0.8%, and clinically important c-spine injury (0.3%). The CCR classified patients for 11 important injuries with sensitivity 91% (95% CI 58-100%), and specificity 67% (95% CI 65-68%). Kappa agreement for interpretation of the CCR between paramedics and study investigators was 0.94 (95% CI 0.92-0.95). Paramedics were comfortable or very comfortable using the CCR in 89.8% of cases. Mean scene time was 3 min (15.6%) shorter for those not immobilized (17 min vs. 20 min; p=0.0001). A total of 2,569 (63.7%) immobilizations were safely avoided using the CCR. Conclusion: Paramedics could safely and accurately apply the CCR to low-risk trauma patients. This had a significant impact on scene times and the number of prehospital immobilizations.

Factors Associated with Failure of Non-invasive Positive Pressure Ventilation in a Critical Care Helicopter Emergency Medical Service.

Non-invasive positive pressure ventilation (NIPPV) is used to treat severe acute respiratory distress. Prehospital NIPPV has been associated with a reduction in both in-hospital mortality and the need for invasive ventilation. The authors of this study examined factors associated with NIPPV failure and evaluated the impact of NIPPV on scene times in a critical care helicopter Emergency Medical Service (HEMS). Non-invasive positive pressure ventilation failure was defined as the need for airway intervention or alternative means of ventilatory support. A retrospective chart review of consecutive patients where NIPPV was completed in a critical care HEMS was conducted. Factors associated with NIPPV failure in univariate analyses and from published literature were included in a multivariable, logistic regression model. From a total of 44 patients, NIPPV failed in 14 (32%); a Glasgow Coma Scale (GCS)<15 at HEMS arrival was associated independently with NIPPV failure (adjusted odds ratio 13.9; 95% CI, 2.4-80.3; P=.003). Mean scene times were significantly longer in patients who failed NIPPV when compared with patients in whom NIPPV was successful (95 minutes vs 51 minutes; 39.4 minutes longer; 95% CI, 16.2-62.5; P=.001). Patients with a decreased level of consciousness were more likely to fail NIPPV. Furthermore, patients who failed NIPPV had significantly longer scene times. The benefits of NIPPV should be balanced against risks of long scene times by HEMS providers. Knowing risk factors of NIPPV failure could assist HEMS providers to make the safest decision for patients on whether to initiate NIPPV or proceed directly to endotracheal intubation prior to transport.

An Evaluation of Emergency Medical Services Stroke Protocols and Scene Times

Background. Acute stroke patients require immediate medical attention. Therefore, American Stroke Association guidelines recommend that for suspected stroke cases, emergency medical services (EMS) personnel spend less than 15 minutes on-scene at least 90% of the time. However, not all EMS providers include specific scene time limits in their stroke patient care protocols. Objective. We sought to determine whether having a protocol with a specific scene time limit was associated with less time EMS spent on scene. Methods. Stroke protocols from the 100 EMS systems in North Carolina were collected and abstracted for scene time instructions. Suspected stroke events occurring in 2009 were analyzed using data from the North Carolina Prehospital Medical Information System. Scene time was defined as the time from EMS arrival at the scene to departure with the patient. Quantile regression was used to estimate how the 90th percentile of the scene time distribution varied by systems with protocol instructions limiting scene time, adjusting for system patient volume and metropolitan status. Results. In 2009, 23 EMS systems in North Carolina had no instructions regarding scene time; 73 had general instructions to minimize scene time; and 4 had a specific limit for scene time (i.e., 10 or 15 min). Among 9,723 eligible suspected stroke events, mean scene time was 15.9 minutes (standard deviation 6.9 min) and median scene time was 15.0 minutes (90th percentile 24.3 min). In adjusted quantile regression models, the estimated reduction in the 90th percentile scene time, comparing protocols with a specific time limit to no instructions, was 2.2 minutes (95% confidence interval 1.3, 3.1 min). The difference in 90th percentile scene time between general and absent instructions was not statistically different (0.7 min [95% confidence interval −0.1, 1.4 min]). Conclusion. Protocols with specific scene time limits were associated with EMS crews spending less time at the scene while general instructions were not. These findings suggest EMS systems can modestly improve scene times for stroke by specifying a time limit in their protocols.

Abstract 210: Association of Emergency Medical Services Stroke Protocols with Minimizing On-Scene Time for Stroke Patients

Background: Acute stroke patients require immediate medical attention. Therefore, American Stroke Association guidelines recommend that for suspected stroke cases, emergency medical services (EMS) personnel spend less than 15 minutes (min) on-scene at least 90% of the time. However, not all EMS providers include specific scene time limits in their stroke patient care protocols. We sought to determine whether a protocol with a specific time goal was associated with less time spent at the scene. Methods: Stroke protocols from each of the 100 EMS systems in North Carolina (NC) were collected and abstracted for scene time instructions. Suspected stroke events occurring in 2009 were analyzed using data from the NC Prehospital Medical Information System, a statewide electronic healthcare record used for evaluation of EMS patient care and system performance. Scene time was defined as the time from EMS arrival at the scene to departure with the patient. Quantile regression was used to estimate how the 90th percentile of the scene time distribution varied by the presence of protocol instructions limiting scene time. Models adjusted for system annual patient volume and metropolitan status. Results: In 2009, NC EMS systems varied in their stroke protocols: 23 had no instructions regarding scene time; 73 had general instructions to minimize scene time; and 4 had a specific limit for scene time (i.e. 10 or 15 min). Among 9,723 eligible suspected stroke events, mean scene time was 15.9 min (standard deviation 6.9 min) and median scene time was 15.0 min (interquartile range 11.0-19.5 min). We observed significantly lower 90th percentile scene times in EMS systems with specific time limit instructions (22.0 min) compared to systems without any instructions on scene time (24.6 min). There was no significant difference between 90th percentile scene times in EMS systems with general instructions compared to systems without instructions (25.0 versus 24.6 min). In adjusted quantile regression models, the estimated reduction in the 90th percentile scene time, comparing specific to no instructions, was 2.2 min (95% confidence interval 1.3, 3.1 min). The adjusted difference in 90th percentile scene time between general and absent instructions was not statistically different (0.7 min (95% confidence interval -0.1, 1.4 min)). Conclusion: Specific scene time limits were associated with EMS crews spending less time at the scene while general instructions were not. These findings suggest that EMS stroke protocols that include specific scene time limits are more likely to reduce on-scene times than those with no or only general instructions.

Antihypertensive Medication in Suspected Stroke Patients in Pre-Hospital Settings in United States (P02.197)

Objective: We performed this study to determine the frequency and patterns of use of parentral antihypertensive agents with EMS settings. Acute hypertensive response has been observed in a large percentage of stroke patients. Background Pre-hospital initiation of antihypertensive agents may be advantageous or deleterious in stroke patients. Design/Methods: We analyzed the data related to the EMS transport of 101,478 stroke patients from in the 2009 National Emergency Medical Services Information System (NEMSIS) Research Dataset, from 26 states in the US.From this dataset we identified medication codes, transport time, and the geographic nature of each EMS dispatch. The transport time and geographic nature of each call was considered relevant as the time of transport will impact EMS provider9s ability to initiate parenteral antihypertensive treatment and the ability of the treatment to have significant impact on the patient9s blood pressure (BP) prior to ED arrival. Results: We found 120 unique medication codes associated with these patients. Overall, 10 agents were administered to 1.9% (1,903/101,478) of the suspected stroke patients in the database. The number of times each agent (number of patients; frequency) was used as follows: Clonidine (1-.00%), Diltiazem (94 –4.9%), Enalapril (1-.00%), Hydralazine (1-.00%), Labatelol(219 – 11.5%),Metroprolol (80 – 4.2%), Nicardipine (14 - .7%), Nifedipine (1 - .00%), Nitroglycerin (1466 – 77%), and Nitroprusside (26 – 1.4%). The mean transport time was 15.7 minutes and the mean scene time was 17.2 minutes. The EMS dispatches occurred within four geographic groups with the following frequencies: rural (10.05%), suburban (10.22%), urban (77.03%), wilderness (2.70%). Conclusions: Although the use of antihypertensive medication in suspected stroked patients in the EMS setting is infrequent and not standardized, the mean scene and transport time provide a sufficient interval to allow for the initiation of IV antihypertensive medication in these patients. Disclosure: Dr. Anderson has nothing to disclose.

Pre-hospital intubation by anaesthesiologists in patients with severe trauma: an audit of a Norwegian helicopter emergency medical service

BackgroundAnaesthesiologists are airway management experts, which is one of the reasons why they serve as pre-hospital emergency physicians in many countries. However, limited data are available on the actual quality and safety of anaesthesiologist-managed pre-hospital endotracheal intubation (ETI). To explore whether the general indications for ETI are followed and what complications are recorded, we analysed the use of pre-hospital ETI in severely traumatised patients treated by anaesthesiologists in a Norwegian helicopter emergency medical service (HEMS).MethodsA retrospective audit of prospectively registered data concerning patients with trauma as the primary diagnosis and a National Committee on Aeronautics score of 4 - 7 during the period of 1994-2005 from a mixed rural/urban Norwegian HEMS was performed.ResultsAmong the 1255 cases identified, 238 successful pre-hospital ETIs out of 240 attempts were recorded (99.2% success rate). Furthermore, we identified 47 patients for whom ETI was performed immediately upon arrival to the emergency department (ED). This group represented 16% of all intubated patients. Of the ETIs performed in the ED, 43 patients had an initial Glasgow Coma Score (GCS) < 9. Compared to patients who underwent ETI in the ED, patients who underwent pre-hospital ETI had significantly lower median GCS (3 (3-6) vs. 6 (4-8)), lower revised trauma scores (RTS) (3.8 (1.8-5.9) vs. 5.0 (4.1-6.0)), longer mean scene times (23 ± 13 vs. 11 ± 11 min) and longer mean transport times (22 ± 16 vs. 13 ± 14 min). The audit also revealed that very few airway management complications had been recorded.ConclusionsWe found a very high success rate of pre-hospital ETI and few recorded complications in the studied anaesthesiologist-manned HEMS. However, a substantial number of trauma patients were intubated first on arrival in the ED. This delay may represent a quality problem. Therefore, we believe that more studies are needed to clarify the reasons for and possible clinical consequences of the delayed ETIs.

12-lead Electrocardiograms during Basic Life Support Care

Objectives Prehospital 12-lead electrocardiograms (PTLs) decrease time to thrombolytics. Paramedics have performed them successfully for years, but emergency medical technicians (EMTs) have not typically performed them. To determine whether PTLs could be considered a basic life support (BLS) skill, the authors conducted a pilot study to determine whether scene times are lengthened when EMTs obtain PTLs, whether EMTs can appropriately select patients for PTLs, and what value physicians place on prehospital PTLs. Methods The authors prospectively evaluated PTL performance in four BLS agencies. EMTs provided standard cardiac care to patients on even days. On odd days, they additionally performed a PTL. Scene times of patients receiving a PTL ( n = 77) were compared with scene times of similar patients not receiving one ( n = 100). Results EMTs attempted to perform 101 PTLs, of which 77 were eligible for inclusion. The mean scene time [95% confidence interval] of patients on even days (no 12-lead) was 11.9 [11.0, 12.8] minutes, compared with 16.9 [15.8, 18.0] minutes for patients who received a PTL. Scene times increased by 5.0 [3.6, 6.4] minutes when a PTL was added to the evaluation. Physician feedback was received on 63 of 77 PTLs. Receiving physicians agreed that 59 of 63 (93.6%) patients needed the PTL and found them moderately helpful (3.56 on a 1 to 5 scale). Conclusion When EMTs performed PTLs, scene times increased approximately 5 minutes. Most physicians agreed that the PTL was indicated. PTL acquisition by EMTs appears feasible with slightly lengthened scene times, but evaluation in other BLS agencies is necessary to validate this conclusion.

12-LEAD ELECTROCARDIOGRAMS DURING BASIC LIFE SUPPORT CARE

Objectives. Prehospital 12-lead electrocardiograms (PTLs) decrease time to thrombolytics. Paramedics have performed them successfully for years, but emergency medical technicians (EMTs) have not typically performed them. To determine whether PTLs could be considered a basic life support (BLS) skill, the authors conducted a pilot study to determine whether scene times are lengthened when EMTs obtain PTLs, whether EMTs can appropriately select patients for PTLs, and what value physicians place on prehospital PTLs. Methods. The authors prospectively evaluated PTL performance in four BLS agencies. EMTs provided standard cardiac care to patients on even days. On odd days, they additionally performed a PTL. Scene times of patients receiving a PTL (n = 77) were compared with scene times of similar patients not receiving one (n = 100). Results. EMTs attempted to perform 101 PTLs, of which 77 were eligible for inclusion. The mean scene time [95% confidence interval] of patients on even days (no 12-lead) was 11.9 [11.0, 12.8] minutes, compared with 16.9 [15.8, 18.0] minutes for patients who received a PTL. Scene times increased by 5.0 [3.6, 6.4] minutes when a PTL was added to the evaluation. Physician feedback was received on 63 of 77 PTLs. Receiving physicians agreed that 59 of 63 (93.6%) patients needed the PTL and found them moderately helpful (3.56 on a 1 to 5 scale). Conclusion. When EMTs performed PTLs, scene times increased approximately 5 minutes. Most physicians agreed that the PTL was indicated. PTL acquisition by EMTs appears feasible with slightly lengthened scene times, but evaluation in other BLS agencies is necessary to validate this conclusion.

Low-cost improvements in prehospital trauma care in a Latin American city.

Prehospital care is a critical component of efforts to lower trauma mortality. In less-developed countries, scarce resources dictate that any improvements in prehospital care must be low in cost. In one Latin American city, recent efforts to improve prehospital care have included an increase in the number of sites of ambulance dispatch from two to four and introduction of the Prehospital Trauma Life Support (PHTLS) course. The effect of increased dispatch sites was evaluated by comparing response times before and after completion of the change. The effect of PHTLS was evaluated by comparing prehospital treatment for the 3 months before initiation of the course (n = 361 trauma patients) and the 6 months after (n = 505). Response time decreased from a mean of 15.5 +/- 5.1 minutes, when there were two sites of dispatch, to 9.5 +/- 2.7 minutes, when there were four sites. Prehospital trauma care improved after initiation of the PHTLS course. For all trauma patients, use of cervical immobilization increased from 39 to 67%. For patients in respiratory distress, there were increases in the use of oropharyngeal airways (16-39%), in the use of suction (10-38%), and in the administration of oxygen (64-87%). For hypotensive patients, there was an increase in use of large-bore intravenous lines from 26 to 58%. The improved prehospital treatment did not increase the mean scene time (5.7 +/- 4.4 minutes before vs. 5.9 +/- 6.8 minutes after). The percent of patients transported who died in route decreased from 8.2% before the course to 4.7% after. These improvements required a minimal increase (16%) in the ambulance service budget. Increase in sites of dispatch and increased training in the form of the PHTLS course improved the process of pre-hospital care in this Latin American city and resulted in a decrease in prehospital deaths. These improvements were low cost and should be considered for use in other less developed countries.

The hot-loaded patient: Review and analysis of 1 year's experience

Introduction: Hot-loading is a common practice among rotor-wing air medical programs that respond to scene calls. Drawbacks include noise, flying debris, and risk of serious injury. The purpose of this study was to identify the frequency, ground time, and short-term outcomes of hot-loaded patients flown by the STAR Flight program. Methods: A 1-year retrospective records review identified all hot-loaded patients. Results were analyzed by call nature, number of patients, and type of aircraft. Results: In 1996 STAR Flight transported 1184 individuals from the scene of illness or injury; 269 (23%) were hot-loaded. Overall, hot-load ground times averaged 7.0 minutes. The shortest mean time, 6.6 minutes, was for single trauma patients. Medicine patients averaged 7.3 minutes, and multipatient transports required 10.3 minutes. Mean scene times for those flown in the Bell 412 and 206 were 6.9 and 7.4 minutes, respectively. Thirty percent of hot-loaded patients were considered critical. Conclusion: Hot-loading rarely was accomplished in less than the helicopter shutdown/startup time. Multipatient hot-loads always exceeded shutdown/restart intervals. Medicine and Bell 206 transports required the longest mean ground times. Most of STAR Flight's hot-loaded patients were not critically ill or injured.