Rural EMS Research Articles

Workforce priorities: three steps to determine what they are & move forward.

In recent years, considerable media attention has been given to the shortage of EMTs and paramedics.(1-8) Reports appear often enough to raise concern among the public, the medical community and policymakers alike that an ongoing or pending nationwide "crisis" or "shortage" of EMS professionals is upon us. Rural challenges are particularly prevalent in media coverage.(5,6,9) The recent inclusion of a special rural EMS session at the National Conference of State Legislatures 2007 annual meeting suggests that concern among local politicians has reached a tipping point, which may prompt action.

Multiple information sources in the analysis of a disaster

Disasters are complex events making epidemiologic studies and determination of accurate denominators difficult due to the poor nature of available records. However, these data are essential to perform useful calculations and accurate descriptions of disaster medical impacts. This study was undertaken to identify the availability and utility of various information sources in the analysis of a mass casualty disaster. In addition, characteristics of cases presenting for care are described. This is a retrospective cohort study abstracting medical records and other documents relating to an explosion and fire. Public domain documents are obtained by written request or by filing a Freedom of Information Act (FOIA) request. A rural EMS and tertiary hospital. Individuals directly exposed to the forces of the explosion. The number of cases detected by various information sources. In addition, the demographics, dispositions, and nature of the physical injuries of the cases are reported. Seven sources of case information were identified. The most cases were identified by investigative agencies (33) and the fewest by medical records (18). Rates include; injury 0.68, admission 0.20, and operative 0.14, with no deaths. Case locations during the explosion were determined for all cases. No association was noted between admission and location in the building. This study demonstrates the availability and usefulness of data in the public domain. Using FOIA requests or partnerships with public or private agencies may more clearly define denominator data in epidemiologic evaluations of disasters.

River Tree Rope Swing Injuries

To review injuries associated with falls from river tree rope swings (RTRS) and identify points of action for prevention. This study was a retrospective analysis of injury reports directly related to falls from RTRS. Case reports for 2002-06 were extracted from the National Electronic Injury Surveillance System (NEISS), US legal literature, and news reports. Direct observation of river tree rope swings was performed with kayak and camera to identify potential hazards. A laboratory study was performed on samples of rope used in RTRS to assess entanglement risk. NEISS detailed 73 injuries directly related to falls from RTRS in ages 5-25 years. Finger fractures were the most commonly reported injury. Based on NEISS data, an estimated 700 injuries may occur related to RTRS each year. RTRS share risk of severe injuries with traditional rope swings such as lower extremity fractures, concussions, and spinal cord injuries. Drowning, finger avulsion and genital lacerations appear more common with river tree rope swings. RTRS are dangerous and are associated with a variety of serious injuries from falls and entanglement. The most hazardous risk factors of RTRS are use by a non-swimmer, shallow water, extreme fall distance, and presence of a small diameter retrieval line. RTRS injuries occurring in remote locations are challenges to rural physicians and EMS providers. Prevention of recreational injuries, including injuries sustained from RTRS, remains a daunting task.

A pilot study of the King LT supralaryngeal airway use in a rural Iowa EMS system

IntroductionIn 2003, the King Laryngeal Tube (LT) received FDA approval for US sales. Prehospital systems in urban setting have begun evaluating and adopting the LT for clinical airway management. However, it is not routinely approved by State EMS Boards for use by all prehospital providers. Given the LT’s simple design there may be benefit to using this tool for airway management in all levels of prehospital providers. This pilot study reviews cases where the King LT was used in a rural Iowa county EMS system.MethodsIn 2006, the Iowa Department of Public Health / Bureau of EMS approved a 12 month pilot evaluating the King LT by all levels of EMS providers in a rural county EMS system. Following a didactic and competency training session on using the King LT, the providers were instructed to continue airway management per usual protocol but were allowed to use the King LT as a first line airway tool if they felt indicated. Successful placement of airway devices used were determined by colourimetric end-tidal CO2, chest auscultation and rise as well as vital sign and skin colour improvement. Review of the data was approved by the University of Iowa Institution Review Board (IRB).ResultsDuring the 12-month pilot period, the King LT was used in 13 patients with a mean age of 60.7 years (24–81). All patients had cardiopulmonary or traumatic arrest. The King LT was successfully placed on the first attempt in all but one case. The King LT was placed following endotracheal intubation failure in 6/13 (46.1%) cases and in 3/13 (23.1%) of cases of Combitube attempt / failure.ConclusionsThis small pilot project emphasizes the need for additional rapid airway management tools given the demonstrated ETI failures. The authors believe the King LT has significant potential to impact prehospital airway management as a primary airway device or backup to other failed strategies. Further study is necessary to evaluate the LT’s efficacy compared to current strategies.

Pay for Performance Improves Rural EMS Quality: Investment in Prehospital Care

Objective. To evaluate the effect of a system of financial reward for emergency medical technicians (EMTs) who meet selected quality marker goals. Methods. This project was reviewed by an institutional review board (IRB) andwas found to be exempt from IRB review. Two operational andfour clinical markers were targeted for improvement. Baseline performance measurements were retrospectively measured for the preceding year, andchallenging but achievable goals for improvement were established. Operational markers included completing run reports within three hours after completion of the run andcall-to-en route (“out-of-chute”) times of less than 90 seconds for emergency calls on our first-line ambulance. Clinical markers included the use of aspirin in adults with nontraumatic chest pain, electrocardiogram (ECG) performance in adults with nontraumatic chest pain, documentation of pain assessment andintervention in patients with traumatic hip pain, anddocumentation of the time of onset of symptoms in stroke calls. Each full-time EMT could earn up to $1,000 in addition to baseline pay, with part-time EMTs eligible for prorated amounts. Results. Postincentive run reports were completed within three hours 99.7% of the time, with 21 of 24 providers meeting the goal 100% of the time. Before the incentive, reports were completed within three hours 64% of the time, with only two of 23 providers meeting the goal 100% of the time. The out-of-chute goal of less than 90 seconds was met 98.7% of the time, compared with 90.1% before the incentive. Aspirin use in adult nontraumatic chest pain improved from 68% to 96.3%, andECG performance in this group improved from 43% to 87.8%. Documentation of the time of onset of symptoms in stroke patients improved from 97% to 100%, andthe assessment of andintervention for pain in traumatic hip pain patients improved from 56% to 100%. Conclusion. Financial motivation improved targeted quality measures in this rural emergency medical service. It appears to be a useful adjuvant to traditional quality improvement mechanisms.

Derivation and evaluation of a termination of resuscitation clinical prediction rule for advanced life support providers

The primary aim was to derive a new termination of resuscitation (TOR) clinical prediction rule for advanced life support paramedics (ALS) and to measure both its pronouncement rate and diagnostic test characteristics. Secondary aims included measuring the test characteristics of a previously derived and published basic life support termination of resuscitation (BLS TOR) clinical prediction rule [Morrison LJ, Visentin LM, Kiss A, et al. Validation of a rule for termination of resuscitation in out-of-hospital cardiac arrest. N Engl J Med 2006;355(5):478-87] on the same cohort of patients for comparison purposes. Secondary data analysis of adult cardiac arrests treated by ALS in rural and urban EMS systems participating in the OPALS study (data extracted from Phase III). A previous study for a basic life support termination of resuscitation (BLS TOR) clinical prediction rule proposed Termination of Resuscitation if the patient had no return of spontaneous circulation (ROSC) before transport; no shock administered; EMS personnel did not witness the arrest [Morrison LJ, Visentin LM, Kiss A, et al. Validation of a rule for termination of resuscitation in out-of-hospital cardiac arrest. N Engl J Med 2006;355(5):478-87]. Multivariable logistic regression was used to examine the relationship between these variables, additional Utstein variables, and the primary outcome of survival to hospital discharge. Diagnostic test characteristics were measured for both the ALS TOR and BLS TOR models on this derivation cohort. Four thousand six hundred and seventy-three cardiac arrest patients were included; 3098 (66%) were male, mean (S.D.) age 69 (15); 239 (5.1%; 95% CI 4.5-5.8) survived to hospital discharge; 3841 patients had no ROSC (82%) and of these only three survived (0.08%; 95% CI 0.02, 0.23). The final ALS TOR model associated with survival, included: ROSC (OR 260.9; 95% CI 96.3, 706.7), bystander witnessed (OR 2.0; 95% CI 1.3, 3.1), bystander CPR (OR 2.8; 95% CI 1.9, 4.1), EMS witnessed (OR 12.3; 95% CI 7.1, 21.3) and shock prior to transport (OR 6.4; 95% CI 4.1, 10.1). A new ALS TOR clinical prediction rule based on these variables was 100% sensitive (95% CI 99.9-100) for survival and had 100% negative predictive value (95% CI 99.9-100) for death. Under the ALS TOR clinical prediction rule, 30% of patients would be pronounced in the field. The BLS TOR clinical prediction rule, was 100% sensitive (95% CI 99.9, 100), had 100% negative predictive value (95% CI 99.9-100) and the field pronouncement rate was 48%. Cardiac arrest patients may be considered for prehospital ALS TOR when there is no ROSC prior to transport, no shock delivered, no bystander CPR and the arrest was not witnessed by bystanders or EMS. A single EMS termination clinical prediction rule for all levels of providers would be optimal for EMS systems to implement. Prospective evaluation of the ALS TOR clinical prediction rule in the hands of ALS providers will be required before implementation.

Endotracheal Tube Placement by EMT-Basics in a Rural EMS System

Objective.To evaluate the effectiveness of an intubation-training module andspecial-waiver project in which Emergency Medical Technicia (EMT)-Basics were trained to perform endotracheal intubations in a rural community.Methods.This was a prospective observational study over a four-year period (July 1998 through May 2002) of all intubation attempts by EMT-Basics in the field. The authors observed intubation data, training methods, andquality-assurance methods of a special-waiver project agreed to by the State Department of Public Health to train andallow EMT-Basics to intubate patients. Data were from documentation unique to the project. Project documentation evaluated the placement andcomplication(s) of endotracheal tube (ETT) placement after arrival to the emergency department. An intubation attempt was defined as direct largyngoscopy. A successful attempt was defined as an appropriately sized ETT placed andsecured in the trachea below the vocal cords andabove the carina. Confirmation of placement in the field included accepted clinical methods andthe use of qualitative colorimetric end-tidal carbon dioxide detectors. The EMT-Basics were trained using a paramedic curriculum, including operating room intubations on live adult patients. All patients were in either cardiopulmonary or respiratory arrest.Results.Thirty-two intubations were performed by EMT-Basics. Thirty attempts were successful andtwo were unsuccessful (94%; 95% confidence interval [CI] 80–98%). Unsuccessful ETT placements were managed with accepted basic life support airway standards. There were no unrecognized esophageal ETT placements (0%; 95% CI 0–11%).Conclusion.This study demonstrated that with an intensive training program using selected highly motivated providers andclose monitoring, a program of EMT-Basic ETT placement in a rural setting can achieve acceptable success rates in patients in cardiac or respiratory arrest.

Emergency medical services in rural areas: the supporting role of state EMS agencies.

EMS is an integral part of health care and is especially important in less densely populated areas. What is known about EMS in rural areas is limited because of fragmentation in the system and rudimentary data collection efforts. The goal of this study is to identify important issues faced by rural EMS systems and describe the support of rural EMS providers by state EMS agencies. A telephone survey of state EMS directors (response rate 95.7%) asked questions regarding issues in medical direction, programs, and initiatives by state EMS agencies that target rural and volunteer EMS providers, integration initiatives, and anticipated effects of the new Medicare fee schedule. Medical direction in rural EMS was identified as a major issue for a majority of states. Integration in EMS is seen as a possible solution but does not occur very commonly. The survey found substantial variation in the state approach to EMS issues. Less than a third of the states in the study have a statewide EMS plan. State EMS agencies address rural EMS provider needs in a limited manner. EMS state agencies focus on regulation and funding of EMS providers, with only approximately a third providing technical assistance to EMS providers. The range in approaches to EMS issues at the state level will need to be taken into account in formulating national EMS policy. The limited provision of technical assistance leaves a void that may be addressed by other agencies and organizations in some states. In the absence of major federal funding initiatives, the development of EMS has become a state and local issue. A new national initiative may help address EMS issues and stimulate the development of EMS as a system beyond its current fragmented state.

Unrecognized Misplaced Endotracheal Tubes in a Mixed Urban to Rural EMS Setting

Unrecognized Misplaced Endotracheal Tubes in a Mixed Urban to Rural EMS Setting

How far is that by air? The derivation of an air:ground coefficient

The objective of this study was to derive a simple equation to convert distances between air miles traveled by a helicopter and ground miles traveled by an ambulance. We performed a retrospective analysis of a convenience sampling of 245 “lights and sirens” ground ambulance transports between 1993 and 1997. Ground distances were recorded from odometer miles for each transport. Air miles were calculated using the Global Positioning System (GPS), measuring the distance in a straight line from the scene to the hospital. Air and ground distances were entered into a computerized spreadsheet, and the correlation coefficient and regression equation were derived. A simple approximation equation was developed and compared against the derived regression equation. There was a strong linear correlation between ground miles and air miles at virtually all distances studied (R = 0.932, R 2 = 0.869). Regression analysis revealed the following relationship: Ground miles = 0.94 + 1.25 (air miles). This was simplified to an approximation of: Ground miles = 1.3 (air miles). The approximation equation yielded an answer within 1 mile of the regression equation for distances up to 40 air miles. It is concluded that in a mixed rural and urban EMS system, one may convert air and ground mileage estimates by using the simple relationship: Ground miles = 1.3 (air miles). This conversion coefficient may prove useful for EMS personnel in designing reasonable helicopter utilization policies, making accurate transport decisions and conducting research.

Initiation of capnography in a rural ems system

Objective. Capnography is an effective means of monitoring cardiopulmonary resuscitation and managing endotracheal intubation. Numerous studies have validated its use in urban settings, but none have described its integration into a rural EMS system. The authors describe the process of integrating capnography training and use in Jackson County, West Virginia. Methods. Two CO2SMOS capnography/ pulse oximeters were placed on the lead ambulances in Jackson County, West Virginia. Training in the operation and application of the equipment was provided, and providers used the monitors for a period of six months. A questionnaire was administered to assess their understanding of the equipment and its utility in prehospital care. Results were compiled and summarized. Results. Ninety percent of the EMS providers subjectively felt that they understood capnography and its clinical application. They answered questions designed to test their understanding with 65% accuracy. Conclusion. In this model, capnography was successfully integrated into a rural EMS system. Reasonable proficiency in the use of the CO2SMOS monitor and an understanding of the information obtained were demonstrated, although the EMS providers tended to overestimate their actual understanding of the clinical application of capnography. This supports the need for ongoing, targeted education. The authors feel that capnography provides information that is uniquely relevant in rural EMS systems.

Demographic differences in the resuscitation knowledge and skills of the Standard First Aid Class ambulance crews in Japan

This study was undertaken to determine the frequency and type of continuing education required in areas with various populations and evaluate the resuscitation knowledge and skills possessed by Standard First Aid Class (SFAC) ambulance crews, who play a major role as prehospital care providers in Japan. Two hundred SFAC ambulance crews were classified into four subgroups based on the population of the areas they serve a population greater than 400,000, 150,000-400,000, 50,000-150,000 and less than 50,000. A survey regarding continuing education in each area revealed that the EMS systems with smaller populations had less adequate continuing education than in larger populated areas. A written test consisted of 80 multiple choice questions showed no difference among each population subgroup. In the five-point skills test, however, it was demonstrated that the resuscitation skills, particularly those required for the airway management, of SFAC ambulance crews in the areas populated by less than 50,000 had deteriorated more than those in larger communities. These findings re-emphasized the importance of adequate continuing education in low-volume, part-time, rural EMS systems where lack of clinical exposure is a significant limiting factor for skill retention.

Accuracy of rural ems provider interpretation of three-lead ecg rhythm strips

Objective. To measure the accuracy of lead II rhythm strip interpretations performed by advanced life support (ALS) emergency medical technicians (EMTs) in a rural emergency medical services (EMS) system.Methods. An electronic rhythm simulator was used to produce 24 three-lead electrocardiogram (ECG) rhythm strips. The rhythms were shown to 57 ALS EMTs participating in regularly scheduled continuing education classes. The participants were asked to identify the rhythms.Results. The three-lead ECG interpretations were generally accurate, although there was some difficulty in distinguishing between specific types of tachydysrhythmias and atrioventricular (AV) block. The overall accuracy of the rhythm interpretations was 79.2%, ranging from 45.6% (second-degree type II heart block) to 98.2% (sinus bradycardia). The sensitivity for specific tachydysrhythmias ranged from 68.4% (supraventricular tachycardia) to 86.0% (atrial fibrillation); the sensitivity for specific types of AV block ranged from 45.6% (second-degree, type II) to 71.9% (third-degree).Conclusion. In this EMS system, ECG interpretations are generally accurate, with tachydysrhythmias and AV blocks being the source of most discrepancies.

Does basic life support in a rural EMS system influence the outcome of patients with respiratory distress?

The purpose of this study was to determine whether basic life support, prehospital emergency medical care in a rural area affects the hospital course of patients with respiratory distress. Medical records for patients admitted from the emergency department with a discharge diagnosis related to respiratory disease were reviewed. Data collected included: 1) mode of arrival; 2) initial symptom; 3) vital signs; 4) prehospital interventions applied; 5) hospital days; 6) discharge status; and 7) principal diagnosis. Multiple logistic regression analysis was used to predict length of hospital stay. Charts for 603 patients were reviewed. Complete data for all variables included in the logistic regression analysis were available for 471 patients (78.1%). Because 55 patients died, only 416 (69.0%) were included in the multiple regression analysis conducted to predict length of hospital stay. Logistic regression analysis demonstrated that patients who arrived by ambulance and older patients were more likely to die; patients with higher systolic blood pressures were more likely to survive. Only patient age predicted length of hospital stay, with older patients having longer stays. Basic life support prehospital care in this rural emergency medical services system does not result in a lower mortality rate or a shorter hospital stay for a broad group of patients with respiratory distress who require hospital admission. Although this study is limited to a single population and a single emergency medical services system, it is one of only a few studies of outcome in basic life support systems.

Rural EMS: Are current levels of training and education meeting local needs?

Rural EMS: Are current levels of training and education meeting local needs?

Therapeutic agents utilized in urban/rural prehospital care.

Objectives of this study were to determine the number of prehospital emergency patients who were given advanced life support (ALS) drugs and to compare utilization rates for ALS drugs in urban and rural environments. Certified ALS emergency medical technicians (Arizona) have 29 therapeutic agents authorized for prehospital administration. These agents may be administered only under direction of a medical control authority or by following standing orders. A retrospective review was made of prehospital emergency encounter records. They were acquired by the Arizona Office of Emergency Medical Services (OEMS) from rural EMS providers who used optically scannable forms and from a metropolitan fire department's medical emergency response records. In 1989 and 1990, 273,611 emergency patient encounter records were entered into the EMS database; 197,260 were urban responses and 76,351 were rural responses. Drugs (ALS) were administered to 16,730 (8.5%) urban emergency patients and to 5,359 (7%) rural emergency patients at the incident site or during transport to a medical care facility. Nitrostat, 0.4 mg sublingual tablet, was the drug most frequently administered to emergency patients in the prehospital setting. Utilization rates found in the urban and the rural data sets were consistent for the individual agents. Variations in use frequency between urban and rural setting were noted for some drugs. Of the 29 approved ALS drugs, seven (24%) were administered to 10% or more urban patients who received drugs. In the rural areas, eight (27.6%) were administered to 10% or more patients who received drugs. There were nine (31%) agents administered to less than 1% of all patients who received drugs. A majority of the approved drugs, 17 (59%) were administered at a rate below 5% of all patients receiving medications. Severity of illness or injury prompted administration of ALS drugs to 8.1% of patients receiving prehospital emergency care. The most frequently utilized medication in the urban/rural areas was for treatment of cardiac symptoms. Variations between urban/rural drug utilization reflected the drugs of choice which are compatible with long transport times to a medical facility.

A Method to Reduce Rural EMS Response Times

AbstractProlonged EMS response times are a significant problem in rural areas. In this study, VHF radios and personal medical kits were placed in the private vehicles of rescue squad members. By coordinating the responses using radios, higher level EMTs were sent directly to the scene to initiate patient assessment and other procedures while others proceeded to an unstaffed station to pick up the rescue truck.Using this response system, EMTs arrived at the scene prior to the rescue vehicle on 30 of 35 calls (85.7%). In 25 of 35 calls (71.4%), the first person at the scene was at an advanced EMT level even though the majority of responses (56%) were made by Basic EMTs (p<0.001). The mean response time for EMTs using privately owned vehicles was 9±4 minutes (means±SD) compared with 16±9 minutes for the rescue truck (p<0.01). There also was a significant difference in response times between the privately owned vehicles and the rescue truck when the time between the receipt of the call and the initial acknowledgement of response was measured (1±1 minutes vs. 7±3 minutes; p<0.01).An effective EMS response can be made in rural areas by sending EMTs directly to a scene in private vehicles. Providing EMTs with VHF radios and personal medical kits enhances this response.

Effectiveness of nitrous oxide in a rural EMS system

Prehospital systems need a safe, effective analgesic agent for the treatment of patients suffering from pain. Recent studies have documented the efficacy of nitrous oxide in urban and rural settings. This study reviews the findings on 200 patients (157 trauma, 23 medical, 18 musculoskeletal problems) who received nitrous oxide during a 28-month period in a rural EMS system. Eighty-five percent of the patients reported pain relief. Only minor side effects were noted. Patient satisfaction was high, and there was no abuse noted among personnel.

Southeast Alaska to Seattle emergency medical air transports: Demographics, stabilization, and outcomes

Most rural EMS aeromedical transport studies have been based on distances of less than 100 miles. No current published studies exist evaluating long-distance transports. A retrospective chart review was conducted of all patients transported from southeast Alaska to Seattle, Washington, by an intensive care air ambulance over a five-year period (1982-1986). During the study period, 442 patients were transported an average one-way distance of 703 +/- 58.9 miles. Of these, 134 had a diagnosis of major or multiple trauma and were the focus of the study. Patient demographics and medical stabilization by Alaskan physicians, the flight team, and the receiving hospital were analyzed. Injury severity and outcomes also were evaluated. Of the study group, 31% required air transport within Alaska before being seen by a physician. The flight team provided major stabilization for 11% of the trauma victims, minor stabilization for 42%, and no further stabilization for 47%. Patient flights were categorized using previously published criteria as "essential" to survival in 27% of the cases, "helpful" in 55%, and "noncontributory" in 18%. This study presents a profile of patients injured in remote areas who require stabilization by rural, often nonsurgical physicians and face long-distance transfers before reaching definitive care. Health-care systems in sparsely populated areas may use this study as a reference for comparing trauma outcomes and quality of care in long-distance air transport.

Financial Considerations in Emergency Medical Services Systems

EMS providers have raised the public's perception and acceptance of paramedic-level care. Both rural and urban EMS policy makers will continue to feel the financial pressure to maintain and upgrade EMS services. The issue of who pays for health care has captured the interest of all and will continue to be scrutinized like no other part of providing quality prehospital medicine.