Regional Emergency Medical System Research Articles

Surge Capacity of Taipei's Regional Emergency Medical System during COVID-19: A System Dynamics Approach.

The community transmission of COVID-19 has caused the breakdown of the regional emergency medical system (REMS), impacting the rights and care of regional patients with acute and severe conditions. This study proposes a model for the surge capacity of REMS to plan for readiness and preparedness during challenging events that overload capacity. The surge capacity of REMS during the COVID-19 pandemic was studied. The data collection included 26 hospitals that received the data. To simulate the dynamics of Taipei's REMS surge capacity, we observed its ability to treat COVID-19 patients with moderate to severe acute respiratory distress syndrome (ARDS). This will involve monitoring the stock of ventilators, physicians, and nurses within the subsystem loops. Healthcare managers and administrators can use the overload model and hypothetical scenarios to develop new scenarios with different demands on surge capacity. The REMS system capacity model can be used as an aid to guide planning and cross-checking for address Prepare to plan. We combined data regarding the availability of ventilators, physicians, nurses, specialized beds, and general acute care beds in our simulations. Thus, our simulations, with support from a well-established regional command and management structure, could help REMS achieve the optimal surge capacity.

Handover Between Prehospital and Intra-hospital Physicians–Utility of Simulation in Enhancing Quality of Transmission

Introduction:Handover is of big value in preserving continuity of the medical services chain when managing patients. Simulation is well accepted as a good learning method to acquire non-technical skills. Actual studies dealing with this issue are performed on paramedics. Studies involving physicians are rare and usually focus on interviews or questionnaires describing practical situations.The aim of our study was to evaluate the utility of simulation in enhancing the quality of handover between both pre-hospital and intra-hospital physicians.Method:We conducted a prospective pre-test/post-test study in a regional Emergency Medical System (EMS) on the handover topic.We included voluntary physicians who signed participation consent. The study was designed as a three-step project: theoretical training with pre-test and post-test, 1st simulation session, 2nd simulation session with post-test. The two simulation sessions were evaluated according to a specific score. We evaluated the progression of knowledge (tests means) and skills (percentages of good answers): before and after theoretical training and before and after simulation sessions.Results:Sixteen EMS physicians were enrolled. Thirteen were under 40 years old and ten were emergency medicine physician specialists. Theoretical training made progression in means and percentage good answers (post-test 1 vs. pré-test : 9.5±3.3 vs 6.9±2 ; p=0.008 et 22 vs. 10% ; p=0,001 respectively). Progression of means after simulation was noticed (2nd session vs. 1st session) (16.3±0.9 vs. 12.3±2.5 ; p<0.001). Simulation enhanced significant quality of handover. Means and percentage of good answers in tests was better after simulation sessions (post-test 2 vs. post-test 1 vs. pre-test : 10.7±2.8 vs. 9.5±3.3 vs. 6.9±2 ; p=0.01 et 29% vs. 22% vs. 10% ; p<0.001 respectively).Conclusion:Our study showed the utility of simulation in enhancing handover between pre-hospital and intra-hospital physicians. Simulation as an active learning method, combined with theoretical training, can improve knowledge and enhance skills.

Impact of COVID-19 on STEMI: Second youth for fibrinolysis or time to centralized approach?

On March 11th 2020 the World Health Organization declared the pandemic infection of SARS-CoV-2 (COVID-19) and Italy was one of the most affected country. The regional Emergency Medical System (EMS) founded itself facing an exponential increase in hospitalizations with a consequent organizational system crisis. Experts from Cina, UK and US suggested to reconsider thrombolysis as the best treatment in term of balance between time consumption and operators safety for ST-segment elevation myocardial infarction (STEMI) patients respect to primary PCI (pPCI). The system reorganization consisted in a centralization of all the emergency nets: from 55 hospitals with cardiac catheterization laboratories distributed within our region offering a 24/7 service we passed to 13 Hub and 42 Spoke centres. Dedicated in-hospital paths for patients COVID positive or suspected (pCOV+) and COVID negative (pCOV−) were instituted. We analysed all consecutive patients undergoing emergency coronary angiogram from March 14 to April 14, 2020 at San Carlo Hospital in Milan comparing the two different in-hospital paths. We collected 30 STEMI patients. Eighteen patients (60%) were treated in pCOV−, while twelve patients (40%) in pCOV+. No significant differences were found among the two groups regarding key time points of STEMI care and interestingly we didn't find any treatment delay in pCOV+. In conclusion, a focused overhaul of the EMS may allow to maintain pPCI as the treatment of choice for patients and operators.

Introduction and characteristics of helicopter emergency medical services

Helicopter emergency medical services (HEMS) are a part of air medical services. The transportation of patients using helicopters or airplanes is a core element of the air medical services. HEMS have developed from militarybased transportation, which used helicopters on the battlefield. HEMS have played an important role in properly transporting critical patients before the golden time elapses. The optimal strategies for the operation of HEMS at any emergency medical system are dependent on the characteristics of the regional emergency medical system, diversitiy of HEMS organizations, and the legal background of each country. Therefore, every participant, including the government, medical personnel, and HEMS organizations, should concentrate their efforts toward the establishment of HEMS. Other than the factors related to patients, the key element in facilitating the establishment of HEMS is the safety of the flight and crew members.

COVID-19 first stage in Japan - how we treat 'Diamond Princess Cruise Ship' with 3700 passengers?

We report the current situation regarding the case of multiple patients who tested positive via polymerase chain reaction (PCR) for the novel coronavirus infection and were transported from the Diamond Princess cruise ship, from the viewpoint of medical facilities in Yokohama City to serve as a reference for future development of emergency medical care systems in each region. Please note that the following numbers are preliminary (unconfirmed) and may change based on the counts determined by related organizations in the future. The Medical Control Council recognizes the importance of verifying the overall situation once the crisis has settled down. Please refer to reports from each organization to gain administrative perspectives. The present report is merely one of the documents that could be used to review regional emergency medical systems when large numbers of coronavirus disease (COVID-19) patients are observed in each region. The Diamond Princess cruise ship (British registered) arrived offshore of Yokohama port on the evening of February 3 (Monday) and the quarantine began. There were 2,666 passengers and 1,045 crew members on the ship (a total of more than 3,700). Initially, quarantine began due to one passenger (a man who boarded in Yokohama on January 20 and disembarked in Hong Kong on January 25) being tested positive for the novel coronavirus infection via PCR, but eventually, many passengers tested positive via PCR for the infection. Transportation of the PCR-positive patients to the designated medical institutions for class I infectious diseases (one location in Yokohama City) and to the designated medical institutions for class II infectious diseases (seven in Kanagawa Prefecture) in Kanagawa Prefecture began on February 4. However, more number of patients tested positive via PCR in the subsequent days, making it a physically difficult situation for such designated medical institutions to accept all the patients. This became even more difficult when some of the patients developed severe illness (the federal government announced on February 9 that the patients may be accepted at facilities other than these designated medical institutions). Due to a rapid increase in the number of patients, the emergency medical facilities in Yokohama City, Kanagawa Prefecture, could not meet the requirements of all patients. During this period, there were cases of life-threatening conditions such as acute myocardial infarction and cerebral infarction among those who were PCR-positive and those with unconfirmed test results who required urgent care (including passengers of foreign nationalities). Regardless of PCR results, patients requiring urgent treatment were admitted to the only advanced emergency medical center in the City (not a designated medical institution for infectious diseases, but the degree of medical emergency was prioritized: there are nine emergency medical facilities in Yokohama City, with only one of them being an advanced emergency medical center). There was a case of a foreign national admitted to a medical facility in the City who developed gastrointestinal perforation, requiring an emergency surgery. Because emergency surgery of PCR-positive patients was considered difficult in general hospitals due to lack of staff, the patient was transported to the abovementioned medical center for emergency surgery. Subsequently, the number of patients requiring transport to medical facilities due to being PCR-positive or due to other symptoms continued to increase—10 (approximately) on February 9, 15 on February 10, and 70 on February 11—reaching a point where it was impossible for medical facilities in Kanagawa Prefecture to handle all patients. Stratified transportation of patients based on their condition was led by the Coronavirus Countermeasures Headquarters and DMAT Adjustment Headquarters set up in the Kanagawa Prefectural Government Office. In this manner, medical facilities of Yokohama City were able to focus on “admitting passengers who needed immediate treatment.” General passengers began disembarking on February 19. The total number of transported cases by the evening of February 18 was 512 (approximate). Because DMATs assigned patients in need of immediate treatment to local medical facilities and asymptomatic and stable PCR-positive patients to distant hospitals based on appropriate medical judgment, we were able to avoid the arrival of 500 transported patients at medical facilities in Yokohama City all at once. It would not be an exaggeration to say that thanks to DMATs, it was possible to balance the regular emergency medical system and admissions of COVID-19 patients in Yokohama City, and as the chairman of the Medical Control Council of the Yokohama City, I appreciate the support provided by DMATs from across the country (and also many other medical teams such as SDF medical officers, Japan Medical Association Team [JMAT], and infection control team for providing support for medical care in Yokohama City). However, I have the impression that if multiple COVID-19 patients are admitted to a local medical facility (with most of such facilities being hospitals that are not designated medical institutions for infectious diseases), it will be difficult to maintain a system in parallel with accepting patients from regular ambulances from an infection prevention aspect. (At this point, there is still no announcement from the Yokohama City Fire Bureau regarding the extended time for hospital selection by on-site ambulances.) The majority of passengers were aged ≥60 years, with more than half being 70 years or older (press report). After disembarkation of passengers, approximately 1,000 crew members were remaining on the ship, mainly comprising Filipinos and Indians. However, these were healthy people without any underlying conditions, and emergency calls have drastically decreased to 1–2 per day. Because the Philippine government had their crews return back to their country, it is likely that the transportation of patients from the Diamond Princess cruise ship in Yokohama has settled down. On the other hand, there have been reports, one after another, of new COVID-19 patients across Japan; thus, Yokohama must prepare for the next phase. As discussed, 64 people (approximate; as of February 18) from the Diamond Princess cruise ship were admitted to emergency medical facilities in Yokohama City. Among these admitted passengers, some patients with a stable respiratory condition at the time of transport gradually deteriorated, requiring ventilator support and extracorporeal membrane oxygenation (ECMO). (For further detail, please refer to reports from The Japanese Society of Intensive Care Medicine and five other associations who have jointly established Japan COVID-19 Countermeasure ECMOnet Project). In nine emergency medical centers in Yokohama City, beds for critical patients have already been filled by COVID-19 patients from the Diamond Princess cruise ship. This is one of the greatest concerns regarding the future increase in the number of patients from the City. On February 20, there was a request to transport ECMO patients from hospital A in Yokosuka City; however, advanced medical facilities in Yokohama City, Kanagawa Prefecture, were unable to accept critical patients from the Diamond Princess cruise ship. Therefore, these patients were transported from Yokosuka to referral hospitals in Tama, Tokyo Prefecture (This was performed by collaborating with COVID-19 Countermeasure ECMOnet Project established by six associations such as Japanese Association for Acute Medicine and The Japanese Society of Intensive Care Medicine, as needed, and paramedics of Yokohama City University went to Yokohama and rode with patients as they were transported from Yokosuka to Tama to secure their safety.). Transportation of patients from the Diamond Princess cruise ship seems to have settled down for the moment. However, even on February 26, patients transported from the cruise ship to the medical facility B in the City became critical and were transported to hospital B; they subsequently required ventilator support. So far, there is no sign of the treatment of critical patients coming to an end. At the same time, the number of critical patients being emergency transported from the City due to symptoms of pneumonia is increasing. Considering that passengers from the Diamond Princess cruise ship who require treatment have nearly filled the beds in medical facilities in Yokohama City, when the number of patients with COVID-19 and pneumonia from the City increase in future, the provision of support by accepting patients at medical facilities outside of Yokohama and Kanagawa Prefecture will be necessary. The emergency medical system of Yokohama City is not only for COVID-19 patients. It cannot have a negative impact on the regular emergency system, handling cases such as traffic injuries and other medical diseases. However, it is not easy to maintain the system to accept routine emergency patients while taking measures to prevent infection, secure staff, and stop harmful rumors. In future, if there are COVID-19 patients all across Japan, the challenge would be to balance COVID-19 patient management (serious patients with ventilator and ECMO requirements, among others) with routine emergency patient management without impacting the latter. The case of transporting 3,700 passengers and crew of the Diamond Princess cruise ship has not yet ended (this document was prepared on February 26, 2020). However, the emergency medical system of Yokohama City has been maintained to date without collapse because of not only the work put forth by medical facilities but also the efforts of the government (Kanagawa Prefecture, Yokohama City, Ministry of Health, Labour and Welfare, and Cabinet Secretariat); expert teams such as DMAT and JMAT infection countermeasure teams; Yokohama City Fire Bureau; private emergency responders; SDF; and especially, all hospital staff members. Hoping that the present case in Yokohama will be expertly and objectively verified from various perspectives and will contribute to future infection countermeasures, we will continue to play our role as the Medical Control Council to address the present situation. Approval of the Research Protocol: N/A. Informed Consent: N/A. Registry and the Registration no. of the Study/trial: N/A. Animal Studies: N/A. Conflict of Interest: None.

Characteristics of patients hospitalised in an emergency department observation unit in Japan

In Japan, transporting elderly patients to emergency departments has recently posed serious problems, including a longer average time from patients’ initial emergency calls to their arrival at hospitals. To manage emergency departments more efficiently, many hospitals in the United States and some other developed countries, including Japan, introduced emergency department observation units (EDOU). However, because the usefulness of EDOUs in managing elderly patients remains uncertain, we analysed data of patients admitted to a Japanese university hospital’s EDOU to gauge its efficacy. We followed 1,426 patients admitted to the hospital’s EDOU from 1 January 2011 to 31 December 2014. The average age of patients who stayed in the EDOU increased, whereas the average length of time that they spent there decreased. Although the percentage of patients older than 65 years increased slightly, from 36.42% (2011–2012) to 37.73% (2013–2014), the proportion of those patients between the two periods did not significantly change (P = .61). Moreover, their average length of stay was 2.16 ± 0.91 days, whereas patients younger than 65 years stayed for significantly less time (1.92 ± 0.82 days). By condition, approximately 36% of patients older than 65 years presented with non-neurosurgical trauma, approximately 59% presented with other forms of trauma, but proportions of both categories of trauma were significantly smaller in patients younger than 65 years (nonneurosurgical trauma, 23%; all trauma, 47%). Most elderly patients with limb trauma prepped for surgery were transferred to other hospitals after a few days. Results suggest that the EDOU at the university hospital has served to as a buffer for regional emergency medical systems in Japan, especially given the continued ageing of the Japanese population.

Practice and experiences of constructing a regional emergency medical system led by research disciplines

The purpose is to establish an emergency medical system that covers a certain region, responds quickly, operates efficiently, functions perfectly and develops sustainably. Such a system leverages the potential social functions of research disciplines, and is guided by the concept of expanding the emergency system of comprehensive emergency medicine . The authors identified the problems and shortcomings of the existing system and proposed to build a regional emergency medical system led by research disciplines. The path, system layout and functions are stated explicitly, while the system construction strategy is proposed by taking emergency treatment of myocardial infarction patients as an example. The system will be the pivotal support for integrating effectively regional emergency medical resources, improving the ability and level of emergency and first aid in medical institutions at various levels and of different types, promoting the formation of a new pattern of regional emergency medical service and achieving homogenized emergency medical services that everyone enjoy. Key words: Health services administration; Disciplines development; Regional; Emergency; Medical service system

Abstract TP240: The PLUMBER (Prevalence of Large Vessel Occlusion Stroke in Mecklenburg County Emergency Response) Study

Introduction: Regional Emergency Medical System (EMS) protocols for acute stroke endorse routing patients with possible large vessel occlusion (LVO) acute ischemic strokes (AIS) directly to endovascular centers. These routing algorithms include prehospital stroke severity screens (PSSS) to determine the likelihood of an LVO AIS. An essential, but unreported, determinant of the predictive value of PSSS tools is the prevalence of LVO AIS stroke in the EMS population screened for stroke. Hypothesis: Among EMS patients transported to Mecklenburg county hospitals screened for stroke, acute LVO AIS prevalence ranges from 5-10%. Methods: We are conducting a prospective, observational study of all patients transported by the Mecklenburg county EMS agency who are either (1) dispatched as a possible stroke and/or (2) with a primary impression of stroke recorded by prehospital providers. We are reviewing medical records and neurovascular imaging studies to determine an acute LVO AIS diagnosis and the site(s) of occlusion. Results: Thus far, over a six-month period we have enrolled 1441 patients, of whom 33% (n=480) had a diagnosis consistent with acute stroke (ischemic stroke, hemorrhagic stroke, or transient ischemic attack), with 20% (n=287) being an AIS. Eighty-eight percent (n=253) of AIS patients underwent an intracranial CTA or MRA. The prevalence of LVO stroke in the EMS population enrolled was 5.7% (n= 82, 95% CI 4.6-7.0%), with the most common vessel occluded being M1 (n=46, 56% of LVO AIS). The prevalence of LVO AIS in patients dispatched as a possible stroke was 4.8% (n =56; 95% CI 3.6-6.1%), while the prevalence in patients with a primary impression of stroke was 10% (n=74; 95% CI 8.2-13%). Conclusions: Among patients screened for stroke by our county’s EMS agency, the prevalence of LVO AIS is low. This low LVO AIS prevalence, combined with a PSSS tool with modest accuracy, will yield poor predictive value for LVO AIS in an EMS population, resulting in a substantial rate of over-triage of non-LVO patients to endovascular centers. Data collection is ongoing to determine the accuracy of a prehospital stroke screen in identifying LVO AIS patients.

Preventable trauma deaths after traffic accidents in Chiba Prefecture, Japan, 2011: problems and solutions.

The incidence of preventable trauma death in the current Japanese emergency medical system remains high. The present study aimed to determine rates of clearly preventable and possibly preventable trauma deaths due to traffic accidents in Chiba Prefecture, Japan, and to consider associated problems and solutions. During 2011, 175 victims died after traffic accidents in Chiba Prefecture. Of these, the deaths of 69 persons who had vital signs at the time of emergency medical service contact were classified as clearly preventable, possibly preventable, or not preventable through the peer review discussion. We also examined problems associated with deaths that were clearly preventable or possibly preventable. Of the 69 deaths, 9 (13%) were classified as clearly preventable, 11 (16%) as possibly preventable, and 49 (71%) as not preventable. Of the 20 clearly or possibly preventable deaths (each death potentially comprising multiple problems), 5 were related to selection of the hospital before hospital arrival, 4 to problems with regional emergency medical systems, and 15 to inappropriate hemodynamic management, including transfusion and delayed (or not attempted) hemostasis in the hospital. Problems of these 20 deaths showed that appropriate triage at the scene, centralization of patients with severe trauma, and trauma centers are necessary in Japan. Under-triage before arrival at the hospital was related to clearly and possibly preventable deaths. Upgrading the triage category for victims with torso injury must be considered. Not all emergency critical care centers in Japan are able to provide severe trauma care. Preventable trauma deaths occur even in some emergency critical care centers; therefore, we need centralization of severe trauma patients from wider area to reduce the incidence of preventable trauma death.

An Utstein-style Examination of Out-of-hospital Cardiac Arrest Patients in Saga Prefecture, Japan

The Utstein-style guidelines have been used in various countries around the world, because they are suitable for evaluating regional emergency medical systems (EMSs) for patients who have an out-of-hospital cardiac arrest (OHCA). This report examined the present status of treating OHCA in Saga Prefecture and examined policies that can contribute to improving the rate of the return of spontaneous circulation (ROSC). This study examined 800 cases of OHCA by means of the Utstein-style guidelines submitted for medical control verification by firefighting organizations in Saga Prefecture from July 1, 2010, to June 30, 2011. The firefighting organizations were divided into 5 areas (A-E) according to each medical classification. The 5 areas were compared in terms of the ROSC rate and background factors (patient age and sex, cardiac arrest cause, place, witnesses, initial electrocardiogram [ECG], hospital ECG, prehospital medical treatment, transfer time, oral instruction, and bystander cardiopulmonary resuscitation [CPR]). The ROSC rate was significantly lower in areas D (24.2%) and E (26.8%). Age, sex, cardiac arrest cause, place, witnesses, initial ECG, hospital ECG, shock, and adrenaline administration did not differ significantly among the 5 areas. The response time was significantly shorter in areas A (8: 25), D (8: 07), and E (8: 12). There were significantly fewer examples of oral CPR instruction in area E (42.1%), and there were fewer examples of CPR in areas A (44.0%), D (41.9%), and E (37.9%). CPR was performed by lay person in approximately 70% of the cases in which oral instructions were provided, but it was not performed in 90% of cases in which no oral instructions were provided. The Utstein-style guidelines were used to clarify differences in the ROSC rate in Saga Prefecture, thus making improvements in regional EMSs possible. Improvements in the quality of oral instruction and a reexamination of the oral instruction manual are expected to improve the ROSC rate, in parallel with education in basic life support for lay person and in advanced cardiac life support for medical personnel. In addition, it is important to reaffirm the effectiveness of CPR and encourage the participation of lay person by providing instructions by telephone from an ambulance that is en route to the scene.

Abstract 200: Regional Difference in Emergency Medical Services Dispatcher Cardiopulmonary Resuscitation Prearrival Instructions for Patients with Out-of-Hospital Cardiac Arrest in Japan

[Background] The 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care recommend that dispatchers should recommend cardio-pulmonary resuscitation (CPR) for unresponsive patients who are not breathing normally. This guideline also recommended special education for dispatchers. Every regional medical control system (the organization which was specially designed for presenting protocols to regional emergency medical system (EMS) and evaluating EMS operation) created dispatcher protocols to recognize cardio-pulmonary arrest and to helping CPR by bystander from July 2009 in Japan. Unfortunately, dispatchers in every regional emergency EMS could not be always specially educated. [Goal] To evaluated regional difference in EMS dispatch prearrival CPR instruction for patients with out-of-hospital cardiac arrest (OHCA). [Methods and Results] From January 1, 2005, through December 31, 2010, we conducted a prospective, population-based, observational study involving the consecutive patients across Japan who had OHCA (n=670,314). Dispatcher recommended CPR increased year by year, 33.8% of OHCA during 2005, 37.7% during 2006, 41.7% during 2007, 44.3% during 2008, 45.3% during 2009 and 46.3% during 2010 across Japan. Regional differences were shown in the figure. [Conclusion] Although EMS dispatch CPR has been increased year by year, bystander CPR recommended by EMS dispatcher has been still less than 50% of all OHCA in Japan. There were regional differences in recommendation of CPR by dispatcher across Japan. Both EMS recommendation of CPR and CPR by bystander responding to EMS recommendation were lowest in Tokyo metropolitan area. Certain detailed protocols which can be done easily even after small amount of educational time for EMS dispatcher are needed.

European Resuscitation Council Guidelines for Resuscitation 2010 Section 9. Principles of education in resuscitation

Survival from cardiac arrest is determined by the quality of the scientific evidence behind the guidelines, the effectiveness of education and the resources for implementation of the guidelines. 1 Chamberlain D.A. Hazinski M.F. Education in resuscitation. Resuscitation. 2003; 59: 11-43 Abstract Full Text Full Text PDF PubMed Scopus (90) Google Scholar An additional factor is how readily guidelines can be applied in clinical practice and the effect of human factors on putting the theory into practice. 2 Yeung J. Perkins G.D. Timing of drug administration during CPR and the role of simulation. Resuscitation. 2010; 81: 265-266 Abstract Full Text Full Text PDF PubMed Google Scholar Implementation of Guidelines 2010 is likely to be more successful with a carefully planned, comprehensive implementation strategy that includes education. Delays in providing training materials and freeing staff for training were cited as reasons for delays in the implementation of the 2005 guidelines. 3 Berdowski J. Schmohl A. Tijssen J.G. Koster R.W. Time needed for a regional emergency medical system to implement resuscitation Guidelines 2005 – The Netherlands experience. Resuscitation. 2009; 80: 1336-1341 Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar , 4 Bigham B.L. Koprowicz K. Aufderheide T.P. et al. Delayed prehospital implementation of the 2005 American heart association guidelines for cardiopulmonary resuscitation and emergency cardiac care. Prehosp Emerg Care. 2010; PubMed Google Scholar

Time needed for a regional emergency medical system to implement resuscitation Guidelines 2005—The Netherlands experience

Introduction In December 2005, updated resuscitation Guidelines (G) were introduced worldwide and will be revised again in 2010. This study sought to elucidate how long it takes to implement new guidelines. Methods This was a prospective observational study. From July 2005 to January 2008, we included all patients with an out-of-hospital cardiac arrest of suspected cardiac cause. We analyzed Emergency Medical System (EMS) Guideline usage via defibrillator recordings of the continuous ECG and impedance signals. We excluded patients with missing or otherwise unusable ECGs. All shocks and CPR cycles were individually classified. The same Guideline needed to be applied for at least 75% of all shocks and CPR cycles. If no shocks had been given, continuous ECGs were classified by its CPR status only. Continuous ECGs were classified as G1992, G2000 or G2005. If at least 75% of the shocks were given according to G2000 and at least 75% of the CPR was according to G2005, the Guideline protocol was classified as intermediate. All analyses that did not fulfil any Guideline criteria were classified as indeterminate. Results Of 1672 analyzable resuscitations, 31 (2%) used G1992, 826 (49%) G2000, 608 (36%) G2005, and 125 (7%) intermediate Guidelines. The Guideline protocol could not be identified for the remaining 81 (5%) patients. It took 17 months (from publication) until EMS personnel applied GL2005 in over 80% of cases. Conclusion Our experience shows it took one-and-a-half years to effectively implement new resuscitation Guidelines. We believe improvements in implementation can shorten this to six months.

TRIAD II: Do Living Wills Have an Impact on Pre-Hospital Lifesaving Care?

Background: Living wills accompany patients who present for emergent care. To the best of our knowledge, no studies assess pre-hospital provider interpretations of these instructions. Objectives: Determine how a living will is interpreted and assess how interpretation impacts lifesaving care. Design setting: Three-part survey administered at a regional emergency medical system educational symposium to 150 emergency medical technicians (EMTs) and paramedics. Part I assessed understanding of the living will and do-not-resuscitate (DNR) orders. Part II assessed the living will's impact in clinical situations of patients requiring lifesaving interventions. Part III was similar to part II except a code status designation (full code) was incorporated into the living will. Results: There were 127 surveys completed, yielding an 87% response rate. The majority were male (55%) and EMTs (74%). The average age was 44 years and the average duration of employment was 15 years. Ninety percent (95% confidence interval [CI] 84.6–95.4%) of respondents determined that, after review of the living will, the patient's code status was DNR, and 92% (95% CI 86.5–96.6%) defined their understanding of DNR as comfort care/end-of-life care. When the living will was applied to clinical situations, it resulted in a higher proportion of patients being classified as DNR as opposed to full code (Case A 78% [95% CI 71.2–85.6%] vs. 22% [95% CI 14.4–28.8%], respectively; Case B 67% [95% CI 58.4–74.9%] vs. 33% [95% CI 25.1–1.6%], respectively; Case C 63% [95% CI 55.1–71.9%] vs. 37% [95% CI 28.1–44.9%]), respectively. With the scenarios presented, this DNR classification resulted in a lack of or a delay in lifesaving interventions. Incorporating a code status into the living will produced statistically significant increases in the provision of lifesaving care. In Case A, intubation increased from 15% to 56% ( p < 0.0001); Case B, defibrillation increased from 40% to 59% ( p < 0.0001); and Case C, defibrillation increased from 36% to 65% ( p < 0.0001). Conclusions: Significant confusion and concern for patient safety exists in the pre-hospital setting due to the understanding and implementation of living wills and DNR orders. This confusion can be corrected by implementing clearly defined code status into the living will.

Intra-Arterial Fibrinolysis for Acute Ischemic Stroke

See related article, pages 2633–2639. For nearly a decade, intra-arterial fibrinolytic therapy for acute ischemic stroke has stood poised on the threshold of a definitive evidential basis and widespread acceptance. The positive result of the phase 3 PROACT II trial in 1999 appeared to validate the pathophysiologically eminently reasonable strategy of endovascular recanalization in acute ischemic stroke.1 Endovascular therapy delivers lytic agent at high concentration directly to the clot, increasing lysis rates compared with intravenous therapy, while minimizing systemic exposure and extracerebral bleeding complications.2 Leading stroke centers adopted endovascular recanalization therapies as a common off-label treatment option for patients beyond the 3-hour window.3 However, proponents of evidence-based medicine noted that a single, small phase 3 clinical trial was insufficient to provide definitive proof of efficacy. The US Food and Drug Administration and international regulatory agencies did not approve a stroke label for pro-urokinase. The expense of a confirmatory phase 3 trial of pro-urokinase proved daunting to pharma and none was undertaken. In US national practice guidelines, intra-arterial fibrinolysis occupied a gray zone, receiving a Level B recommendation, indicating the incomplete foundation of a single dose-ranging and single positive phase 3 trial.4 The limitations of this evidential base have prevented regional emergency medical systems from organizing delivery of patients directly to endovascular hospitals. The results of the MELT trial, reported in this issue of Stroke , are therefore very welcome, providing additional information regarding intra-arterial fibrinolytic therapy that complements and supports previous studies. …

Edlich Drive: A metaphor for the Edlich tradition

Richard F. Edlich, md, the Raymond F. Morgan Professor of Plastic Surgery and Professor of Biomedical Engineering, has been honored with the naming of a new road at North Fork Business Park: Edlich Drive. North Fork Business Park is a high-technology center for biomedical research, and the designation of this new road celebrates Dr. Edlich's instrumental role in the formation of a successful partnership between the University of Virginia and private industry. This partnership provides a mechanism to move technology from the laboratory to the marketplace and, ultimately, to the patient's bedside. Dr. Edlich's unparalleled contributions to his community include the establishment of the Emergency Department at the University of Virginia, the implementation of a regional emergency medical system, and the development of the Pegasus Emergency Flight Operations. Other accomplishments include the founding of the Ira DeCamp Regional Burn Center and the Department of Rehabilitation Medicine. “Drive” aptly characterizes Dr. Edlich's unfailing commitment to his many roles as physician, research scientist, community leader, and mentor for medical students and residents.

Some trends in the delivery of ambulance services : Chaiken JM and Gladstone RJ (1974) Report R-1551, The Rand Corporation, 1700 Main Street, Santa Monica, California 90406, U.S.A.

A composite description of present (1973) and planned emergency ambulance systems is provided based on information from 179 applicants to the Robert Wood Johnson Foundation for grants for regional emergency medical systems. The data indicate that only 11.1 percent of the ambulance services are now provided by funeral homes and 34.5 percent are provided by local government agencies. Local government agencies operate 28.9 percent of all emergency vehicles and volunteer agencies operate 19.2 percent. Most ambulance services are provided primarily by small agencies, with minimal coordination. A great deal of confusion surrounds telephone numbers for emergency services, but centralized systems are being initiated in a number of communities. Some obstacles remain to the installation of 911 emergency numbers across State or service boundaries. The advantages and disadvantages of a centralized command and control system of dispatching ambulances for several ambulance agencies are weighed and several configurations are proposed. Analysis of the time between dispatch of the ambulance and its arrival show a median of four minutes for urban areas and up to 25 minutes in rural areas. The 1973 level of ambulance attendant training shows that many areas depend on personnel with little or no training for providing initial emergency care. Training courses developed by the United States Department of Transportation for emergency medical technicians and dispatchers appear acceptable as reasonable goals for implementation within two years.