Accuracy of Paramedic Broselow Tape Use in the Prehospital Setting

Introduction. Previous literature has documented that prehospital 12-lead electrocardiography (ECG) decreases the time to reperfusion in patients with an acute ST-segment elevation myocardial infarction (STEMI). Objective. To compare time to ECG, time to angioplasty suite (laboratory), andtime to reperfusion in emergency medical services (EMS) STEMI patients, who received care through three different processes. Methods. The setting was a large suburban community teaching hospital with emergency department (ED)-initiated single-page acute myocardial infarction (AMI) team activation for STEMI patients. The population was STEMI patients transported by EMS from January 2003 to October 2005. Not all EMS agencies had prehospital 12-lead ECG capability. Paramedics interpret andverbally report clinical assessment andECG findings via radio. The AMI team is activated at the discretion of the emergency physician 1) before patient arrival to the ED based on EMS assessment, 2) after ED evaluation with EMS ECG, or 3) after ED evaluation andED ECG. Time intervals were calculated from ED arrival. To assess the impact of interventions on performance targets, we also report the proportion of patients who arrived in laboratory within 60 minutes andreperfusion within 90 minutes of arrival. Parametric andnonparametric statistics are used for analysis. Results. During the study period, there were 164 STEMI patients transported by EMS; mean age was 66.1 years, and56% were male. Of these, 93 (56.7%) had an EMS ECG and31 (33%) had AMI team activation before ED arrival. Mean time to laboratory for all patients was 49.8 ± 34.4 minutes andtime to reperfusion was 93.2 +/? 34.5 min. Patients with prearrival activation were transported to laboratory sooner (mean, 24.3 vs. 53. 4 minutes; p < 0.001) andreceived reperfusion sooner than all other patients (mean, 70.4 vs. 96.3 minutes; p = 0.007). More prearrival activation patients met performance targets to laboratory (96.7% vs. 73.7%; p = 0.009) andreperfusion (85.2% vs. 51.0%; p = 0.003). There was no difference in time to laboratory or to reperfusion for patients who received EMS ECG but no prearrival activation compared with those who received EMS transport alone. Conclusions. A minority of patients with EMS ECGs had prearrival AMI team activation. EMS ECGs combined with systems that activate hospital resources, but not EMS ECGs alone, decrease time to laboratory andreperfusion.     

Acute alcohol intoxication across different age groups in 2014–2018: Prehospital care and biochemical correlates at a large University Hospital in southern Italy

BackgroundRisky alcohol consumption can occur from a young age and affects people of all age groups, sometimes requiring the intervention of the emergency medical services.ObjectivesDetermining the timing and characteristics of emergency calls (to the “118” emergency number) relating to subjects in all age groups, in which alcohol was a contributing factor, along with the biochemical correlates, in a great metropolitan area. On the basis of these, future interventions would target specific training for nurses and paramedics working in emergency medical services.MethodAn observational single-centre retrospective study carried out from 1 January 2014 to 31 December 2018 involving patients requiring emergency care and attending the Emergency Department of an University Hospital.ResultsOut of a total of 47,252 emergency calls, 2.22% were for alcohol-related conditions and mainly involved male patients (78.4%).A high incidence of alcoholic coma was found in patients aged 11 to 17 years.Emergency medical assistance was required mainly at night on weekdays by patients aged 11–17, 25–44 years and during the weekend and on weekdays by patients aged 18–24 years.A blood alcohol concentration higher than 50 mg/dL was found in more than 67% of patients aged 11–17 and 18–24 years at weekends.ConclusionsThe most alarming finding from our data is that, despite prevention policies, young people requiring emergency medical assistance showed similar alcohol levels as adults and a high incidence of alcoholic coma.     

Emergency department visits for electric scooter-related injuries after introduction of an urban rental program

BackgroundProviders in Salt Lake City emergency departments (EDs) anecdotally noted a significant number of electronic scooter (e-scooter)-related injuries since the launch of e-scooter rentals in the downtown area in June 2018. The aim of this study was to quantify and characterize these injuries.MethodsWe reviewed the electronic medical records of the University of Utah ED and the Salt Lake Regional Medical Center ED. Using a broad keyword search for “scooter,” we examined all notes for ED visits between June 15–November 15, 2017, and June 15–November 15, 2018, and identified e-scooter related injuries. The 2017 data pre-dated the launch of the e-scooter share programs in Salt Lake City and served as a control period.ResultsWe noted 8 scooter-related injuries in 2017 and 50 in 2018. Injury types from the 2018 period included: major head injury (8%); major musculoskeletal injury (36%); minor head injury (12%); minor musculoskeletal injury (34%); and superficial soft tissue injury (40%). 24% of patients presented via ambulance and 6% presented as a trauma activation. 16% of patients required hospital admission and 14% had an injury requiring operative repair. 16% reported alcohol intoxication and none of the patients reported wearing a helmet at the time of the injury.ConclusionSince the launch of e-scooter share programs in Salt Lake City, we have seen a substantial increase in e-scooter related trauma in our EDs. Of particular note is the number of patients with major head injuries and major musculoskeletal injuries.     

Factors affecting attitudes and barriers to a medical emergency team among nurses and medical doctors: A multi-centre survey

AimTo identify factors underlying attitudes towards the medical emergency team (MET) and barriers to its utilisation among ward nurses and physicians.MethodsMulticentre survey using an anonymous questionnaire in hospitals with a fully operational MET system in the Piedmont Region, Italy. Response to questions was scored on a 5-point Likert-type agreement scale. Dichotomised results were included in a logistic regression model.ResultsAmong 2279 staff members who were contacted, 1812 (79.6%) completed the survey. The vast majority of respondents valued the MET. Working in a surgical vs. medical ward and having participated in either the MET educational programme (METal course) or MET interventions were associated with better acceptance of the MET system. Reluctance by nurses to call the covering doctor first instead of the MET for deteriorating patients (62%) was significantly less likely in those working in surgical vs. medical wards or having a higher seniority or a METal certification (OR 0.51 [0.4–0.65], 0.69 [0.47–0.99], and 0.6 [0.46–0.79], respectively). Reluctance to call the MET in a patient fulfilling calling criteria (21%), was less likely to occur in medical doctors vs. nurses and in surgical vs. medical ward staff, and it was unaffected by the METal certification.ConclusionsThe MET was well accepted in participating hospitals. Nurse referral to the covering physician was the major barrier to MET activation. Medical status, working in surgical vs. medical wards, seniority and participation in the METal educational programme were associated with lower likelihood of showing barriers to MET activation.     

Comparison of physician-staffed helicopter with ground-based emergency medical services for trauma patients

IntroductionFew studies have discussed whether physician-staffed helicopter emergency medical services (HEMS) provide temporal and geographical benefits for patients in remote locations compared to ground emergency medical services (GEMS). Our study seeks to clarify the significance of HEMS for patients with severe trauma by comparing the mortality of patients transported directly from crash scenes by HEMS or GEMS, taking geographical factors into account.MethodsUsing medical records from a single center, collected from January 2014 to December 2018, we retrospectively identified 1674 trauma patients. Using propensity score analysis, we selected adult patients with an injury severity score ≥16, divided them into groups depending on their transport to the hospital by HEMS or GEMS, and compared their mortality within 24 h of hospitalization. For propensity score-matched groups, we analyzed distance and time.ResultsOf the 317 eligible patients, 202 were transported by HEMS. In the propensity score matching analysis, there was no significant difference in mortality between the HEMS and GEMS groups: 8.7% vs. 5.8%, odds ratio (OR), 1.547 (95% confidence interval [CI], 0.530–4.514). The inverse probability of treatment weighting (IPTW): 11% vs. 7.8%, OR, 1.080 (95% CI, 0.640–1.823); stabilized IPTW: 11% vs. 7.8%, OR, 1.080 (95% CI, 0.502–2.324); and truncated IPTW: 10% vs. 6.4%, OR, 1.143 (95% CI, 0.654–1.997). The distance from the crash scene to the hospital was farther in the HEMS group, and it took a longer period of time to arrive at the hospital (P < 0.001).ConclusionsHEMS may provide equal treatment opportunities and minimize trauma deaths for patients transported from a greater distance to an emergency medical center compared to GEMS for patients transported from nearby regions.     

Implementation of an All-Day Artificial Intelligence–Based Triage System to Accelerate Door-to-Balloon Times

ObjectiveTo implement an all-day artificial intelligence (AI)–based system to facilitate chest pain triage in the emergency department.MethodsThe AI-based triage system encompasses an AI model combining a convolutional neural network and long short-term memory to detect ST-elevation myocardial infarction (STEMI) on electrocardiography (ECG) and a clinical risk score (ASAP) to prioritize patients for ECG examination. The AI model was developed on 2907 twelve-lead ECGs: 882 STEMI and 2025 non-STEMI ECGs.ResultsBetween November 1, 2019, and October 31, 2020, we enrolled 154 consecutive patients with STEMI: 68 during the AI-based triage period and 86 during the conventional triage period. The mean ± SD door-to-balloon (D2B) time was significantly shortened from 64.5±35.3 minutes to 53.2±12.7 minutes (P=.007), with 98.5% vs 87.2% (P=.009) of D2B times being less than 90 minutes in the AI group vs the conventional group. Among patients with an ASAP score of 3 or higher, the median door-to-ECG time decreased from 30 minutes (interquartile range [IQR], 7?59 minutes) to 6 minutes (IQR, 4?30 minutes) (P<.001). The overall performances of the AI model in identifying STEMI from 21,035 ECGs assessed by accuracy, precision, recall, area under the receiver operating characteristic curve, F1 score, and specificity were 0.997, 0.802, 0.977, 0.999, 0.881, and 0.998, respectively.ConclusionImplementation of an all-day AI-based triage system significantly reduced the D2B time, with a corresponding increase in the percentage of D2B times less than 90 minutes in the emergency department. This system may help minimize preventable delays in D2B times for patients with STEMI undergoing primary percutaneous coronary intervention.     

Quantifying Emergency Physician Interruptions due to Electrocardiogram Review

BackgroundInterruptions are recognized as potentially harmful to safety and efficiency, and are especially prevalent in the emergency department (ED) setting. Policies urging immediate review of all electrocardiograms (ECGs) may lead to numerous and frequent interruptions.ObjectiveWe assessed the role of ECG review as a source of ED interruptions to characterize a potential target for interventions.MethodsWe analyzed emergency physician time use during the course of a clinical shift using a time-and-motion design. A research assistant observed a convenience sample of shifts, observing and logging transitions between different tasks using an electronic device. Instances of ECG review were tallied, with start and ending times of ECG review recorded to the nearest second. An ECG review was considered an interruption if the immediate prior and subsequent tasks were the same.ResultsTwenty shifts were observed for a total of 149 h. There were 211 ECG reviews, (mean rate 1.4 per hour), with more frequent review among physicians staffing a zone with higher-acuity patients (2.8 per hour), where clustering of multiple ECG reviews in succession was more common. Seventy-five percent of ECG reviews required < 30 s. Of all 211 ECG reviews, 102 (48%) were an interruption. The tasks most frequently interrupted were electronic medical record system use (68 of 102, 67%) and communicating with ED staff in person (18 of 102, 18%).ConclusionsReview of ECGs was a substantial driver of interruptions for emergency physicians. Interventions to integrate ECG review more naturally into physician workflow may improve patient safety by reducing these interruptions.     

A Quality Improvement Project on Agitation Management in the Emergency Department

IntroductionAgitation is common in the emergency department. When agitation is not detected early, patients can become aggressive and violent, potentially leading to restraint use and subsequent injury. The goals of the project were early detection and management of patient agitation, reduction of restraint use in the emergency department, and determination of the usability of the Behavioral Activity Rating Scale.MethodsThis quality improvement project was assessed using a pre- and posttest single unit design, comparing 4 months of postimplementation data to historic controls at the same time of year in the previous year. The intervention was implementing the Behavioral Activity Rating Scale in the ED electronic medical record. Data were collected through retrospective chart review and nurse survey. From September through December of both 2017 and 2018, data were collected on restraint use. The 4-month 2018 data collection period included measures of Behavioral Activity Rating Scale documentation and the System Usability Scale survey for nurses to measure ease of usability of the Behavioral Activity Rating Scale.ResultsThe Behavioral Activity Rating Scale was documented frequently (n = 4 867 documentations) by emergency nurses to assess patients with behavioral health and medical complaints (n = 780). Nurses identified 18 episodes of violent behavior in behavioral health patients on the Behavioral Activity Rating Scale (2.31%) and applied restraints 18 times. The most common chief complaints for patients who were identified as violent was suicidal ideation (n = 6; 33.33%).In 2017, there were 20 episodes of restraint use during the same time period, a nonsignificant difference (χ² = 0.72; P = 0.40). However, only 2 patients were kept in restraints longer than 1 day in 2018 compared with 8 in 2017. Emergency nurses found the Behavioral Activity Rating Scale to be usable in the structured usability assessment (μ = 83.46; SD = 11.73).DiscussionThe Behavioral Activity Rating Scale is a usable tool for emergency nurses to assess for patient agitation. With the incorporation of agitation management interventions, the ED team can potentially manage agitation before violence occurs. Further studies are needed on the use of agitation or aggression assessment tools for managing patient behavioral activity such as aggression in the emergency department.     

Time Is Brain: Prehospital Emergency Medical Services Response Times for Suspected Stroke and Effects of Prehospital Interventions

ObjectivesTo compare prehospital time for patients with suspected stroke in Florida with the American Stroke Association (ASA) time benchmarks, and to investigate the effects of dispatch notification and stroke assessment scales on prehospital time.Patients and MethodsA retrospective analysis was performed using data from Florida’s Emergency Medical Services Tracking and Reporting System database. All patients with suspected stroke transported to a treatment center from January 1, 2018, through December 31, 2018, were analyzed. Time intervals from 911 call to hospital arrival were evaluated and compared with ASA benchmarks.ResultsIn 2018, 11,577 patients with suspected stroke were transported to a hospital (mean age, 71.5±15.7 years; 51.5% women). The median alarm-to-hospital time was 33.98 minutes (27.8 to 41.4), with a total emergency medical services (EMS) time of 32.30 minutes (26.5 to 39.478). The on-scene time was the largest time interval with a median of 13.28 minutes (10.0 to 17.4). Emergency medical services encounters met the ASA benchmarks for time in 58% to 62% of the EMS encounters in Florida (recommended 90%; P<.001). The total EMS time was reduced when a stroke notification was reported by the dispatch center (32.00 minutes vs 32.62 minutes; P=.006) or when a stroke assessment scale was used by the EMS personnel (31.88 minutes vs 32.96 minutes; P=.005).ConclusionThis study reveals a substantial opportunity for improvement in stroke care in Florida. Two prehospital EMS stroke interventions seem to reduce prehospital time for patients with suspected stroke. Adoption of these interventions might improve the stroke systems of care.     

Specialty Psychiatric Services in US Emergency Departments and General Hospitals: Results From a Nationwide Survey

ObjectiveTo explore the handling of psychiatric patients in medical hospitals and emergency departments (EDs) as well as hospital characteristics associated with the availability of psychiatric services in these settings.MethodsFrom October 1, 2017, to April 1, 2018, a telephone survey regarding the presence and nature of psychiatric services was attempted among all US registered Medicare hospitals.ResultsOf the included 4812 US hospitals, 2394 (50%) were surveyed. Of these hospitals, 1108 (46%) have some psychiatric services available, either in medical EDs or through psychiatric consultation on general medical inpatient wards. If medical ED patients with active psychiatric issues need admission, 59% of hospitals transfer the patient to a different hospital and 28% admit the patient to a medical ward. Exploration by logistic regression analysis of the association of selected variables and available psychiatric expertise suggested that larger hospitals, nonprofit services, or hospitals in urban settings were more likely to have psychiatrists on staff or available for consultation.ConclusionDespite the growing number of psychiatric patients seeking help in medical EDs and general hospitals, more than 50% of the EDs and general hospitals lack psychiatric services. These results suggest that accessibility to psychiatric care in medical settings requires improvement.     

Impact of the San Diego county firestorm on emergency medical services

BACKGROUND: In October 2003, San Diego County, California, USA, experienced the worst firestorm in recent history. During the firestorm, public health leaders implemented multiple initiatives to reduce its impact on community health using health updates and news briefings. This study assessed the impact of patients with fire-related complaints on the emergency medical services (EMS) system during and after the firestorm. METHODS: A retrospective review of a prehospital database was performed for all patients who were evaluated by advanced life support (ALS) ambulance personnel after calling the 9-1-1 emergency phone system for direct, fire-related complaints from 19 October 2003 through 30 November 2003 in San Diego County. The study location has an urban, suburban, rural, and remote resident population of approximately three million and covers 4,300 square miles (2,050 km2). The prehospital patient database was searched for all patients with a complaint that was related directly to the fires. Charts were abstracted for data, including demographics, medical issues, treatments, and disposition status. RESULTS: During the firestorm, fire consumed > 380,000 acres (> 938,980 hectares), including 2,454 residences and 785 outbuildings, and resulted in a total of 16 fatalities. Advanced life support providers evaluated 138 patients for fire-related complaints. The majority of calls were for acute respiratory complaints. Other complaints included burns, trauma associated with evacuation or firefighting, eye injuries, and dehydration. A total of 78% of the injuries were mild. Twenty percent of the victims were firefighters, most with respiratory complaints, eye injuries, or injuries related to trauma. A total of 76% of the patients were transported to the hospital, while 10% signed out against medical advice. CONCLUSION: Although the firestorm had the potential to significantly impact EMS, pre-emptive actions resulted in minimal impact to emergency departments and the prehospital system. However, during the event, there were a number of lessons learned that can be used in future events.     

Emergency Department Use by Young Adults With Chronic Illness Before and During the COVID-19 Pandemic

IntroductionThere was a significant decrease in emergency department encounters during the COVID-19 pandemic. Our large urban emergency department observed decreased encounters and admissions by youths with chronic health conditions. This study aimed to compare the frequency of emergency department encounters for certain young adults before the pandemic and during the COVID-19 pandemic.MethodsA retrospective cohort study using medical records of patients ages 20 to 26 years from October 2018 to September 2019 and February 2020 to February 2021. Files set for inclusion were those with a primary diagnosis of human immunodeficiency virus, diabetes mellitus, epilepsy, cerebral palsy, sickle cell disease, asthma, and certain psychiatric disorders for potentially preventable health events.ResultsWe included 1203 total encounters (853 before the pandemic and 350 during the pandemic), with the total number of subjects included in the study 568 (293 before the pandemic to 239 during the pandemic). During the pandemic, young adults with mental health conditions (53.1%) accounted for most encounters. Encounters requiring hospital admissions increased from 27.4% to 52.5% during the pandemic, primarily among patients with diabetes (41.8% vs 61.1%) and mental health conditions (50% vs 73.3%).DiscussionThe number of young adults with certain chronic health conditions decreased during COVID-19, with encounters for subjects with mental health conditions increasing significantly. The proportion of admissions increased during the pandemic with increases for subjects with mental health disorders and diabetes. The number of frequent users decreased during COVID-19. Future research is needed to understand better the causes for these disparities in young adults with chronic conditions who use the emergency department as a source of care.     

Facilitators of and barriers to emergency medical service use by acute ischemic stroke patients: A retrospective survey

ObjectiveThe objective of the study was to identify facilitators and barriers to emergency medical service use among acute ischemic stroke patients in Korea.MethodsThis paper presents a secondary analysis of a retrospective survey that collected data from questionnaires and medical records. Among 233 acute ischemic stroke patients enrolled in a large-scale study, 160 patients who had arrived at a hospital within 72 h after symptom onset were included in the data analysis.ResultsUsers of emergency medical services needed a shorter time than non-users to arrive at hospital (140 min vs. 625 min., p = 0.001) and were more likely to arrive at hospital within 3 h of symptom onset (51.9% vs. 31.5%, p = 0.013). For those who first contacted emergency medical service, the facilitators of emergency medical service use were the presence of hemiparesis (p = 0.003), bilateral paralysis (p = 0.040), and loss of balance (p = 0.021). The predominant barrier was the failure to recognize the urgency of symptoms (p = 0.006).ConclusionsThe use of emergency medical services reduced prehospital delay and increased the likelihood of patient arrival at hospital within 3 h. Given that experiencing typical stroke symptoms was a facilitator of emergency medical service use yet failure to recognize the urgency of symptoms was a barrier, public awareness should be raised as regards stroke symptoms and the benefits of using emergency medical services.     

Cellular technology improves transmission success of pre-hospital electrocardiograms

Study objectiveIn rural settings, long distances and transport times pose a challenge for achieving early reperfusion goals in patients with ST-elevation myocardial infarction (STEMI). This study investigated the association between the method of pre-hospital 12-lead ECG transmission (radio transmission vs. cellular phone transmission) and the success of transmission and legibility of 12-lead ECGs in a rural setting.MethodsObservational study of pre-hospital 12-lead ECG transmission to the emergency department (ED) in a predominantly rural area. Success of transmission and the legibility of the 12-lead ECG were analyzed to identify barriers to 12-lead ECG transmission and reasons for failed transmission.ResultsEmergency medical services performed ECGs on 1140 patients, 917 of which they attempted to transmit, including 43 cases requiring emergent catheterization. Twelve-lead ECG transmission was successful in 236 (70%) of 337 radio attempts and 441 (76%) of 580 cellular attempts (difference 6.0%, 95% CI 1.1-12.1). Legibility increased from 164 (49%) of 337 radio attempts to 389 (67%) of 580 cellular attempts (difference 18.4%, 95% CI 11.8–24.9).ConclusionThe success of transmission and legibility of 12-lead ECGs was significantly higher with cellular technology by emergency medical service agencies in comparison to radio transmission. In rural settings with lengthy transport times, utilization of cellular technology for transmission of pre-hospital 12-lead ECGs may improve door-to-balloon times for STEMI patients.     

The use of a Swedish telephone medical advice service by the elderly – a population-based study

Objective: The present study aimed to describe contact made by the elderly to Sweden’s nationwide medical helpline, Healthcare Guide 1177 by Phone (HGP). Other objectives were to study potential gender differences and the association between different HGP referral levels and acute visits to hospital-based emergency departments and acute visits to primary care centres.

Design: De-identified data from recorded calls to HGP was extracted for analysis (n?=?7477 for the oldest age group). Information about acute visits to emergency departments and to primary care reception was extracted from the patient administration system.

Setting: Västerbotten County, Sweden.

Subjects: Patients over 80 years.

Main outcome measures: Calling and visiting frequencies for different age groups as well as reasons for contact and individual recommendations.

Results: The utilisation rate of the telephone advice service for the oldest age group was high, with an incidence rate of 533 per 1000 person-years. Women had a 1.17 times higher incidence rate compared with men. The most common reason for contact was drug-related questions (17% of all contacts). Calls that were recommended to care by a medical specialist correlated with total emergency department visits (r?=?0.30, p?r?=?0.38, p?=?0.005).

Conclusion: The high utilisation of the telephone advice service by the elderly gives the telephone advice service a unique ability to function as a gatekeeper to further healthcare. Our data suggest that with the telephone advice service’s present guidelines, a significant proportion of all calls are being directed to further medical help. The high frequency of drug-related questions raises concerns about the elderly’s medication regimens.

• Key points

• Patients over 80 years of age had a high utilisation of the telephone medical advice service compared with other age groups.

• Drug-related questions were the most common reason for contact.

• A significant proportion of all calls made resulted in further heatlhcare contacts.

     

Refusal of emergency medical care: An analysis of patients who left without being seen,eloped, and left against medical advice

ObjectiveEmergency department (ED) patients may elect to refuse any aspect of medical care. They may leave prior to physician evaluation, elope during treatment, or leave against medical advice during treatment. This study was undertaken to identify patient perspectives and reasons for refusal of care.MethodsThis prospective study was conducted at an urban Level 1 Trauma Center. This study examined ED patients who left without being seen (LWBS), eloped during treatment, or left against medical advice during September to December 2018. This project included both chart review and a prospective patient survey.ResultsAmong 298 participants, the majority were female (54%). Most participants were White (61%) or African American (36%). Thirty-eight percent of participants left against medical advice, 23% eloped, and 39% left without being seen by a provider. When compared to the general ED population, patients who refused care were significantly younger (p < 0.001). When comparing by groups, patients who left AMA were significantly older than those who eloped or left without being seen (p < 0.001). Among 68 patients interviewed by telephone, the most common stated reasons for refusal of care included wait time (23%), unmet expectations (23%), and negative interactions with ED staff (15%).ConclusionED patients who refused care were significantly younger than the general ED population. Common reasons cited by patients for refusal of care included wait time, unmet expectations, and negative interactions with ED staff.