Medical Services Agencies Research Articles

Negotiating the service system: Professionals and patients talk about healthcare for the homeless in a Midwestern City in the U.S.

This article presents and discusses themes generated from in-depth interviews with 10 key informants and four homeless adults in a medium-sized city in the Midwest, United States. The purpose of the interviews was to gain an understanding of the healthcare system that was in place for the homeless, both from the perspective of professionals and consumers alike. Key informants represented the major medical and social service agencies involved in the provision of healthcare services for the homeless in this city. Based on these interviews, the following themes were generated and are presented here for analysis and discussion: Lack of Services, Need for Medicaid, Coordination of Care, Lack of End-of-Life Care, and Suggestions for Change. Practice implications are presented.

Abstract 18761: Mechanical CPR associated With Decreased Survival From Out-of-hospital Cardiac Arrest

Background: Randomized trials have shown mechanical CPR yields equivalent outcomes when compared to manual CPR for out-of-hospital cardiac arrest (OHCA). Many Emergency Medical Services (EMS) agencies have adopted mechanical CPR but data are lacking on the association of mechanical CPR with survival in real-world clinical practice. Objective: To assess the utilization of mechanical CPR and its association with survival to hospital discharge among adult cardiac arrest patients in Pennsylvania. Methods: Utilizing data from Pennsylvania within the Cardiac Arrest Registry to Enhance Survival, we identified all resuscitation events in which mechanical CPR was used and compared these to all other manual CPR cases. Events where ROSC occurred before mechanical CPR would have arrived on scene were excluded. Demographic and survival data were analyzed using chi-squared testing for categorical variables and t-test for continuous variables. Multivariable regression was used to control for confounding, including: age, witnessed arrest, arrest location, bystander CPR, arrest rhythm, and no flow time. Results: From 1/2012 to 12/2014, 10,457 cardiac arrests met inclusion criteria. Of those 1955 (19%) received mechanical CPR. Mean age was 66.7 ±15.9 years, and 34% received bystander CPR. Survival to hospital discharge was lower in the cohort receiving mechanical CPR compared to the cohort receiving manual CPR (106/1836 [5.8%] vs. 583/8048[7.2%], p=0.02). Good neurologic outcome was similarly reduced (80/1836[4.4%] vs. 453/8046[5.6%], p=0.02). In the adjusted model, use of mechanical CPR corresponded to reduced odds of survival to discharge (OR 0.75; CI 0.59-0.95; p=0.02) and good neurologic recovery (OR 0.75; CI 0.57-0.98; p=0.04). In this population, race or ethnicity were not associated with survival. We were unable to control for hospital and EMS agency characteristics or duration of resuscitation as possible confounders. Conclusions: Mechanical CPR is associated with a 25% lower likelihood of survival from OHCA in Pennsylvania, even after adjustments for patient and arrest characteristics. Further research needs to be conducted to understand factors associated with mechanical CPR use and OHCA outcomes, including possible unmeasured confounders.

Does Limiting Time on Ambulance Diversion Reduce Diversions? Signaling Equilibrium and Network Effect

Several Emergency Medical Service (EMS) agencies across the US have demonstrated that the time spent by EDs on ambulance diversion can be reduced by implementing community-wide policies that restrict the duration and frequency of diversion episodes. However, the mechanisms through which these reductions materialize are not well understood. EDs can respond to such restrictions by improving their patient flow processes to reduce crowding and, thereby reducing the need for frequent and prolonged diversion episodes. Alternatively, they can raise the diversion crowding-threshold, thereby tolerating a higher level of crowding. Paramedics -- who decide whether to comply with an ED's diversion signal by diverting the ambulance or not -- are likely to respond differently to these two strategies. We use the framework of strategic communication between a service provider and customers arriving to a queuing system and obtain differential hypotheses on two outcome variables (diversion probability and ambulance waiting time) depending on which of the above mechanisms are actually operative. We test these hypotheses using evidence from a community-wide intervention to reduce diversion in LA County, California. We estimate a binary choice model for the paramedics' diversion decision as well as a two-part model for ambulance waiting time using data on more than 45000 ambulance transports to a network of seven neighboring EDs for a period of seven years (2003-2009). Our results uncover a multifaceted impact of the policy intervention on relevant operational measures. Specifically, a relatively hands-off intervention that restricts the amount of time spent by EDs on diversion can induce them to improve patient flow processes. However, the intervention is likely to be less effective in reducing the fraction of diverted ambulances and the ambulance waiting time due to the complex network dynamics of ambulance diversion and the strategic signaling between paramedics and EDs.

Development and application of regional collaborative medical information platform

Described in the paper are the development ideas,technology architecture,functional applications and problems found so far in the regional collaborative medical information platform.The platform is designed to achieve the interconnection and resources sharing among medical institutions,service agencies and regulatory agencies within the region,paving the way for future development of the health and medical system Key words: Regional collaborative medical care; Information platform; Technology architecture; Application

Survival and Neurologic Outcome after Out-of-Hospital Cardiac Arrest: Results One Year after Regionalization of Post-Cardiac Arrest Care in a Large Metropolitan Area

Background. Post-resuscitation care of cardiac arrest patients at specialized centers may improve outcome after out-of-hospital cardiac arrest (OOHCA). This study describes experience with regionalized care of resuscitated patients. Methods. Los Angeles (LA) County established regionalized cardiac care in 2006. Since 2010, protocols mandate transport of nontraumatic OOHCA patients with field return of spontaneous circulation (ROSC) to a STEMI Receiving Center (SRC) with a hypothermia protocol. All SRC report outcomes to a registry maintained by the LA County Emergency Medical Services (EMS) Agency. We report the first year's data. The primary outcome was survival with good neurologic outcome, defined by a Cerebral Performance Category (CPC) score of 1 or 2. Results. The SRC treated 927 patients from April 2011 through March 2012 with median age 67; 38% were female. There were 342 patients (37%) who survived to hospital discharge. CPC scores were unknown in 47 patients. Of the 880 patients with known CPC scores, 197 (22%) survived to hospital discharge with a CPC score of 1 or 2. The initial rhythm was VF/VT in 311 (34%) patients, of whom 275 (88%) were witnessed. For patients with an initial shockable rhythm, 183 (59%) survived to hospital discharge and 120 (41%) had survival with good neurologic outcome. Excluding patients who were alert or died in the ED, 165 (71%) patients with shockable rhythms received therapeutic hypothermia (TH), of whom 67 (42%) had survival with good neurologic outcome. Overall, 387 patients (42%) received TH. In the TH group, the adjusted OR for CPC 1 or 2 was 2.0 (95%CI 1.2–3.5, p = 0.01), compared with no TH. In contrast, the proportion of survival with good neurologic outcome in the City of LA in 2001 for all witnessed arrests (irrespective of field ROSC) with a shockable rhythm was 6%. Conclusion. We found higher rates of neurologically intact survival from OOHCA in our system after regionalization of post-resuscitation care as compared to historical data.

Multivariate Analysis of Successful Intravenous Line Placement in the Prehospital Setting

Background. Intravenous (IV) line placement is an important prehospital advanced life support skill, but IV success rates are variable among providers. Little is known about what factors are associated with successful IV placement, limiting the ability to develop benchmarks for skill maintenance, such as requiring a specific number of IV placements per year. Objective. We aimed to identify whether first-pass IV success was associated with the number of attempted or successful previous IV attempts. We hypothesized that IV success is associated with the number of successful IV placements in the preceding year. Methods. We retrospectively studied 800 consecutive charts with an IV attempt from 11 suburban and rural emergency medical services (EMS) agencies over a one-month period. Cases involving pediatric patients (age <18 years) and those with incomplete data were excluded. Success of the first IV attempt was identified. Potential predictor variables were collected and analyzed by univariate logistic regression, including patient age, systolic blood pressure, history of IV drug abuse or renal disease, traumatic event, catheter size, and location of IV attempt, as well as the individual provider's numbers of total and successful IV attempts in the preceding year. Variables significantly associated with IV success at the p < 0.10 level were included in a multivariate regression model using a p-value of 0.05. Results. Of 602 cases meeting the study criteria, 469 (77.9%) had a successful first-pass IV placement. Significantly associated with IV success in the univariate regression were patient age (p = 0.054), trauma (p = 0.074), IV catheter size (p < 0.001), IV location (p = 0.056), and the number of previous successful IV attempts (p = 0.039), whereas the number of total previous IV attempts was not significantly associated (p = 0.871). In the multivariate logistic regression model, only IV catheter size had a significant association (p < 0.001), with a larger-bore IV catheter size associated with higher success. Conclusion. In this retrospective study, larger IV catheter size, but not the prehospital providers’ previous year's experience, was associated with successful IV placement in adult patients. These data fail to support requirements for a minimum number of yearly IV placements by full-time paramedics to improve success rates.

Energy, emissions and emergency medical services: Policy matters

Understanding the energy consumption and emissions associated with health services is important for minimizing their environmental impact and guiding their adaptation to a low-carbon economy. In this post-hoc analysis, we characterize the energy burden of North American emergency medical services (EMS) agencies and estimate the potential marginal damage costs arising from their emissions as an example of how and why health services matter in environmental and energy policy, and how and why environmental and energy policy matter to health services. We demonstrate EMS systems are energy intensive, and that vehicle fuels represent 80% of their energy burden while electricity and natural gas represent 20%. We also demonstrate that emissions from EMS operations represent only a small fraction of estimated health sector emissions, but for EMS systems in the United States the associated marginal damage costs are likely between $2.7 million and $9.7 million annually. Significant changes in the supply or price of energy, including changes that arise from environmental and energy policy initiatives designed to constrain fossil fuel consumption, could potentially affect EMS agencies and other health services. We encourage cross disciplinary research to proactively facilitate the health system's adaptation to a low-carbon economy.

Abstract 2721: Probabilistic Matching of Computerized Emergency Medical Services (EMS) records and Emergency Department and Patient Discharge Data: a Novel Approach to Evaluation of Prehospital Stroke Care

Background and Purpose: Emergency Medical Services is an important element of acute stroke care. However, evaluation of prehospital stroke care is limited by lack of exchange of patient outcome data between hospitals and emergency medical services (EMS) agencies. In this study, we describe and demonstrate the feasibility of linking county wide patient level ambulance data with emergency department (EDD) and patient discharge data (PDD) using a probabilistic matching algorithm. Methods: Probabilistic linkage was used to match county-wide ambulance data from 2005-2007 to hospital (EDD and PDD) records with a final ICD -9 diagnosis of stroke (430-436). The linkage model was based on the patient’s transport/admission date, date of birth, race, sex, county of residence, and destination hospital. Probabilistic linkage was performed using LinkSolv version 8.29746 which calculates the probability that a pair of records is a true match based on agreement/disagreement patterns of the linkage variables. Pairs of records with a match probability of 0.8 or higher were considered true matches. All other pairs were false matches and rejected. Results: During 2005 - 2007 there were 310,731 patients transported to a facility in county and 34,785 hospital records with a diagnosis of stroke. Using the linkage algorithm we identified 11,473 (33%) matches with EMS records. Linkage rates increased each year with 30%, 34%, and 36% of hospital patients matching EMS record for 2005, 2006, and 2007 respectively. The median match probability was 0.993 and the IQR was 0.974 to 0.9996. By taking the compliment of the match probability we estimate our linked sample to include 255 (2%) false matches. Date of treatment/admission and the patient’s sex were observed to be the most reliable, disagreeing on less than one percent (1%) of all matched pairs. Patient’s zip code was the least reliable, disagreeing on one third of matched pairs. Conclusions: Our study demonstrates that probabilistic matching can be used to create a comprehensive patient care record which in turn can provide opportunities for researchers to study different phases of stroke care.

Carbon Footprinting of North American Emergency Medical Services Systems

Objectives. This study was undertaken to characterize the carbon emissions from a broad sample of North American emergency medical services (EMS) agencies, and to begin the process of establishing voluntary EMS-related emission targets. Methods. Fifteen diverse North American EMS systems with more than 550,000 combined annual responses and serving a population of 6.3 million reported their direct and purchased (“Tier 2”) energy consumption for one year. We calculated total carbon dioxide equivalent (CO2e) emissions using Environmental Protection Agency, Energy Information Administration, and locality-specific emission conversion factors. We also calculated per-response and population-based emissions. We report descriptive summary data. Results. Participants included government “third-service” (n == 4), public utility model (n == 1), private contractor (n == 6), and rural rescue squad (n == 4) systems. Call volumes ranged from 800 to 114,280 (median 20,093; interquartile range [[IQR]] 1,100–55,217). Emissions totaled 46,941,690 pounds of CO2e (21,289 metric tons); 75%% of emissions were from diesel or gasoline. For systems providing complete Tier 2 data, median emissions per response were 80.7 (IQR 65.1–106.5) pounds of CO2e and median emissions per service-area resident were 7.8 (IQR 4.7–11.2) pounds of CO2e. Two systems reported aviation fuel consumption for air medical services, with emissions of 2,395 pounds of CO2e per flight, or 0.7 pounds of CO2e per service-area resident. Conclusion. EMS operations produce substantial carbon emissions, primarily from vehicle-related fuel consumption. The 75th percentiles from our data suggest 106.5 pounds of CO2e per unit response and/or 11.2 pounds of CO2e per service-area resident as preliminary maximum emission targets. Air medical services can anticipate higher per-flight but lower population-based emissions.

Barriers to Adoption of Evidence-Based Prehospital Airway Management Practices in California

Objective. To describe current prehospital airway management practices for adults and children and barriers to adoption of evidence-based airway management practices in California. Methods. We surveyed local medical directors of California's 31 emergency medical services (EMS) agencies regarding prehospital airway management, including provider scope of practice, continuous quality improvement practices, and perceptions regarding barriers to the implementation of evidence-based airway management practices. The survey instrument was a Web-based, closed-response form (www.surveymonkey.com) that medical directors could access by an e-mailed link provided by investigators. Medical directors were contacted by phone, mail, and e-mail to request their participation in the Web-based survey. Results. Twenty-five of 31 (81%) EMS medical directors completed the survey. Five medical directors completed surveys for two agencies over which they had responsibility. All responding medical directors employ bag–mask ventilation (BMV), airway adjuncts, and adult endotracheal intubation (ETI), which are procedures widely accepted in EMS practice. Rapid-sequence intubation (RSI), which has been shown to cause harm in certain patient subgroups, was not employed by any of the respondents. Prehospital pediatric ETI, which has been shown not to provide any benefit over BMV, was employed by 22 of 25 (88%) medical directors. Thirteen of 23 (57%) respondents identified “more evidence is needed” or “these results do not apply to my EMS system” as the top reasons to continue the practice of prehospital pediatric ETI. Conclusions. The results of our study suggest that in areas of EMS where robust evidence exists, medical directors (100%) will discontinue or not adopt skills that potentially harm patients, such as RSI, but are unlikely (12%) to discontinue procedures that show no benefit to patients (such as pediatric ETI). Barriers to adoption of evidence-based practice include difficulty in generalizing results of studies across diverse EMS systems and perceived lack of evidence that the procedure should be abandoned.

Centralized vs. Decentralized Ambulance Diversion: A Network Perspective

In recent years, growth in the demand for emergency medical services along with decline in the number of hospitals with emergency departments (EDs) has led to overcrowding. In periods of overcrowding, an ED can request the Emergency Medical Services (EMS) agency to divert incoming ambulances to neighboring hospitals, a phenomenon known as “ambulance diversion”. The EMS agency will accept this request provided that at least one of the neighboring EDs is not on diversion. From an operations perspective, properly executed ambulance diversion should result in resource pooling and reduce the overcrowding and delays in a network of EDs. Recent evidence indicates, however, that this potential benefit is not always realized. In this paper, we provide one potential explanation for this discrepancy and suggest potential remedies. Using a queueing game between two EDs that aim to minimize their own waiting time, we find that decentralized decisions regarding diversion explain the lack of pooling benefits. Specifically, we find the existence of a defensive equilibrium, wherein each ED does not accept diverted ambulances from the other ED. This defensiveness results in a de-pooling of the network and, in turn, in delays that are significantly higher than when a social planner coordinates diversion. The social optimum is, itself, difficult to characterize analytically and has limited practical appeal as it depends on problem parameters such as arrival rates and length of stay. Instead, we identify an alternative solution that is more amenable to implementation and can be used by the EMS agencies to coordinate diversion decisions even without the exact knowledge of these parameters. We show that this solution is approximately optimal for the social planner’s problem. Moreover, it is Pareto improving over the defensive equilibrium whereas the social optimum might not be.

Paramedic Determinations of Medical Necessity: A Meta-Analysis

Introduction. Reducing unnecessary ambulance transports may have operational and economic benefits for emergency medical services (EMS) agencies and receiving emergency departments. However, no consensus exists on the ability of paramedics to accurately and safely identify patients who do not require ambulance transport. Objective. This systematic review and meta-analysis evaluated studies reporting U.S. paramedics' ability to determine medical necessity of ambulance transport. Methods. PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Cochrane Library databases were searched using Cochrane Prehospital and Emergency Care Field search terms combined with the Medical Subject Headings (MeSH) terms “triage”; “utilization review”; “health services misuse”; “severity of illness index,” and “trauma severity indices.” Two reviewers independently evaluated each title to identify relevant studies; each abstract then underwent independent review to identify studies requiring full appraisal. Inclusion criteria were original research; emergency responses; determinations of medical necessity by U.S. paramedics; and a reference standard comparison. The primary outcome measure of interest was the negative predictive value (NPV) of paramedic determinations. For studies reporting sufficient data, agreement between paramedic and reference standard determinations was measured using kappa; sensitivity, specificity, and positive predictive value (PPV) were also calculated. Results. From 9,752 identified titles, 214 abstracts were evaluated, with 61 studies selected for full review. Five studies met the inclusion criteria (interrater reliability, kappa = 0.75). Reference standards included physician opinion (n = 3), hospital admission (n = 1), and a composite of physician opinion and patient clinical circumstances (n = 1). The NPV ranged from 0.610 to 0.997. Results lacked homogeneity across studies; meta-analysis using a random-effects model produced an aggregate NPV of 0.912 (95% confidence interval: 0.707–0.978). Only two studies reported complete 2 × 2 data: kappa was 0.105 and 0.427; sensitivity was 0.992 and 0.841; specificity was 0.356 and 0.581; and PPV was 0.158 and 0.823. Conclusion. The results of the few studies evaluating U.S. paramedic determinations of medical necessity for ambulance transport vary considerably, and only two studies report complete data. The aggregate NPV of the paramedic determinations is 0.91, with a lower confidence limit of 0.71. These data do not support the practice of paramedics' determining whether patients require ambulance transport. These findings have implications for EMS systems, emergency departments, and third-party payers.

Effect of Emergency Medical Technician–Placed Combitubes on Outcomes After Out-of-Hospital Cardiopulmonary Arrest

Objective. While emergency medical technicians–basic (EMT-Bs) in select emergency medical services (EMS) agencies use the Esophageal Tracheal Combitube (ETC) for the airway management of out-of-hospital cardiopulmonary arrests, the effect of this intervention on patient outcomes is not known. We compared the associations between initial EMT ETC placement and initial paramedic endotracheal intubation (ETI) on patient survival after out-of-hospital cardiopulmonary arrest. Methods. We utilized data on adult (age > 21 years), out-of-hospital cardiopulmonary arrests from a large, urban, county-based, two-tiered (EMT-B first responder, paramedic ambulance) EMS system for the years 1997–2005. EMT-Bs placed an ETC on cardiopulmonary arrest patients if they arrived before paramedics. Paramedics managed the airway primarily using ETI. We included cases in which rescuers accomplished ETC insertion or ETI on the first airway effort. We excluded cases in which an invasive airway was not used. We excluded cases with failed airway insertion or multiple airway efforts. We examined return of spontaneous circulation (ROSC), survival to hospital admission, and survival to hospital discharge. We evaluated the association between outcome and airway type (ETC vs. ETI) using multivariate logistic regression, adjusting for age, gender, bystander-witnessed arrest, bystander cardiopulmonary resuscitation (CPR), bystander automated external defibrillator (AED) use, initial electrocardiogram (ECG) rhythm, and response time. Results. Of 7,010 adult cardiopulmonary arrests, we excluded 747 cases without airway insertion and 441 cases involving failed or multiple airway efforts. Of the remaining 5,822 cardiopulmonary arrests, 4,335 (74%) received initial paramedic ETI and 1,437 (26%) received initial EMT-B ETC insertion. Compared with paramedic ETI, EMT-B ETC placement was not associated with ROSC (adjusted odds ratio [OR] 0.93; 95% confidence interval [CI]: 0.82–1.05), survival to hospital admission (adjusted OR 0.99; 95% CI: 0.86–1.13), or survival to hospital discharge (adjusted OR 1.02; 95% CI: 0.79–1.30). Conclusions. Compared with initial paramedic ETI, initial EMT-B ETC placement was not associated with patient survival after out-of-hospital cardiac arrest.

A LABORATORY COMPARISON OF EMERGENCY PERCUTANEOUS AND SURGICAL CRICOTHYROTOMY BY PREHOSPITAL PERSONNEL

Objective. To compare the speeds and success rates of placement for percutaneous cricothyrotomy versus surgical or open cricothyrotomy. Methods. Twenty-two paramedics (mean 9.7 years of experience), with training in both methods, were timed using a pig trachea in a crossover model. An emergency physician performed timing and documentation of success; timing commenced after the equipment was ready and the membrane was identified. Paramedics were randomly assigned by a coin toss to start in either group. All were actively employed by a municipal third-service emergency medical services (EMS) agency. Paramedics who did not complete one of the methods correctly were excluded from speed analysis. Data were analyzed using descriptive statistics, a t-test of paired samples, and confidence intervals for matched samples. Results. Placement of a surgical cricothyrotomy was significantly faster (mean 28 seconds, range 10-78 seconds) than the percutaneous method (mean 123 seconds, range 58-257 seconds) (p < 0.001). Mean difference between the 20 matched percutaneous versus surgical pairs was 93.75 seconds (95% CI 72.3, 115.2). The surgical route had a 100% success rate at obtaining airway control, whereas the percutaneous method had a 90.9% success rate (p = 0.1). Conclusion. In an animal model, surgical cricothyrotomy appeared to be a preferable method for establishing a definitive airway over the percutaneous method. Further research is required to define the optimal approach in the prehospital setting for the invasive airway.

Community Referral Sources and Entry of Treatment-Naïve Clients into Outpatient Addiction Treatment

This study assessed the association of sources of client referral with enrollment of treatment-naïve clients. Data from the 1995 (n=618) and 2000 (n=745) waves of the National Drug Abuse Treatment Survey (DATSS), a panel study of outpatient substance abuse treatment units (OSAT), were analyzed. Enrollment of treatment-naïve clients was defined as the percentage of OSAT clients who entered treatment in the past 30 days with no prior treatment for substance abuse. A generalized estimating equation model simultaneously assessed the association of each referral source with the dependent variable, while controlling for potential confounding and accounting for correlation of unit-level responses over time. In the multivariable model, OSAT units with a greater proportion of treatment-naïve clients had received more referrals from employee assistance programs and the criminal justice system, and fewer referrals from mental health agencies. No effect of referral from medical or social service agencies was observed. These results highlight the role of coercive community institutions in treatment outreach efforts to persons in earlier phases of the “addiction career.”

A N E MERGENCY M EDICAL S ERVICES P ROGRAM OF A LTERNATE D ESTINATION OF P ATIENT C ARE

Objective: The emergency department (ED) is ideally reserved for urgent health needs. The ED, however, is often the site of care for nonurgent conditions. The authors investigated whether emergency medical technicians could decrease ED use by patients with nonurgent concerns who use 911 by appropriately identifying and triaging them to alternate care destinations. Methods: From August 2000 through January 2001, two King County fire-based emergency medical services (EMS) agencies participated in an alternate care destination program for patients with specific low-acuity diagnosis codes (intervention group). Eligible patients were offered care at a clinic-based destination as an alternate to the ED (n = 1,016). The frequency of the destination of care (ED, clinic, or home) for the intervention group was compared with a matched control group that was comprised of a preintervention historical cohort of EMS encounters from the same two fire-based agencies and with the same acuity and diagnosis criteria and seasonal interval (n = 2,617). Results: Compared with the preintervention group, a smaller proportion of patients in the intervention group received care in the ED (44.6% vs. 51.8%, p = 0.001), while a greater proportion of patients in the intervention group received clinic care (8.0% vs. 4.5%, p = 0.001) or home care (no transport) (47.4 vs. 43.7%, p = 0.043). Results were comparable when adjusted for other patient characteristics. Similar relationships were not evident among nonparticipating King County EMS agencies. Based on physician review and patient interview, the alternate care intervention appeared to be safe and satisfactory. Conclusion: An EMS-based program may represent one approach to limiting nonurgent ED use.

I S T HERE G ENDER B IAS IN THE P REHOSPITAL M ANAGEMENT OF P ATIENTS WITH A CUTE C HEST P AIN ?

Objective. Prior emergency department (ED) and inpatient studies have found that women with coronary artery disease are more frequently misdiagnosed and undertreated compared with men. This study was performed to determine whether there is a gender bias in the prehospital management of patients with acute chest pain. Methods. This study was performed in a large urban county emergency medical services (EMS) agency with approximately 40,000 patient contacts/year. The study population comprised consecutive patients ≥45 years old with a chief complaint of atraumatic chest pain. Using χ2 analysis and the unpaired Student's t-test, male and female patient encounters were compared. This study had >80% power (alpha 0.05) to detect a 3% difference between populations. Results. Data from 2,858 consecutive patient encounters were analyzed, with females comprising 1,508 (53%). Females were significantly older than males (67 ± 13.1 vs. 62.7 ± 12.3 years, p < 0.001). Male patients were more likely to receive aspirin (42.3% vs. 35.4%, p < 0.001) and 12-lead electrocardiograms (ECGs) (46.8% vs. 39.3%, p < 0.001) compared with female patients. The rates of transport refusal, oxygen, nitroglycerin, and narcotic administration did not differ between populations. Conclusion. Although females presenting to this urban EMS system with acute chest pain were older, they received significantly less aspirin and fewer 12-lead ECGs in the field. These results suggest strategies must be developed to ensure that appropriate therapy is provided to women presenting to EMS systems with acute cardiac ischemia.

Claims against a paramedic ambulance service: a ten-year experience

Liability claims made against Emergency Medical Services (EMS) agencies are a source of significant anxiety, time expenditure, and often monetary loss. Past literature reviewing EMS liability has been limited in scope. In this study, all claims made against an urban 911 ambulance service, whether or not a lawsuit resulted, were analyzed for the 10-year period ending in 1993. Eighty-two claims resulting in 11 lawsuits were filed. Motor vehicle accidents involving an ambulance produced the overwhelming majority (72%) of claims and 53% of the dollars paid out. Medical negligence claims were few but were the next largest cause of dollars lost (35%). Review of all legal claims may be used to help guide risk management efforts.

The 1989 Loma Prieta earthquake: issues in medical control.

The role of the base-hospital and on-line medical control in a disaster has not been investigated previously. This study assesses the roles of base-hospitals and the value and feasibility of on-line medical control during the 1989 Loma Prieta earthquake. The researchers studied five Bay Area counties most affected by the earthquake: San Francisco, Alameda, San Mateo, Santa Clara, and Santa Cruz. Researchers sent questionnaires to all 1,498 registered EMTs and paramedics in these counties; 620 were returned (41.4%). Respondents answered questions about activities performed, contacts with base-hospitals and other agencies, and problems encountered the night of the earthquake. Researchers selected 63 paramedics for in-depth interviews based on their performance of significant advanced life support (ALS) activities performed during the disaster. The coordinators of the 13 base-hospitals (BHCs) in the region also received and returned questionnaires about medical control, base-hospital roles during the disaster, and problems encountered. Researchers interviewed all five county emergency medical services (EMS) agency directors. The surveys of EMS directors, base-hospital coordinators, and paramedics indicate that confusion existed over the status of medical control after the earthquake. There was general agreement among base-hospital coordinators (BHCs) that suspension of medical control is appropriate in a major disaster. Three bases had appropriate equipment to function as back-up dispatch centers. Eight bases had adequate personnel, but only one BHC felt his personnel had adequate training to function in a dispatch capacity. Nine paramedics did not start or continue resuscitation on patients whom they ordinarily would have begun resuscitation. Emergency medical services should suspend medical control immediately following a major disaster and ensure that all prehospital and base personnel are notified. Disrupted communications protocols for prehospital personnel should reflect the skill and knowledge level of paramedics and the need for rapid, advanced practice in a disaster. Disaster planners should consider other roles for base hospitals in major disasters.

A Prospective Evaluation of Prehospital Patient Assessment by Direct In-field Observation: Failure of ALS Personnel to Measure Vital Signs

AbstractWe prospectively evaluated the frequency with which advanced life support (ALS) personnel fail to attempt to measure blood pressure (BP) and/or pulse (P) during prehospital patient assessment. A single in-field observer rode on ALS rescue vehicles from 20 Emergency Medical Services (EMS) agencies throughout Arizona during a one-year study (1/89–12/89). Data were collected from urban, suburban, and rural systems. Statistical evaluation was performed by Chi Square analysis with p &lt;0.05 considered significant.Among 227 patient encounters, BP and/or P measurements were omitted in 84 cases (37.0%). BP and/or P were omitted in 50.0% of children (age &lt;18 years) compared to 26.5% of adults (p=0.023). Among patients who were transported to a hospital, 19.4% had BP omitted compared to 49.1% of those not transported (p=0.00003). Seven of 58 patients in whom TVs were attempted (12.1 %) had BP omitted compared to 54 of 169 patients without IV attempts (32.0%, p=0.0055). Blood Pressure was omitted in 21.9% of patients transported Code 3 and in 24.2% of patients with Glasgow Coma Scale ≤13. Omission of BP occurred more frequently in non-urban agencies (33.9%) than in urban ones (20.0%, p=0.027).In a statewide evaluation of prehospital patient assessment, failure to measure vital signs (VS) occurred on a frequent basis. Our data indicate that a concerning lack of attention to the most basic details of patient assessment is common. It is possible that failure to measure VS might even happen more frequently during routine patient encounters without an observer present. Medical control physicians must emphasize to EMS personnel the paramount importance of careful assessment to ensure optimal patient care.