On-line Medical Control Research Articles

292 Designing Didactic and Simulation Sessions for Online Medical Control Training for Emergency Medicine Residents

292 Designing Didactic and Simulation Sessions for Online Medical Control Training for Emergency Medicine Residents

Medi-Health: Sistema web de código abierto para el control de citas médicas e historiales médicos mediante la metodología de desarrollo OSCRUM.

Digital tools are an essential part of the development and progress of society, even during the health emergency that the world is going through, allowing people to communicate remotely and perform various activities. The present research work has been developed after identifying the needs and deficiencies some medical centers face due to the lack of knowledge of the advantages offered by information systems. The main objective is to develop a web-based system to improve the interaction between the physician and his patients, providing adequate service by assigning and canceling medical appointments online. In addition, the medical staff will have real-time access to medical records. For the development of this web system, the OSCRUM methodology was used to guarantee effectiveness and security during the implementation and continuous improvement of the web system. Likewise, the SMS methodology was applied to the selection of relevant literature. In the performance of the "Medi-Health" web system, a system designed and developed to improve the current conditions of medical centers that do not have an online medical appointment control system was obtained. Finally, in the results obtained through the evaluation of users for this research work, it is concluded that web systems improve the management of medical appointment scheduling and the registration of medical history, significantly optimizing time and improving patient care. Keywords: open source, OSCRUM, Web system, methodology, development, health.

COVID-19 PANDEMİ SÜRECİNİN HASTANE ÖNCESİ ACİL SAĞLIK HİZMETLERİ ÇALIŞANI VE ON-LİNE MEDİKAL KONTROLÖR ARASINDAKİ İLETİŞİME ETKİSİ

Objectives: This study aims to evaluate the effects of the Covid-19 pandemic process on the communication between the pre-hospital emergency health system employee and online medical control. Methods: The studobjectives: This study aims to evaluate the effects of the Covid-19 pandemic process on the communication between the pre-hospital emergency health system employee and online medical control.Methods: The study, which collected data collected between May-July 2021, was planned as descriptive. Five hundred health professionals working in the Turkish pre-hospital emergency health system participated in the study. The data were collected online with a 17-question questionnaire applied to the participants.Results: 64.0% of the participants stated that they could always communicate with the online medical control during the regular period without any problems, and 55% of the participants stated that they were not adversely affected by communicating and consulting with the online medical control during the pandemic process, and 74.0% of the participants stated that they were unable to communicate with the online medical control during the pandemic period and that there aren’t situations where they could not perform the medication and/or medical intervention that should be done for the benefit of the patient. It is seen that the pandemic process has less effect on communication and consultation with the online medical control and has less effect on the inability to perform a medical intervention, which should be done for the benefit of the patient, in those who have effective communication with the online medical control and can conduct a positive consultation process.Conclusion: The Covid-19 pandemic process adversely affected the communication between the pre-hospital emergency health system employee and the online medical control. This is a situation that can negatively affect the quality of pre-hospital emergency health system service and increase mortality.

Improvement in regional disparities in prehospital emergency medical care systems using the prehospital care index: how the timing of adrenaline administration by paramedics impacts cerebral functioning prognosis

Objective In Japan, the protocol for timing of adrenaline administration by paramedics is determined by the local medical control council. The purpose of this study was to compare, via prehospital care indices, how differences in ‘adrenaline times’ across prefectures influence cerebral functioning prognoses. Methods We included 13,326 cases registered in the nationwide Utstein style database. To compare adrenaline administration times and cerebral functioning at 1-month post-event, the average time of adrenaline administration was calculated for each prefecture. A scatter plot showing the correlation of the rating of ‘good’ cerebral function at 1 month, and an approximately linear, were used to review the correlation. All cases where emergency medical technicians administered adrenaline within 10 minutes of field activity were examined bases on the prehospital care index. Results The nationwide average adrenaline time was 15.4±6.3 minutes, and the rating of good cerebral outcome at 1 month was 3.0%. 5.4% of good cerebral outcome. The prefecture with the slowest average adrenaline time was Hiroshima, with an average of 19.4±6.4 minutes and a 0.9% good cerebral outcome. Examination between average adrenaline times and good ratings for cerebral outcome at 1 month revealed a negative correlation (R2=0.1295) by prefecture. Aichi prefecture achieved the highest prehospital care index at 75.1%. Conclusion Adrenaline administration and the security of intravenous lines should be standardized in practice, with a view to shortening adrenaline administration times, rather than giving adrenaline under on-line medical control. Keywords: Heart Arrest, Epinephrine, Emergency medical technicians, Out-of-hospital cardiac arrest, Survival analysis, Time factors

4 Outcomes Following Consultation With Online Medical Control During Out-of-Hospital Cardiac Arrest in the Portland Metropolitan Area

Emergency medical services (EMS) frequently seeks advice, often as a local protocol requirement, on further care or termination of resuscitation (TOR) during an out-of-hospital cardiac arrest (OHCA) resuscitation via online medical control (OLMC). Our objective was to characterize the recommendations made by OLMC in OHCA, and to determine the impact of these on EMS transport decisions and patient outcomes.

ED EMS time: A COVID-friendly alternative to ambulance ride-alongs.

BackgroundAmbulance ride‐alongs are frequently a critical element of educational programs for learners of prehospital emergency care. We describe a novel alternative to the EMS ride‐along experience more conducive to COVID‐19 restrictions.Methods“ED EMS time” was developed as an alternative training method to provide a field‐type experience within the emergency department (ED) setting. Over the course of a 4‐h shift, medical students observe and complete standardized reflections on online medical control radio consultations and EMS‐to‐ED patient handoffs. Medical students also interview EMS clinicians to gain insight into prehospital care and the challenges that occur in the field. Experiences are debriefed with an EMS attending.ResultsMedical students expressed increased knowledge around the challenges and treatment capabilities of EMS through the ED EMS time experience. They were able to explain what information obtained from the scene was helpful to EMS clinicians. Medical students were able to realize the objectives of ambulance ride time through an ED experience designed around EMS.ConclusionsED EMS time represents a novel approach to teaching medical students the intricacies of prehospital medicine from the confines of the ED while avoiding direct patient contact, preserving PPE, and limiting COVID‐19 exposure.

Remote certification of out-of-hospital deaths in a Canadian Province: An 8-year experience of a novel practice.

Introduction:Certification of out-of-hospital deaths is challenging as physicians are often unavailable at the scene. In these situations, emergency medical services will generally transport the decedent to the nearest hospital. In 2011, a remote death certification program was implemented in the province of Québec, Canada. The program was managed through an online medical control center and enabled death certification by a remote physician. We sought to evaluate the implementation and feasibility of the remote death certification program and to describe the challenges we experienced.Methods:We retrospectively reviewed all remote death certification requests received at the online medical control center between 2011 and 2019. Data were collected from the online medical control center database and records. Feasibility was determined by evaluating the remote death certification rate.Results:Overall, 84.1% of remote death certification requests were realized, producing a total of 9776 death certificates. Male decedents accounted for 61.5% of remote death certification requests and were more likely than females to undergo a coroner’s investigation for cause of death (36.3% vs 20.8%, p = 0.017). Urban/mixed regions had higher rates of achieved remote death certifications (mean 87.3% vs 76.9%, p = 0.033) and putrefied bodies (mean 3.8% vs 2.2%, p = 0.137) compared to rural regions. Among unrealized remote death certification requests, the most common reason was failure of relatives to designate a funeral home (36.8%).Conclusion:Our 8-year experience with the remote death certification program demonstrates that despite facing numerous challenges, this process is feasible and offers a valuable option to manage out-of-hospital deaths. The remote death certification program is spreading in the remaining regions of Québec. Future studies will aim to quantify how much time this process saves for emergency medical services in each region of the province.

Video or Telephone? A Natural Experiment on the Added Value of Video Communication in Community Paramedic Responses

The objective of this study was to determine the effect of video versus telephonic communication between community paramedics and online medical control physicians on odds of patient transport to a hospital emergency department (ED). This was a retrospective analysis of data from a telemedicine-capable community paramedicine program operating within an advanced illness management program that provides home-based primary care to approximately 2,000 housebound patients per year who have advanced medical illness, multiple chronic conditions, activities of daily living dependencies, and past-year hospitalizations. Primary outcome was difference in odds of ED transport between community paramedicine responses with video communication versus those with telephonic communication. Secondary outcomes were physicians' perception of whether video enhanced clinical evaluation and whether perceived enhancement affected ED transport. Of 1,707 community paramedicine responses between 2015 and 2017, 899 (53%) successfully used video; 808 (47%) used telephonic communication. Overall, 290 patients (17%) were transported to a hospital ED. In the adjusted regression model, video availability was not associated with a significant difference in the odds of ED transport (odds ratio 0.80; 95% confidence interval 0.62 to 1.03). Online medical control physicians reported that video enhanced clinical evaluation 85% of the time, but this perception was not associated with odds of ED transport. We found support that video is considered an enhancement by physicians overseeing a community paramedicine response, but is not associated with a statistically significant difference in transport to the ED compared with telephonic communication in this nonrandom sample. These results have implications for new models of out-of-hospital care that allow patients to be evaluated and treated in the home.

Online Medical Control for EMS: A Lecture and Case-Based Teaching Module.

IntroductionThe provision of real-time medical direction to emergency medical services (EMS) providers is a core skill for the emergency physician, yet it is one with a wide variability of training received within residency.MethodsWe developed a complete training module for providing online medical control to EMS providers, including two lectures, multiple case-based scenarios for practice via two-way radio, a survey of participants’ self-perceived knowledge and comfort in this area, and a postmodule knowledge test. Participants completed the survey both before and after the module. The module was given during the regularly scheduled didactic conference series. There were 22 participants, some of whom were attendings and medical students.ResultsThe survey responses showed a statistically significant improvement after completion of the module for all questions, including improved self-perceived comfort with providing online medical control. Additionally, all participants passed the postmodule knowledge test with a mean score of 95%.DiscussionThis module was well received and showed significant results in improving the participants’ self-perceived and tested knowledge of EMS as well as their comfort with providing online medical control. The module offers an excellent baseline training experience for use by other residencies or agency medical directors.

Abstract 252: Implementation and Ongoing Evaluation of a Novel Method for Stroke Severity Assessment and Routing: NYC S-LAMS

Introduction: For the New York City 911 system stroke population, we sought to create and monitor a system for identifying stroke and large vessel occlusion (LVO) and to route LVO patients to thrombectomy capable centers which would reduce delays in the provision of endovascular care. Methods: We trained all emergency medical technicians and paramedics in the NYC 911 system to perform the Los Angeles Motor Score and to evaluate speech in cases of suspected stroke. We used a minimum score of 4/6 on a combined scale to screen positive for a possible LVO. An on-line medical control (OLMC) contact was required for every case that screened positive. Patients were eligible for transport specifically to thrombectomy capable centers if they screened positive, symptoms were present for less than 5 hours, symptoms were not due to trauma or seizure and the patient was previously ambulatory. Results: In the first six months of activity, there were 907 OLMC contacts, consistent with our prediction of approximately 5 patients per day that was derived from our 911 system’s historical database. After excluding ineligible patients, of these, 328 were transported to primary stroke centers and 579 were transported to thrombectomy capable centers. Of the 579 transported to thrombectomy capable centers, 447 (77.2%) had a confirmed stroke diagnosis. There were 189 (32.6%) LVO cases and 76 (13.1%) intracranial hemorrhages. Median time from EMS arrival to endovascular intervention first pass was 182.6 minutes and from hospital arrival to first pass was 141.5 minutes. Discussion: Overall, the process behaved as expected. We believe that our system can be further refined to reduce time to intervention. Further investigation is required to determine whether or not the system improved outcomes for patients and whether or not any cases of LVO or ICH were missed.

P093: Evaluating factors related to effective interpersonal communication during mandatory paramedic patches

Introduction: Delegation of controlled medical acts by physicians to paramedics is an important component of the prehospital care framework. Where directives indicate that physician input is needed before proceeding with certain interventions, online medical control (a “patch”) exists to facilitate communication between a paramedic and a Base Hospital Physician (BHP) to request an order to proceed with that intervention. Many factors contribute to success or failure of effective interpersonal communication during a patch call. The aim of this study was to examine areas of potential improvement in communication between paramedics and physicians during the patch call. Methods: Prehospital paramedic calls that included a mandatory patch point (excluding requests for termination of resuscitation and those records which were unavailable) were identified through review of all patch records from January 1, 2014 to December 31, 2017 for Paramedic Services in our region. Written Ambulance Call Reports (ACRs) and audio recordings of paramedic patches were obtained and reviewed. Pre-specified time intervals, clinical factors, specific patch requests and resulting orders from the BHP to the paramedics were extracted. Differences between groups were compared using t-tests. Results: 214 records were initially identified and screened. 91 ACRs and audio patch records were included in the analysis. 51/91 (56%) of patch order requests for interventions were granted by the BHP. Clarification of information provided by the paramedic or reframing of the paramedic's request was required less often, but not statistically significant, in calls ultimately resulting in granted requests versus those that were not granted (mean 1.4 versus 1.7, Δ-0.28; 95% CI -0.75-0.18 p = 0.64). The mean time from first contact with the BHP to statement of the request was similar in patches where the request was granted and not granted (44.9 versus 46.3, Δ-1.4; 95% CI -12.9-10.2, p = 0.49). Conclusion: The communication between BHPs and paramedics is an important and under-investigated component of prehospital emergency care. This retrospective review presents some novel targets for further research and potential education in patch communication to improve efficiency and quality of prehospital care for patients.

MP42: Evaluating clinical and situational factors related to the likelihood of physician authorization for time-sensitive procedures during mandatory paramedic patches

Introduction: Delegation of controlled medical acts by physicians to paramedics is an important component of the prehospital care framework. Where directives indicate that physician input is needed before proceeding with certain interventions, online medical control (a “patch”) exists to facilitate communication between a paramedic and a Base Hospital Physician (BHP) to request an order to proceed with that intervention. The clinical and logistical setting will contribute to the decision to proceed with or withhold an intervention in the prehospital setting. The aim of this study was to examine the impact of various clinical and situational factors on the likelihood of a patch request being granted. Methods: Prehospital paramedic calls that included a mandatory patch point (excluding requests exclusively for termination of resuscitation and those records which were unavailable) were identified through review of all patch records from January 1, 2014 to December 31, 2017 for Paramedic Services in our region. Written Ambulance Call Reports (ACRs) and audio recordings of paramedic patches were obtained and reviewed. Results: 214 patch records were identified and screened for inclusion. 91 ACRs and audio patch records were included in the analysis. 51 of 91 (56%) patch requests were granted by the BHP. Of the 40 paramedic requests that were not granted, the most commonly cited reason was close proximity to hospital (22/40; 55%) followed by low likelihood of the intervention making a clinical impact in the prehospital setting (11/40; 27.5%). Requests for certain interventions were more likely to be granted than other requests. All requests to perform needle thoracostomy for possible tension pneumothorax, administer atropine for symptomatic bradycardia and treat hemodynamically unstable hyperkalemia were granted (2/2, 3/3 and 7/7, respectively), while requests for synchronized cardioversion (7/19; 37%) and transcutaneous pacing (2/6; 33%) were approved less than half of the time. Conclusion: This retrospective review suggests that requests to perform certain critical and potentially time sensitive interventions are more likely to be granted which calls into question the requirement for a mandatory patch point for these procedures. Furthermore, the interplay between proximity to hospital and the decision to proceed with an intervention potentially informs future modifications to directives to facilitate timely, safe and efficient care.

MP43: Evaluating factors related to quality of audio transmission during mandatory paramedic patches and technical barriers to efficient communication in the prehospital setting

Introduction: Delegation of controlled medical acts by physicians to paramedics is an important component of the prehospital care framework. Where directives indicate that physician input is needed before proceeding with certain interventions, online medical control (a “patch”) exists to facilitate communication between a paramedic and a Base Hospital Physician (BHP) to request an order to proceed with that intervention. The quality and clarity of audio transmission is paramount for effective and efficient communication. The aim of this study was to examine the impact of audio transmission quality on the results of paramedic patch calls. Methods: Prehospital paramedic calls that included a mandatory patch point (excluding requests exclusively for termination of resuscitation and those records which were unavailable) were identified through review of all patch records from January 1, 2014 to December 31, 2017 for Paramedic Services in our region. Written Ambulance Call Reports (ACRs) and audio recordings of paramedic patches were obtained and reviewed. Pre-specified patch audio quality metrics, markers of transmission quality and comprehension as well as the resulting orders from the BHP were extracted. Differences between groups was compared using chi-square analyses. Results: 214 records were identified and screened initially. 91 ACRs and audio records were included in the analysis. At least one explicit reference to poor or inadequate call audio quality was made in 55/91 (60.4%) of calls and on average, 1.4 times per call. Of the 91 audited call records, 48 of 91 (52.7%) patches experienced an interruption of the call. Each time a call was interrupted, re-initiation of the call was required, introducing a mean [IQR] delay of 81 [33-68] seconds to re-establish verbal communication. Order requests made by paramedics in calls with no interruptions were approved in 30 of 43 patches (70%) while those requests made in calls with one or more interruptions were approved in only 21 of 48 cases (44%) (Δ26.0%; 95%CI 5.6-43.5%, p = 0.01). Conclusion: This retrospective review suggests that audio quality and interruptions of patch calls may impact a physician's ability to approve orders for interventions in the prehospital setting. Focus on infrastructure and technology underlying this important mode of communication may be a fruitful avenue for future improvements in systems where this may be an issue.

Intranasal Fentanyl versus Subcutaneous Fentanyl for Pain Management in Prehospital Patients with Acute Pain: A Retrospective Analysis

Objective: Retrospective analysis evaluating and comparing the feasibility, effectiveness and safety of intranasal fentanyl (INF) and subcutaneous fentanyl (SCF) for pain management of patients with acute severe pain in a rural/suburban Emergency Medical Services (EMS) system. Methods: Pre- and post-pain management data of all patients (aged ≥14 years) who were transported to the emergency department (January 2015–August 2017) were extracted from EMS and online medical control center records, and compared for groups receiving INF or SCF. Kaplan-Meier analysis and the log-rank test were used to describe and compare the percentage of patients in both groups who experienced relief according to their clinically significant pain relief score. Subgroup analysis was performed by patient age (<70 years, ≥70 years). Results: 94.6% (SCF = 94.8%; INF = 94.4%) of patients successfully received fentanyl and 82.7% (SCF = 81.2%; INF = 84.0%) had complete data and were included in the analysis. No difference was observed in time to administration or in the effectiveness of INF and SCF, and neither route of administration resulted in major adverse events that required intervention by paramedics. Upon subgroup analysis, INF patients ≥70 years were more likely to experience relief compared to those <70 years. Conclusion: This retrospective analysis of prehospital patients in the Chaudière-Appalaches EMS system demonstrates that both IN and SC are feasible, effective and safe routes for administering fentanyl. The observed effects of INF were found to be greater among patients ≥70 years. Further research is required to compare these routes with more conventional methods of pain management.

Paramedic-Identified Enablers of and Barriers to Pediatric Seizure Management: A Multicenter, Qualitative Study

Background: Seizures have the potential to cause significant morbidity and mortality, and are a common reason emergency medical services (EMS) are requested for a child. An evidence-based guideline (EBG) for pediatric prehospital seizures was published and has been implemented as protocol in multiple EMS systems. Knowledge translation and protocol adherence in medicine can be incomplete. In EMS, systems-based factors and providers’ attitudes and beliefs may contribute to incomplete knowledge translation and protocol implementation. Objective: The purpose of this study was to identify paramedic attitudes and beliefs regarding pediatric seizure management and regarding potential barriers to and enablers of adherence to evidence-based pediatric seizure protocols in multiple EMS systems. Methods: This was a qualitative study utilizing semi-structured interviews of paramedics who recently transported actively seizing 0–17 year-old patients in 3 different urban EMS systems. Interviewers explored the providers’ decision-making during their recent case and regarding seizures in general. Interview questions explored barriers to and enablers of protocol adherence. Two investigators used the grounded theory approach and constant comparison to independently analyze transcribed interview recordings until thematic saturation was reached. Findings were validated with follow-up member-checking interviews. Results: Several themes emerged from the 66 interviewed paramedics. Enablers of protocol adherence included point-of-care references, the availability of different routes for midazolam and availability of online medical control. Systems-level barriers included equipment availability, controlled substance management, infrequent pediatric training, and protocol ambiguity. Provider-level barriers included concerns about respiratory depression, provider fatigue, preferences for specific routes, febrile seizure perceptions, and inaccurate methods of weight estimation. Paramedics suggested system improvements to address dose standardization, protocol clarity, simplified controlled substance logistics, and equipment availability. Conclusions: Paramedics identified enablers of and barriers to adherence to evidence-based pediatric seizure protocols. The identified barriers existed at both the provider and systems levels. Paramedics identified multiple potential solutions to overcome several barriers to protocol adherence. Future research should focus on using the findings of this study to revise seizure protocols and to deploy measures to improve protocol implementation. Future research should also analyze process and outcome measures before and after the implementation of revised seizure protocols informed by the findings of this study.

Establishing Recommendations for Stroke Systems in the Thrombectomy Era: The Upstate New York Stakeholder Proceedings

The American Heart Association/American Stroke Association and Department of Health Stroke Coverdell Program convened a stakeholder meeting in upstate NY to develop recommendations to enhance stroke systems for acute large vessel occlusion. Prehospital, hospital, and Department of Health leadership were invited (n=157). Participants provided goals/concerns and developed recommendations for prehospital triage and interfacility transport, rating each using a 3-level impact (A [high], B, and C [low]) and implementation feasibility (1 [high], 2, and 3 [low]) scale. Six weeks later, participants finalized recommendations. Seventy-one stakeholders (45% of invitees) attended. Six themes around goals/concerns emerged: (1) emergency medical services capacity, (2) validated prehospital screening tools, (3) facility capability, (4) triage/transport guidelines, (5) data capture/feedback tools, and (6) facility competition. In response, high-impact (level A) prehospital recommendations, stratified by implementation feasibility, were (1) use of online medical control for triage (6%); (2) regional transportation strategy (31%), standardized emergency medical services checklists (18%), quality metrics (14%), standardized prehospital screening tools (13%), and feedback for performance improvement (7%); and (3) smartphone application algorithm for screening/decision-making (6%) and ambulance-based telemedicine (6%). Level A interfacility transfer recommendations were (1) standardized transfer process (32%)/timing goals (16%)/regionalized systems (11%), performance metrics (11%), image sharing capabilities (7%); (2) provider education (9%) and stroke toolbox (5%); and (3) interfacility telemedicine (7%) and feedback (2%). The methods used and recommendations generated provide models for stroke system enhancement. Implementation may vary based on geographic need/capacity and be contingent on establishing standard care practices. Further research is needed to establish optimal implementation strategies.

P055: EMS boot camp: a real-world, real-time educational experience for emergency medicine residents

Introduction/Innovation Concept: In 2014, Eastern Ontario paramedic services, their medical director staff and area community colleges developed an EMS Boot Camp experience to orient Queen’s University and the University of Ottawa emergency medicine residents to the role of paramedics and the challenges they face in the field. Current EMS ride-alongs and didactic classroom sessions were deemed ineffective at adequately preparing residents to provide online medical control. From those early discussions came the creation of a real-world, real-time (RWRT) educational experience. Methods: Specific challenges unique to paramedicine are difficult to communicate to a medical control physician at the other end of a telephone. The goal of this one-day educational experience is for residents to gain insight into the complexity and time sensitive nature of delivering medical care in the field. Residents are immersed as responding paramedics in a day of intense RWRT simulation exercises reflecting the common paramedic logistical challenges to delivering patient care in an uncontrolled and dynamic environment. Curriculum, Tool, or Material: Scenarios, run by paramedic students, are overseen by working paramedics from participating paramedic services. Residents learn proper use of key equipment found on an Ontario ambulance while familiarize themselves with patient care standards and medical directives. Scenarios focus on prehospital-specific clinical care issues; performing dynamic CPR in a moving vehicle, extricating a bariatric patient with limited personnel, large scale multi-casualty triage as well as other time sensitive, high risk procedures requiring online medical control approval (i.e. chest needle thoracostomy). Conclusion: EMS Boot Camp dispels preconceived biases regarding “what it’s really like” to deliver high quality prehospital clinical care. When providing online medical control in the future, the residents will be primed to understand and expect certain challenges that may arise. The educational experience fosters collaboration between prehospital and hospital-based providers. The sessions provide a reproducible, standardized experience for all participants; something that cannot be guaranteed with traditional EMS ride-alongs. Future sessions will evaluate participant satisfaction and self-efficacy with the use of a standard evaluation form including pre/post self-evaluations.

Effectiveness of a Prehospital Wireless 12-Lead Electrocardiogram and Cardiac Catheterization Laboratory Activation for ST-Elevation Myocardial Infarction

The aim of the study was to determine the prevalence of false-positive and inappropriate cardiac catheterization laboratory (CCL) activation in patients suspected with ST-elevation myocardial infarction (STEMI) diverted to a percutaneous coronary intervention (PCI) facility after paramedics wireless 12-lead electrocardiogram transmission to an emergency physician at an online medical control center. This retrospective study collected data from medical records of patients with suspected STEMI from 2006 to 2014. It included demographics, coronaropathic risk factors, cardiac biomarkers, time from the first medical contact to treatment, and final diagnosis. Primary outcome was the rate of false-positive and inappropriate CCL activation. As secondary outcomes, we compared patient characteristics between cases of appropriate and inappropriate CCL activation, and we assessed the presence of cardiac biomarkers, time from first medical contact to start of PCI, and final diagnosis. Overall, 673 patients with suspected STEMI were included in the analysis. A total of 640 patients (95%) had coronarography, of which 10% (62 of 640) did not have a culprit coronary artery (false positive). Angiography was canceled for 5% (33 of 673) of patients. The total false-positive and inappropriate CCL activation rate was 14% (95 of 673). Average time from the first medical contact to the start of PCI was 47 ± 18.1minutes. Unwanted CCL activations were more likely to involve men aged >65years and patients with a history of coronary artery disease. In conclusion, our system of transmitted prehospital electrocardiography and STEMI interpretation by emergency physicians at an online medical control center showed a total false-positive and inappropriate CCL activation rate of 14% over the 8-year study period.

P077: Subcutaneous fentanyl administration for pain management in prehospital setting

Background: Intravenous (IV) and Intranasal (IN) route for analgesic administration cannot always be used to provide adequate pain management in pre-hospital setting. Objective: In a rural and suburban pre-hospital setting, studying the feasibility, safety and effectiveness of the subcutaneous (SC) route for fentanyl administration by Basic Life Service-Emergency Medical Technician (BLS-EMT) for pain management, with the support of an online medical control (OLMC) center. Methods: Retrospective study of patients who received subcutaneous fentanyl and were transported by BLS-EMT to an emergency department (ED). Safety and feasibility were characterized by collecting vital signs, Ramsey sedation scores and adverse events following fentanyl administration, and effectiveness was evaluated by changes in pain scores. Parametric and non-parametric tests were used for statistical analyses comparing age groups (&lt;70 &amp; ≥70 years old) regarding transport time. Results: Pain scores ≥7 were found in 288 patients (14-93 years old) who were eligible for analgesia. 249 (86.5%) of the 284 (98.6%) who received subcutaneous fentanyl were included for analysis. At baseline, no difference (p&gt;0.05) in pain scores pre-fentanyl between groups even if patients&lt;70 years old received a significant higher dose of fentanyl than those ≥70 years old (1.4±0.3 v/s 0.8±0.2mcg/kg, p&lt;0.05). Post-administration pain score decreased significantly while proportion of patients achieving a pain relief increased significantly (p&lt;0.05) regarding transport time (15, 30 or 45min) to ED. Adverse events were present in 1.6% of the patients [hypotension (n=2; 0.8%), nausea (n=1; 0.4%), and Ramsey score&gt;3 (n=1; 0.4%)]. Conclusion: Under the supervision of an OLMC center, subcutaneous fentanyl administration by BLS-EMT for pain management seems to be a feasible approach, with a safe and effective route without major adverse event in pre-hospital setting. Pain relief increased with longer transport time. Further studies are needed to determine the benefits of SC route when compared to other administration routes in EMS.

MP030: Problems in paramedic-physician telecommunication

Introduction: Clear paramedic-physician telecommunications (patches) are critical in systems utilizing on-line medical control. In systems using extensive medical directives individual paramedics patch infrequently. Investigations of specific problem calls indicated that communication problems were more common than believed. Existing literature on this topic is sparse. This project is a quality assurance exercise undertaken to understand the extent and nature of problems in paramedic-physician telecommunications Methods: Retrospective analysis of anonymized transcriptions made from MP3 audio files recorded as part of normal operating procedures by the Central Ambulance Communication Centre during January-March 2014. All calls where telecommunication occurred between paramedics from 4 ambulance services and base hospital physicians providing on-line medical oversight during ambulance calls were included. Transcripts were read multiple times and data extracted onto spreadsheets for frequency analysis. Further thematic framework analysis of emergent themes was done. Results: All 42 patches were transcribed and used for analysis. 36 (85.7%) were for termination of resuscitation orders, 4 (9.5%) were for advice, and 2 (4.8%) were for orders not covered by medical directives. Communication problems were identified in 40 (95.2%) patches. Most had multiple problems. These included disconnections (23.8%), difficulty hearing one another (40.5%) - indicated by phrases such as “sorry?” “what?”, “I can’t hear you” - or caused by individuals interrupting each other (83.3%), and talking simultaneously (47.6%). Signaling the end of “talk turns” - such as “10-4” or “over” - was never used. Instead, terms like “yah” and “OK” were used. When communication went awry, time was spent trying to repair the mis/poor communication. This led to repeating information or attempting to ‘sell’ the case by providing information unnecessary for decision making - such as during a request for termination of resuscitation, “there is vomit on the floor”. Conclusion: Paramedic-physician telecommunication problems were extremely common. They involved technical (mechanical problems) and human factors (disorganized radio ‘technique’). The high incidence of telecommunication problems identified is concerning. Critical clinical decisions (e.g. ceasing resuscitation) depend on clear communication. Further study of these issues is warranted.