Trip Sheets Research Articles

Bhutan's First Emergency Air Medical Retrieval Service: The First Year of Operations

ObjectiveThe Bhutan Emergency Aeromedical Retrieval (BEAR) Team is the only helicopter emergency medical service in Bhutan. This study was performed to review the clinical cases cared for by the BEAR Team, ascertain the types of interventions that were performed, and determine the outcomes of patients evacuated in its first year of operations. MethodsThis is a retrospective observational study in which medical evacuations performed in the first year of operations were analyzed. The number of airlifts activated during the study period determined the sample size (171). Data were obtained from case logs and trip sheets. ResultsThe BEAR Team provided services to all regions of the country in its first year. The overall survival rate was 73.1%. The most common intervention required was securing a definitive airway (n = 24). The top 3 conditions requiring air medical retrieval were sepsis, acute mountain sickness, and trauma. ConclusionHelicopter emergency medical services are known to decrease the time to definitive treatment. This is particularly pertinent in Bhutan, given the scattered population distribution, long transport times, and distribution of medical resources and specialty care. This study is the first of its kind in Bhutan, and this can pave way to conduct more studies involving patients transported by air ambulance.

231: Discrepancies Between the Prehospital and Hospital Record: What is the Value of the Trip Sheet?

Critical patient data, such as abnormal vital signs, have relevance when noted in the prehospital (PH) environment, even if they normalize in the emergency department (ED). Prehospital medical records or “trip sheets” (TS) may detail these data, but are not always required to be delivered with the patient. We evaluated the extent to which the trip sheet contains prehospital clinical information that is not recorded in the emergency/hospital record.

Emergency Medical Service Transport Times for Acute Stroke and Myocardial Infarction

P188 It is currently recommended by the American Heart Association that both stroke and myocardial infarction (MI) patients be treated with urgency, as time dependent medical therapies are available for both conditions. Since stroke symptoms are often vague, it has been hypothesized that stroke patients may not be treated with the same urgency as MI patients by emergency medical services (EMS). To examine this hypothesis, EMS transport times were examined for both stroke and MI patients who used a paramedic-level, county based EMS system for transportation to a single hospital during 1999. Patients were identified by their hospital discharge diagnosis as stroke (ICD-9 430–438) or MI (ICD-9 410–414). Trip sheets with the corresponding transport times were retrospectively obtained from the 911 center. Thirteen patients with both a stroke and MI discharge diagnosis code were excluded from these analyses, leaving 75 stroke and 127 MI patients. While stroke patients were older than MI patients (median 81.1 vs. 73.3 years, p=0.01), the distribution of gender (56.9% women) and ethnicity (68.3% white) was not significantly different between stroke and MI patients. The use of lights and sirens to the scene (84.4%) and to the hospital (10.6%) also was not significantly different between stroke and MI patients. Mean EMS transport times are presented below in minutes, with the corresponding Wilcoxon rank sum test. In this study, all components of EMS transport times were similar for stroke and MI patients. Multiple linear regression predicting transport times confirmed these results. In this single county, EMS urgency for delivery of care was not different for stroke and MI patients.

Emergency Medical Service Transport Times for Acute Stroke and Myocardial Infarction

P188 It is currently recommended by the American Heart Association that both stroke and myocardial infarction (MI) patients be treated with urgency, as time dependent medical therapies are available for both conditions. Since stroke symptoms are often vague, it has been hypothesized that stroke patients may not be treated with the same urgency as MI patients by emergency medical services (EMS). To examine this hypothesis, EMS transport times were examined for both stroke and MI patients who used a paramedic-level, county based EMS system for transportation to a single hospital during 1999. Patients were identified by their hospital discharge diagnosis as stroke (ICD-9 430–438) or MI (ICD-9 410–414). Trip sheets with the corresponding transport times were retrospectively obtained from the 911 center. Thirteen patients with both a stroke and MI discharge diagnosis code were excluded from these analyses, leaving 75 stroke and 127 MI patients. While stroke patients were older than MI patients (median 81.1 vs. 73.3 years, p=0.01), the distribution of gender (56.9% women) and ethnicity (68.3% white) was not significantly different between stroke and MI patients. The use of lights and sirens to the scene (84.4%) and to the hospital (10.6%) also was not significantly different between stroke and MI patients. Mean EMS transport times are presented below in minutes, with the corresponding Wilcoxon rank sum test. In this study, all components of EMS transport times were similar for stroke and MI patients. Multiple linear regression predicting transport times confirmed these results. In this single county, EMS urgency for delivery of care was not different for stroke and MI patients.

A C OMPARISON OF E MERGENCY M EDICAL S ERVICES T IMES FOR S TROKE AND M YOCARDIAL I NFARCTION

Objective. Since stroke symptoms are often vague, and acute therapies for stroke are more recently available, it has been hypothesized that stroke patients may not be treated with the same urgency as myocardial infarction (MI) patients by emergency medical services (EMS). To examine this hypothesis, EMS transport times were examined for both stroke and MI patients who used a paramedic-level, county-based EMS system for transportation to a single hospital during 1999. Methods. Patients were first identified by their hospital discharge diagnosis as stroke (ICD-9 430–436, n = 50) or MI (ICD-9 410, n = 55). Trip sheets with corresponding transport times were retrospectively obtained from the 911 center. A separate analysis was performed on patients identified by dispatchers with a chief complaint of stroke (n = 85) or MI (n = 372). Results. Comparing stroke and MI patients identified by ICD-9 codes, mean EMS transport times in minutes did not meaningfully differ with respect to dispatch to scene arrival time (8.3 vs 8.9, p = 0.61), scene time (19.5 vs 21.4, p = 0.23), and transport time (13.7 vs 16.2, p = 0.10). Mean total call times in minutes from dispatch to hospital arrival were similar between stroke and MI patients (41.5 vs 46.4, p = 0.22). Results were similar when comparing patients identified by dispatchers with a chief complaint indicative of stroke or MI. Conclusion. In this single county, EMS response times were not different between stroke and MI patients. Replication in other EMS settings is needed to confirm these findings.

Seeking Help When Strokes Happen: A Study of 911 Tapes

43 Recommendations from the American Stroke Association stress the importance of treating stroke symptoms as medical emergencies and encourages the public to call 911 if they witness or experience a stroke. However, many patients experience delays from onset of symptoms to hospital arrival of 4 to 6 hours. Use of emergency medical service (EMS) is an important link in the chain of recovery. To investigate EMS use, tapes of calls to 911 were evaluated for 93 confirmed stroke cases arriving at the hospital by ambulance in 2 North Carolina counties during 1999. Tapes were transcribed and linked to EMS trip sheets. Seventy-two percent of patients were women, 30% were black, and their mean age was 76 years. Forty-three percent of the calls were placed by medical personnel and 37% by a family member. Only 5 of the 93 calls were made by the patient. In 42 (45%) of calls, the term “stroke” or “cerebrovascular accident” was recorded. In most instances (35 of 42) the term was first used by the caller. A decreased ability to walk or altered mental status were the two most frequently reported symptoms (30% each), followed by breathing difficulty (27%), impaired speech (25%), and muscle weakness (16%). In 78% of the calls, dispatchers sent EMS personnel to the scene at highest priority, with lights and sirens. The median time from dispatch to arrival of EMS personnel on the scene was 7 minutes. The median elapsed time from receiving the 911 call to the patient’s arrival at the hospital was 42 minutes. This study suggests that most 911 calls in these two counties were dispatched with highest priority. While EMS arrived in 7 minutes, it took more than one-half hour from arrival at the scene to reach the hospital. Few calls to 911 were made by the patients themselves. The information from this study will be useful in designing public health strategies to reduce prehospital delay for stroke patients.

Seeking Help When Strokes Happen: A Study of 911 Tapes

43 Recommendations from the American Stroke Association stress the importance of treating stroke symptoms as medical emergencies and encourages the public to call 911 if they witness or experience a stroke. However, many patients experience delays from onset of symptoms to hospital arrival of 4 to 6 hours. Use of emergency medical service (EMS) is an important link in the chain of recovery. To investigate EMS use, tapes of calls to 911 were evaluated for 93 confirmed stroke cases arriving at the hospital by ambulance in 2 North Carolina counties during 1999. Tapes were transcribed and linked to EMS trip sheets. Seventy-two percent of patients were women, 30% were black, and their mean age was 76 years. Forty-three percent of the calls were placed by medical personnel and 37% by a family member. Only 5 of the 93 calls were made by the patient. In 42 (45%) of calls, the term “stroke” or “cerebrovascular accident” was recorded. In most instances (35 of 42) the term was first used by the caller. A decreased ability to walk or altered mental status were the two most frequently reported symptoms (30% each), followed by breathing difficulty (27%), impaired speech (25%), and muscle weakness (16%). In 78% of the calls, dispatchers sent EMS personnel to the scene at highest priority, with lights and sirens. The median time from dispatch to arrival of EMS personnel on the scene was 7 minutes. The median elapsed time from receiving the 911 call to the patient’s arrival at the hospital was 42 minutes. This study suggests that most 911 calls in these two counties were dispatched with highest priority. While EMS arrived in 7 minutes, it took more than one-half hour from arrival at the scene to reach the hospital. Few calls to 911 were made by the patients themselves. The information from this study will be useful in designing public health strategies to reduce prehospital delay for stroke patients.

Effects of on-line medical control in the prehospital treatment of atraumatic illness

Objective. On-line medical control (OLMC) is costly and time-consuming, yet little is known about the direct effect of OLMC on the quality of care provided. The objective of this study was to analyze the effect of OLMC on adherence to protocol and quality of care provided.Methods. Retrospective review of trip sheets completed by out-of-hospital personnel in an urban/suburban/rural emergency medical services system with a volume of 144,000 calls/year; approximately 15,000/year are ALS calls. Two levels of provider—paramedics and critical care technicians (CCTs)—work under single standard protocols and a single medical director. Prehospital trip sheets of 774 sequential patients with atraumatic illnesses for whom an ALS crew was dispatched were re-viewed for adherence to standard protocol and for appropriateness of deviations from protocol, with and without the use of OLMC.Results. Adherence to protocols occurred in 78.3% of all patient encounters. OLMC was utilized in 61.5% of patient encounters. The CCTs were more likely to utilize OLMC than were the paramedics, 72% vs 56% (p < 0.001). There was a trend towards paramedics' adhering to protocol more frequently than did the CCTs, 80% vs 74%, which did not reach statistical significance (p = 0.057). Adherence to protocol was significantly less likely to occur with OLMC than without OLMC, regardless of the training of the provider, 72.8% vs 86.5% (95% CI 8.1-19.3%, p < 0.001). Adherence to protocol was significantly less likely to occur as the acuity of the patient's condition increased (p < 0.001). Nonadherence was more likely to be judged appropriate rather than inappropriate (p < 0.05) as the acuity level increased. When there was nonadherence to protocol, the use of OLMC did not improve the care provided.Conclusions. OLMC does not improve adherence to protocol or the quality of care provided in the treatment of atraumatic illness.

Effectiveness of Interactive Videodisc Instruction for the Continuing Education of Paramedics

To evaluate the effectiveness of interactive videodisc (IVD) instruction of paramedics through the use of computer analysis of trip sheets. Prospective, controlled, in an urban 9-1-1, paramedic, emergency medical services (EMS) system with total call volume of 62,000/year; 15,000 advanced life support (ALS). All 150 paramedics in the system received eight hours of IVD instruction covering five subject areas: 1) airway; 2) head/cervical trauma; 3) chest; 4) shock; and 5) cardiac arrest. Trip sheets from 9,943 runs in the pre-IVD period were subjected to computer analysis, and a compliance score was generated using previously developed algorithms that assigned a weight to each omission and commission. After a nine-month IVD training period, 4,303 cases were collected and analyzed in the post-IVD period. Statistical analyses were made using "Student's" t-test and Chi-square with alpha set at 0.05. Only those records of adult patients who fit one of the five protocols were eligible for computer analysis. Of the 9,943 cases in the pre-IVD group, 480 (4.8%) were excluded, all due to inadequate data recording by the paramedics. A statistically similar portion, 233 (5.4%) of the 4,303 post-IVD instruction cases were excluded (p = .15). Overall the mean compliance score of the pre-IVD group was 0.65 +/-0.19 (+/-SD). The post-IVD group score was 0.65 +/-0.19 (p = 0.99). Analysis of scores for each algorithm also showed no significant differences. This study had an observed power of .94 to detect a difference in compliance as small as 0.030. (ABSTRACT TRUNCATED AT 250 WORDS)

Decrease in medical command errors with use of a “standing orders” protocol system

The purpose of this study was to determine the physician medical command error rates and paramedic error rates after implementation of a “standing orders” protocol system for medical command. These patientcare error rates were compared with the previously reported rates for a “required call-in” medical command system (Ann Emerg Med 1992; 21(4):347–350). A secondary aim of the study was to determine if the on-scene time interval was increased by the standing orders system. Prospectively conducted audit of prehospital advanced life support (ALS) trip sheets was made at an urban ALS paramedic service with on-line physician medical command from three local hospitals. All ALS run sheets from the start time of the standing orders system (April 1, 1991) for a 1-year period ending on March 30, 1992 were reviewed as part of an ongoing quality assurance program. Cases were identified as nonjustifiably deviating from regional emergency medical services (EMS) protocols as judged by agreement of three physician reviewers (the same methodology as a previously reported command error study in the same ALS system). Medical command and paramedic errors were identified from the prehospital ALS run sheets and categorized. Two thousand one ALS runs were reviewed; 24 physician errors (1.2% of the 1,928 “command” runs) and eight paramedic errors (0.4% of runs) were identified. The physician error rate was decreased from the 2.6% rate in the previous study ( P < .0001 by χ 2 analysis). The on-scene time interval did not increase with the “standing orders” system. Concurrent with implementation of a standing orders protocol system, there was a decrease in the overall patient care error rate in this prehospital care system, and a slight decrease in the mean on-scene time interval. Paramedic errors occurred at a relatively low frequency with the standing orders system, demonstrating the safety of this system of medical command.

The effect of a quality improvement feedback loop on paramedic skills, charting, and behavior.

A mechanism was initiated for conveying quality improvement (QI) results to paramedics as a means of improving chart documentation in difficult-to-correct areas. This study examines the impact of this QI feedback loop on charting, resuscitation rates from cardiac arrest, endotracheal intubation (ETI) success rates, and trauma scene times. Paramedic trip sheets were reviewed before and after the institution of the QI feedback loop in this interrupted time series design. The New Castle County, Delaware, Paramedic Program. All New Castle County paramedics participated in the study. In January 1990, the medical director began to circulate a QI summary among the paramedics in an effort to improve performance and chart documentation. The summary focused on the management of respiratory distress or arrest, cardiac arrest, and major trauma. The success rate for ETI was compared with the rate of field resuscitation from cardiac arrest, the percentage of unjustified prolonged trauma scene times (longer than 10 minutes), and the percent compliance with minimum endotracheal intubation documentation (ETID) requirements from a six-month period before institution of the QI feedback mechanism with data obtained from a six-month period after the program had been operational for one year. Comparing results from before with after the initiation of the QI program, the ETI success rate was 273 of 295 (92.5%) before and 300 of 340 (88.2%) after (chi 2 = 3.04, p < .1, ns); field resuscitations totaled 26 of 187 (13.9%) before and 44 of 237 (18.6) after (chi 2 = 1.40, p < .25, ns); ETID rate was 249 of 295 (84.4%) before and 336 of 340 (98.8%) after (chi 2 = 44.24, p < .001), and unjustified prolonged trauma scene times were 69 of 278 (24.8%) before and seven of 501 (1.4%) after (chi 2 = 320.5, p < .001). The use of QI feedback had little effect on psychomotor skills as the ETI success rate or resuscitation rate, but had a dramatic effect on chart documentation, as evidenced by ETID rate, and behavior, as evidenced by the reduction in prolonged trauma scene times. The use of QI feedback is recommended as a means of correcting charting deficiencies or modifying behavior.

One-year survival after prehospital cardiac arrest: The Utstein style applied to a rural-suburban system

To evaluate the recently published Utstein algorithm (Ann Emerg Med 1991;20:861), the authors conducted a retrospective review of all advanced life support (ALS) trip sheets and hospital records of patients with prehospital cardiac arrests between January 1988 and December 1989. Telephone follow-up was used to determine 1-year survival rates. Of 713 arrests in the 24-month study period, 601 were of presumed cardiac etiology. Approximately 599 of these charts were available for analysis. One hundred ninety-three (32.2%) of these had return of spontaneous circulation (ROSC), 36 (6.0%) survived to hospital discharge, and 24 were alive at 1-year follow-up (4.0% of total or 67% of survivors to discharge). The Utstein style was found to be a useful algorithmic format for reporting prehospital cardiac arrest data in a manner that should allow direct comparison between emergency medical service (EMS) systems. Existing prehospital record-keeping practices (trip sheets) are easily adapted to this style of data collection, although certain data for the template (eg, resuscitations not attempted and alive at 1-year) are more difficult to ascertain. Additionally, the authors report their own experience during a 2-year period, including data that suggest that the majority of patients with cardiac arrest who survive to hospital discharge are still alive at 1 year.

An analysis of invasive airway management in a suburban emergency medical services system.

Airway management is the most critical and potentially life-saving intervention performed by emergency medical service (EMS) providers. Invasive airway management often is required in non-cardiac-arrest patients who are combative or otherwise uncooperative. The success of prehospital invasive airway management in this patient population was evaluated. A retrospective review was undertaken of the records of all such patients requiring endotracheal intubation over a three-year period (1987-1989). The study population included 278 patients enrolled by five advanced life support (ALS) units serving a suburban population of 425,000. Field trip sheets were reviewed for diagnosis, intubation method and success, number of intubation attempts, provider experience, reasons for unsuccessful intubations, and complications. A total of 394 invasive airway management attempts were performed on 278 patients. The overall successful intubation rate was 75% (41% orotracheal, 52% nasotracheal, 7% other or unknown). The most common diagnoses were COPD and pulmonary edema (30%) and trauma (24%). Experienced providers were successful on the first attempt in 57% of cases compared to 50% by inexperienced providers (p=.24). Multiple intubation attempts were required in 33% of the patients. There was no statistically significant difference in success rates between the orotracheal and nasotracheal methods (p=.51). The most common reason for unsuccessful intubation was altered level of consciousness. Complications occurred with 7% of successful attempts and in 18% of unsuccessful attempts (p less than .001). Forty-six percent of the patients who were not intubated successfully in the field and required intubation in the emergency department (ED) received a neuromuscular blocking agent prior to successful intubation. Prehospital providers can intubate a high but improvable proportion of non-cardiac-arrested patients by both the orotracheal and nasotracheal routes. The use of pharmacologic adjuncts to facilitate the prehospital intubation of selected, non-cardiac-arrested patients is a promising adjunct that needs further evaluation.

Medical command errors in an urban advanced life support system

Study objective: The aim of this study was to assist in focusing educational efforts for command physicians by identifying the most common types of errors made by on-line medical command. Design: Retrospective survey of prehospital advanced life support (ALS) trip sheets. Setting: An urban ALS paramedic service with on-line physician medical command rotating on a monthly basis among three hospitals. Participants: From September 1988 through December 1990, all ALS run sheets were reviewed as part of an ongoing quality assurance program. Cases were identified as deviating from regional emergency medical services protocols as judged by agreement of three physician reviewers. Cases were excluded if all three reviewers did not agree that the command rendered was inappropriate. Interventions: Command errors were identified from the prehospital ALS run sheets and categorized. Results: One hundred ninety-four command errors in 167 cases were identified from 3,839 runs (4.4% of all runs). Six types of errors accounted for 80% of the total errors, with the most common error (34%) being failure to address the possibility of hypoglycemia with altered level of consciousness. Error rate decreased from 7.9% to 2.6% of total runs during the study period. Conclusion: To reduce the medical command error rate, physician education should be directed at the six problem areas identified. Ongoing quality assurance review of medical command may result in a decrease of the command error rate.

The Role of the Pneumatic Antishock Garment in Penetrating Cardiac Wounds

OBJECTIVE--To determine the impact of the pneumatic antishock garment on survival in patients with cardiac wounds. DESIGN--A retrospective review of a 6.5-year experience in a population of patients with gunshot or stab wounds to the heart (N = 70). SETTING--The city and county of Denver, Colo, where all patients were transported by paramedic ambulances to Denver General Hospital, an urban, level 1 trauma center. PATIENTS--All patients were analyzed, including those transported to the emergency department with no vital signs at the trauma scene. Only patients with definite penetrating cardiac injuries were included. METHODS--Paramedic trip sheets and emergency department, operating room, in-hospital, and autopsy records were reviewed. Demographic, clinical outcome, and treatment data were collected. A multiple logistic regression model was developed to determine which characteristics and treatment variables were independently predictive of patient outcome. The ability of each independent variable to predict outcome was determined by calculating adjusted odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS--Seventy patients (31 gunshot and 39 stab wounds) had a revised trauma score of 2.8 +/- 4.0 (mean +/- SD; range, 0-12; median, 0). Thirty-two (46%) had cardiac tamponade. Overall, 21 (30%) of the patients survived. In the logistic model, the presence of cardiac tamponade (OR, 9.1; 95% CI, 1.5 to 56.1) and a higher revised trauma score were associated with higher survival. Inflation of the pneumatic antishock garment was associated with sevenfold lower survival (adjusted OR, 0.14; 95% CI, 0.02 to 0.86); the effect was negative across all trauma score groups. --Survival in patients with penetrating cardiac wounds is highly associated with anatomic and physiologic factors, while application of the pneumatic antishock garment appears to be detrimental.

Out-of-hospital cardiac arrest: a six-year experience in a suburban-rural system.

All out-of-hospital cardiac arrest advanced life support (ALS) trip sheets were collected from January 1980 through December 1985 for this suburban-rural system. Information was extracted according to a uniform reporting format. In our study, 18% of patients with early CPR (less than four minutes) and early ALS (less than ten minutes) survived to hospital discharge, compared with 7% with early CPR and late ALS, 6% with late CPR and early ALS, and 3% with both occurring late. Although 75% of the survivors had ventricular tachyarrhythmias as initial rhythms, bradyasystolic arrests were not uniformly lethal, even with long CPR and ALS times. This study supports the need for early CPR in the prehospital care of potential sudden-death victims. We recommend, with qualification, this reporting format to emergency medical services systems to describe their cardiac arrest experience.