A N E MERGENCY M EDICAL S ERVICES P ROGRAM OF A LTERNATE D ESTINATION OF P ATIENT C ARE

Objective: The emergency department (ED) is ideally reserved for urgent health needs. The ED, however, is often the site of care for nonurgent conditions. The authors investigated whether emergency medical technicians could decrease ED use by patients with nonurgent concerns who use 911 by appropriately identifying and triaging them to alternate care destinations. Methods: From August 2000 through January 2001, two King County fire-based emergency medical services (EMS) agencies participated in an alternate care destination program for patients with specific low-acuity diagnosis codes (intervention group). Eligible patients were offered care at a clinic-based destination as an alternate to the ED (n = 1,016). The frequency of the destination of care (ED, clinic, or home) for the intervention group was compared with a matched control group that was comprised of a preintervention historical cohort of EMS encounters from the same two fire-based agencies and with the same acuity and diagnosis criteria and seasonal interval (n = 2,617). Results: Compared with the preintervention group, a smaller proportion of patients in the intervention group received care in the ED (44.6% vs. 51.8%, p = 0.001), while a greater proportion of patients in the intervention group received clinic care (8.0% vs. 4.5%, p = 0.001) or home care (no transport) (47.4 vs. 43.7%, p = 0.043). Results were comparable when adjusted for other patient characteristics. Similar relationships were not evident among nonparticipating King County EMS agencies. Based on physician review and patient interview, the alternate care intervention appeared to be safe and satisfactory. Conclusion: An EMS-based program may represent one approach to limiting nonurgent ED use.     

A MIODARONE AND R URAL E MERGENCY M EDICAL S ERVICES C ARDIAC A RREST P ATIENTS : A C OST A NALYSIS

Objective: Recent American Heart Association guidelines suggest amiodarone as an antiarrhythmic in refractory ventricular fibrillation (VF) and pulseless ventricular tachycardia (VT). The authors sought to assess the impact of amiodarone use on outcomes and cost associated with this practice in a rural emergency medical services (EMS) state. Methods: Statewide EMS records were reviewed for the calendar year 1999. Data reviewed included prehospital diagnosis, medications given by prehospital providers to patients with cardiac arrest, and procedures performed, including cardiopulmonary resuscitation (CPR) and defibrillation. Cost-benefit analysis assumed the cost of amiodarone treatment to be $137.65 per patient encounter. Absolute risk reduction (ARR) and number needed to treat (NNT) analysis utilized resuscitation rates published in the ARREST and ALIVE trials. Results: During the study period, EMS providers diagnosed 2,189 patients as having cardiac arrest. Five hundred thirty-five (24.4%) cardiac arrest patients were defibrillated. One hundred sixty patients (7.3%), including 15 who did not receive defibrillation, were given lidocaine during resuscitation efforts. The annual cost increase from current practice for a statewide amiodarone VF/VT protocol was $21,822.40 (10,572.87%). The initial cost to stock EMS vehicles for this protocol would be $50,115.52. The cost-benefit analysis yielded a potential for one additional patient survival to hospital discharge in Maine per 3.125 years of system-wide practice at a cost of $68,840.00. Conclusion: Based on current data, instituting amiodarone treatment for refractory VF and pulseless VT in a rural EMS setting requires the investment of substantial resources, relative to current treatment strategies, for any potential survival benefit.     

U SE OF E MERGENCY M EDICAL S ERVICES BY C HILDREN WITH S PECIAL H EALTH C ARE N EEDS

Objective. This study describes emergency medical services (EMS) responses for children with special health care needs (CSHCN) in an urban area over a one-year period. Methods. A prospective surveillance system was established to identify EMS responses for children, 21 years of age or younger, with a congenital or acquired condition or a chronic physical or mental illness. Responses related to the special health care needs of the child were compared with unrelated responses. Results. During a one-year period, 924 responses were identified. Fewer than half of the responses were related to the child's special health care need. Younger children were significantly more likely to have a response related to their special needs than older children. Among related responses, seizure disorder was the most common diagnosis, while asthma was more common for unrelated responses. Almost 58% of the responses resulted in transport of the child to a hospital. Conclusions. Emergency medical services responses related to a child's special health care needs differ from unrelated responses. The most common special health care needs of children did not require treatment beyond the prehospital care provider's usual standard of care. These results are relevant for communities providing EMS services for CSHCN.     

E MERGENCY M EDICAL S ERVICES AND C ULTURAL D ETERMINANTS OF AN E MERGENCY IN K ARACHI,P AKISTAN

Objectives. The study was conducted to understand the prehospital system in Karachi, the mode of transport that adult inpatients use to reach the emergency departments (EDs), and the barriers to the use of ambulances. Methods. The study consisted of two parts. The first part involved interviewing the administrators of major ambulance services in Karachi. The second part consisted of a structured interview of randomly selected adult inpatients admitted to one government and one private hospital. Results. Seven ambulance service administrators were interviewed. The interviews revealed that ambulances in Karachi are mainly involved in transporting patients from hospital to hospital or to home. A large number of calls are for transporting dead bodies. A total of 92 patients were interviewed (58 male, 34 female). Admission complaints included abdominal pain (22), blunt trauma (11), penetrating trauma (3), chest pain (6), shortness of breath (4), hematemesis (3), acute focal weakness (4), high fever (4), and other (32). The most common mode of transport to the ED was taxi (53, 58%), followed by private car (21, 23%). Specific reasons for not using ambulances included a perception that the patient was not sick enough (34, 45%), slow response of the ambulance services (17, 23%), not knowing how to find one (8, 11%), and the high cost (6, 8%). Conclusion. In case of a medical emergency, most people in Karachi do not use ambulances. The reasons for this low usage include not only poor accessibility, but also cultural barriers and lack of education in recognition of danger signs.     

E MERGENCY M EDICAL S ERVICES I NFORMATION S YSTEMS AND A F UTURE EMS N ATIONAL D ATABASE

Since the early 1970s, various publications and legislation have contributed to the development of emergency medical services (EMS) information systems and databases. Yet, even today, EMS systems vary in their ability to collect patient and systems data and to put these data to use. In addition, no means currently exists to easily link disparate EMS databases to allow analysis at local, state, and national levels. For this reason, the National Association of State EMS Directors is working with its federal partners at the National Highway Traffic Safety Administration (NHTSA) and the Trauma and EMS program of the Health Resources and Services Administration's (HRSA's) Maternal and Child Health Bureau to develop a national EMS database. Such a database would be useful in developing nationwide EMS training curricula, evaluating patient and EMS system outcomes, facilitating research efforts, determining national fee schedules and reimbursement rates, and providing valuable information on other issues related to EMS care.     

E MERGING C OMMUNICATION T ECHNOLOGIES IN E MERGENCY M EDICAL S ERVICES

Advances in communication technologies are changing the face of emergency medical services (EMS). Two communication technologies in particular—cellular-enhanced 9-1-1 service and automatic crash notification (ACN)—will have a considerable impact on EMS. Although enhanced 9-1-1 service from land-line phones is now available in nearly every EMS system across the country, enhanced 9-1-1 service from cell phones currently does not exist. With more and more emergency calls made from cell phones, the implementation of this service is a clear priority. Automatic crash notification, a quickly emerging technology, can potentially provide EMS systems with invaluable data within seconds of when a collision occurs. However, many issues with regard to ACN systems need to be addressed, including liability concerns, access to ACN data, ability of drivers to understand the ACN system, and ACN system architecture. The potential interfaces between ACN systems and EMS systems create significant opportunities to enhance EMS resource management and care of patients involved in motor vehicle crashes. With both cellular-enhanced 9-1-1 and ACN in their infancy, EMS physicians and administrators have a valuable opportunity to provide leadership in the development of these services.     

P NEUMOCOCCAL V ACCINATION : A N O PPORTUNITY FOR E MERGENCY M EDICAL S ERVICES

This report examines the literature regarding pneumococcal disease and the current state of pneumococcal vaccination. Improvements in medical care have reduced the number of deaths from pneumococcal disease. However, vaccination is still the most effective measure. The U.S. Department of Health and Human Services, through the Healthy People 2000 and Healthy People 2010 reports, have recommended widespread pneumococcal vaccination practices. In spite of this, vaccination rates remain low among all segments of the population, with minorities and groups at risk for pneumococcal disease the most neglected. The authors propose implementation of emergency medical services (EMS)-delivered vaccination against pneumococcal disease. The epidemiology of pneumococcal disease is presented. The efficacy, availability, and use recommendations for the vaccine are described within this report. Finally, the benefits and possible implementation strategies for EMS delivery are detailed.     

R EIMBURSEMENT IN E MERGENCY M EDICAL S ERVICES : H OW TO A DAPT IN A C HANGING E NVIRONMENT

The proposed Medicare fee schedule for medically necessary ambulance transportation will have a profound impact on emergency medical services (EMS) systems throughout the country. When the new Medicare rules are implemented, reimbursement for Medicare patients will be largely based on national relative value units that vary depending on the level of service provided, from basic life support to advanced life support emergency. Under the new fee schedule, nearly all EMS systems will lose money when compared with the actual cost of providing the service, particularly advanced life support services, rural services, efficient systems, and those that bill for services. To adapt to these impending changes, EMS administrators and medical directors must work together to diversify and solidify their revenue sources and to seek out ways to make their systems even more efficient while maintaining a high quality of clinical care.     

P REDICTED U TILIZATION OF E MERGENCY M EDICAL S ERVICES T ELEMEDICINE IN D ECREASING A MBULANCE T RANSPORTS

Objective. To determine predicted utilization, decrease in ambulance transports, and target population for emergency medical services (EMS) if telemedicine capabilities were available to the medic units in the field. Methods. A retrospective chart review of 345 consecutive ambulance transports to four hospitals (Level I urban trauma center, urban tertiary care center, children's hospital, and suburban community hospital) was performed by a panel of three board-certified emergency medicine physicians experienced and credentialed in emergency telemedicine. They independently reviewed the emergency department (ED) and EMS records and were asked to determine whether patients required ambulance transport for evaluation or whether disposition could be made following paramedic and emergency physician assessment via telemedicine. A five-point Likert scale was used to grade feasibility of telemedicine disposition (definitely yes, probably yes, maybe, probably no, definitely no). Other variables analyzed included age, sex, race, chief complaint, phone, private medical doctor, and call location by patient zip code, call site, and receiving hospital. Results. In 14.7% of cases (6% definitely yes and 8.7% probably yes), disposition could be made without transport using telemedicine. The age range for eliminating transport was 2 weeks through 92 years, with mean age of 26.6 years. Under the age of 50 years, 46 out of 238 patients (19.3%) could have possibly been managed by telemedicine. Conclusion. Use of EMS telemedicine could result in an approximately 15% decrease in ambulance transports when it alone is added to the prehospital care provider's armamentarium. Emphasis for implementation should be placed on younger patients and an identified subset of chief complaints conducive to management using telemedicine.     

T HE O UT-OF-HOSPITAL U SE OF A D OMESTIC V IOLENCE S CREEN FOR A SSESSING P ATIENT R ISK

Objectives. To determine the following: 1) whether a Domestic Violence Scene Assessment Screen (DVSAS) is accurate at predicting domestic violence (DV) when compared with results on the validated Abuse Assessment Screen (AAS), and 2) whether EMTs can perform accurately on a DVSAS after they have finished a transport so as not to interfere with routine care. Methods. All patients transported by ambulance from domestic environments (i.e., home) by an urban EMS system were included in the study. A ten-question screen was developed to assess whether a domestic environment had a high risk of having DV (DVSAS). A positive answer to any of the questions was considered to be a positive result on the screen. A trained observer with no clinical duties rode on the ambulance for randomized shifts during a two-month period. The observer completed the DVSAS while at the scene, then the patient, if able, completed the AAS. After finishing the transport, the EMT completed the DVSAS based on his or her memory of the scene. Results of the observer DVSAS were compared with the results of the EMT DVSAS and with the AAS. Results. A total of 43 transports from domestic scenes were included in the study. The observer DVSAS alone was positive in five cases (12%), the EMT DVSAS alone was positive in five cases (12%), and both were positive in seven cases (17%). Agreement between the EMT and the observer yielded a kappa of 0.56 adjusted for chance. Of 15 (42%) patients able to complete the AAS, one (7%) was positive on the AAS alone, four (27%) were positive on the observer DVSAS alone, and three (29%) were positive on both. The observer DVSAS agreed with the AAS results in ten of 15 (66%) of cases. When compared with the AAS, the observer DVSAS had a sensitivity of 75%, specificity of 55%, positive predictive value of 38%, and negative predictive value of 86%. Conclusion. Emergency medical technicians can complete the DVSAS at the end of a transport with good agreement with results obtained by an independent observer at the scene. The DVSAS is able to reflect the results of the AAS with moderate to good agreement.     

E MERGENCY M EDICAL P LANNING FOR THE 2000 R EPUBLICAN N ATIONAL C ONVENTION

Planning for emergency medical services (EMS) coverage for the 2000 Republican National Convention in Philadelphia was a complex process that involved the cooperation of municipal, state, and federal agencies as well as local hospitals. The medical needs of the delegates, members of the media, and support personnel at the convention venue had to be met. Contingency plans for the possibility of large, organized political protests and associated injuries had to be developed. Steps had to be taken to ensure the safety of emergency personnel who may have to respond to such incidents. Because of the heightened threat of terrorist attacks on civilian populations in recent years, specialized training and material to respond to such incidents were required. The important role that local hospitals may play in providing care to victims of a large, multicasualty incident, especially one involving weapons of mass destruction, was recognized. Therefore, steps were taken to increase the awareness of hospital staff to patient decontamination and isolation techniques as well as specific therapies for the chemical, biological, and radioactive agents that terrorists might use. Finally, despite the focus placed on the convention, the day-to-day emergency medical needs of the citizens of Philadelphia had to be met. Through careful planning, flexibility, and cooperation, it was possible to successfully address all of these issues.     

T HE U SE OF E TOMIDATE FOR R APID - SEQUENCE I NTUBATION IN THE A IR M EDICAL S ETTING

Objective. To describe the use of etomidate for rapid-sequence intubation (RSI) in the air medical environment. Methods. This was a retrospective review of a consecutive series of patients receiving etomidate for RSI by a university hospital-based air medical program. Records of all patients more than 10 years of age requiring intubation during a 13-month period were reviewed. Data collected included demographics, site of intubation, person performing intubation, indication, diagnosis, medications administered, complications, and pre- and post-RSI vital signs. Results. Of 79 patients who underwent intubation, 53 (67%) received etomidate for RSI. Forty-two (79%) patients who received etomidate were also given succinylcholine. The overall intubation success rate was 96%. Two patients required a cricothyrotomy. Hemodynamic data were complete for 46 patients. The average systolic blood pressures (SBPs) were 139.11 ± 31.21?mm?Hg prior to RSI and 137.85 ± 32.00?mm?Hg after RSI. These were not significantly different (p = 0.82). The mean change in SBP was ?1.26 ± 37.03?mm?Hg (95% CI ?6.61 to 4.09). The average heart rates (HRs) were 101.59 ± 23.95 beats/min prior to RSI and 97.76 ± 23.45 beats/min after RSI. These were also not significantly different (p = 0.15). The mean change in HR was ?3.52 ± 15.67 beats/min (95% CI ?5.79 to ?1.26). Conclusion. This study supports the safety of etomidate for RSI in the air medical setting. The intubation success rate was comparable to those in other studies evaluating RSI. There was no significant change in average SBP or HR during RSI.     

P REHOSPITAL U SE OF A NALGESIA FOR S USPECTED E XTREMITY F RACTURES

Introduction. Pain and its control have been studied extensively in the emergency department. Numerous studies indicate that inadequate treatment of pain is common, despite the availability of myriad analgesics. It has been suggested that oligoanesthesia is also a common practice in the prehospital setting. Objective. To assess the use of prehospital analgesia in patients with suspected extremity fracture. Methods. Emergency medical services (EMS) call reports were reviewed for all patients with suspected extremity fractures treated from June 1997 to July 1998 in a midwestern community with a population base of 223,000. Data collected included demographic information, mechanism of injury, medications given, and field treatment. Standing orders for administration of analgesia were available and permitted paramedics to give either morphine sulfate or nitrous oxide per protocol. Results. The EMS call reports were analyzed for 1,073 patients with suspected extremity fractures. The mean patient age was 47 years. Accidental injuries comprised 86.5% of those reviewed. Suspected leg fractures were most common (20%), followed by hips (18%), arms (11%), knees (10%), ankles (9%), shoulders (7.2%), hands (5.5%), and wrists (5.3%). Multiple trauma and assorted broken digits accounted for the remaining 14%. The most common mechanisms of injury were: fall (43%), motor vehicle collision (21%), and human assault (10%). Intravenous lines were placed in 9.4% of patients; 17% received ice packs; 16% received bandage/dressings; 25% received air splints; and 19% were fully immobilized. Analgesia was administered to 18 patients (1.8%): 16 patients received nitrous oxide and two received morphine. Conclusion. Administration of analgesics to prehospital patients with suspected fractures was rare. Prehospital identification and treatment of pain for patients with musculoskeletal trauma could be improved.     

M EDICAL D IRECTION AND M EDICAL C ONTROL OF A IR M EDICAL S ERVICES Position statement of the Air Medical Physician Association

Abstract

Introduction. Traumatic injury is a leading cause of morbidity and mortality, but these can be minimized by timely transport to definite care. Helicopter emergency medical services (HEMS) provide timely transport and can influence survival. However, accident analyses indicate that landing at an unsecured landing zone (LZ), particularly at night, increases the risk of aviation accidents. To ensure safety, some HEMS operations land only at designated, secured LZs. Objective. This study utilized geographic information systems (GISs) to compare locations of scene call requests and secure LZs. The goal was to determine the optimal placement of new helipads as a strategy to improve access while mitigating the risk of aviation accidents. Methods. Call request data from a large air medical transport service were used to determine the geographic locations of all requests for scene responses in 2006. Request locations were compared with the locations of existing helipads, and straight-line distances between scene and helipad were determined using the GIS application. The application was then used to determine potential locations for new helipads. Results. During the study period, 748 requests for scene calls and 269 helipads were available. There were 476 (52.4%) requests at least 10 kilometers from a helipad and 356 (36.6%) requests at least 15 kilometers from a helipad. One particular region, Southwestern Ontario, was identified as having the highest number of requests >15 kilometers from the closest helipad. Conclusion. GISs can be used to determine potential locations for new helipad construction using historical call request data. This evidence-based approach can improve HEMS access while mitigating operational risk.