S TUDY D ESIGN AND O UTCOMES IN O UT-OF-HOSPITAL E MERGENCY M EDICINE R ESEARCH : A T EN-YEAR A NALYSIS

Objective. Lack of rigorous study design and failure to follow diverse patient outcomes have been identified as critical gaps in the medical research literature. This study sought to determine whether similar gaps exist in the literature for out-of-hospital interventions. Methods. A computerized MEDLINE search was conducted for the ten-year period 1985 through 1994 using the MeSH terms “emergency medical services,” “prehospital,” and “transportation of patients.” Using a standard abstraction form, two investigators independently analyzed articles meeting these inclusion criteria: original research evaluating an out-of-hospital intervention and measuring a patient outcome. Study design was categorized in order of scientific rigor, moving from case series to randomized trial. Measures of outcomes were classified into the six Ds: death, disease, discomfort, disability, dissatisfaction, and debt (cost). Results. Interobserver agreement was high (kappa = 0.80). For the ten-year period, 3,686 titles, 1,454 abstracts, and 373 articles were examined serially; all 285 studies meeting inclusion criteria were analyzed. Case series (44%) was the most frequently used design, while only 15% were randomized trials. The majority of the studies were retrospective (53%). A single outcome was assessed in 45% of the articles; 41% measured two outcomes, 13% three outcomes, and 1% four outcomes. Death and disease were the most common outcomes evaluated. Disability, debt, discomfort, and dissatisfaction were infrequently measured. Conclusion. Studies of out-of-hospital emergency medical interventions are limited in the scientific rigor of study design and the diversity of patient outcomes measured. To adequately assess the effectiveness of out-of-hospital care, efforts should be directed toward strengthening study designs and examining the full range of patient outcomes.     

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.     

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.     

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 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.     

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.     

E MERGENT F IELD M EDICINE

Abstract

Objective. We sought to categorize and characterize the utilization of statewide emergency medical services (EMS) protocols as well as state recognition of specialty receiving facilities for trauma and time-sensitive conditions in the United States. Methods. A survey of all state EMS offices was conducted to determine which states use mandatory or model statewide EMS protocols and to characterize these protocols based on the process for authorizing such protocols. The survey also inquired as to which states formally recognize specialty receiving facilities for trauma, STEMI, stroke, cardiac arrest, and burn as well as whether or not states have mandatory or model statewide destination protocols for these specialty centers. Results. Thirty-eight states were found to have either mandatory or model statewide EMS protocols. Twenty-one states had mandatory statewide EMS protocols at either the basic life support (BLS) or advanced life support (ALS) level, and in 16 of these states, mandatory protocols covered both BLS and ALS levels of care. Seventeen states had model statewide protocols at either the BLS or ALS level, and in 14 of these states, the model protocols covered both BLS and ALS levels of care. Twenty states had separate protocols for the care of pediatric patients, while 18 states combined pediatric and adult care within the same protocols. When identified, the median age used to consider a patient for pediatric care was ≤14 years (range ≤8 to ≤17 years). Three states’ protocols used a child's height based on a length-based dosage tool as the threshold for identifying a pediatric patient for care using their pediatric protocols. States varied in recognition of receiving centers for EMS patients with special medical needs: 46 recognized trauma centers, 25 recognized burn centers, 22 recognized stroke centers, 11 recognized centers capable of percutaneous coronary intervention for ST-elevation myocardial infarction, and 3 recognized centers for patients surviving cardiac arrest. Conclusion. Statewide mandated EMS treatment protocols exist in 21 states, and optional model protocol guidelines are provided by 17 states. There is wide variation in the format and characteristics of these protocols and the recognition of specialty receiving centers for patients with time-sensitive illnesses.     

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.     

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.     

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.     

U SE OF E MERGENCY M EDICAL S ERVICES FOR S USPECTED A CUTE C ARDIAC I SCHEMIA AMONG D EMOGRAPHIC AND C LINICAL P ATIENT S UBGROUPS : T HE REACT T RIAL

Objective. Barriers to the use of emergency medical services (EMS) and patient delay in seeking care can limit the receipt or effectiveness of reperfusion therapies and the availability of prehospital emergency cardiac care. The Rapid Early Action for Coronary Treatment (REACT) trial was designed to determine the impact of a community intervention on use of EMS among demographic and clinical subgroups of patients with suspected acute cardiac ischemia. Methods. A randomized controlled community trial was conducted in 20 pair-matched communities in the United States. One community from each pair received an 18-month, multicomponent community education program. Data were collected at 44 participating hospitals during a four-month baseline period and throughout the 18-month trial, using medical record abstracts to collect information on mode of transport to the hospital and other sociodemographic and clinical variables. Eligible patients were persons aged ≥30 years presenting with chest pain or discomfort to emergency departments (EDs) who were admitted and discharged with a cardiac-related diagnoses (ICD 410-414, 427-429, 440, 786.9). Results. The net change in the odds of EMS use was an increase of 34% in intervention compared with control communities [adjusted odds ratio (OR) 1.34, 95% CI 1.07–1.67]. We observed greater increases in the odds of EMS use among patients who had chronic or other cardiac diagnoses (adjusted OR 1.53, 95% CI 1.18–1.99, and adjusted OR 1.52, 95% CI 1.17–1.97, respectively) than in those diagnosed as having acute ischemia (adjusted OR 1.14, 95% CI 0.91-1.44). We observed greater increases in odds of EMS use in those who were retired (adjusted OR 1.62, 95% CI 1.29–2.04) or had systolic blood pressure (SBP) at or below 160?mm Hg upon presentation to the ED (adjusted OR 1.55, 95% CI 1.26–1.91 for SBP 100-160 mm Hg; 1.61, 95% CI 0.88–2.97 for SBP <100?mm Hg). Conclusions. The REACT trial demonstrated a significant impact on the use of EMS among patients admitted to the hospital for suspected acute myocardial infarction, with greater increases among patients with chronic or other cardiac ICD-9 discharge diagnoses, those presenting with lower SBP, and retired persons.     

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.     

H OSPITAL F OLLOW - UP OF P ATIENTS C ATEGORIZED AS N OT N EEDING AN A MBULANCE U SING A S ET OF E MERGENCY M EDICAL T ECHNICIAN P ROTOCOLS

Objective. Using hospital outcomes, this study evaluated emergency medical technicians' (EMTs') ability to safely apply protocols to assign transport options. Methods. Protocols were developed that categorized patients as: 1) needs ambulance; 2) may go to emergency department (ED) by alternative means; 3) contact primary care provider (PCP); or 4) treat and release. After education on application of the protocols, EMTs categorized patients at the scene prior to transport but did not change current practice. Hospital charts were reviewed to determine outcome of patients whom EMTs categorized as not needing an ambulance. Category 2 patients were assumed to need the ambulance if they were admitted to a monitored bed or intensive care unit. Category 3 and 4 patients were assumed to need the ED if they were admitted. Results. The EMTs categorized 1,300 study patients: 1,023 (79%) ambulance transport, 200 (15%) alternative means, 63 (5%) contact PCP, and 14 (1%) treat and release. Hospital data were obtained for 140 (51%) patients categorized as not needing ambulance transport. Thirteen of 140 (9%) patients who transporting EMTs determined did not need the ambulance were considered to be undertriaged: five in category 2, six in category 3, and one in category 4. Six of 13 (46%) undertriaged patients had dementia or a psychiatric disorder as one of their presenting complaints. Conclusion. These protocols led to a 9% undertriage rate. Patients with psychiatric complaints and dementia were at high risk for undertriage.     

P REHOSPITAL E MERGENCY C ARE , 6 TH E DITION

Abstract

Background. Traumatic brain injury (TBI) represents a serious subset of injuries among persons in the United States, and prehospital care of these injuries can mitigate both the morbidity and the mortality in patients who suffer from these injuries. Guidelines for triage of injured patients have been set forth by the American College of Surgeons Committee on Trauma (ACS-COT) in cooperation with the Centers for Disease Control and Prevention (CDC). These guidelines include physiologic criteria, such as the Glasgow Coma Scale (GCS) score, systolic blood pressure, and respiratory rate, which should be used in determining triage of an injured patient. Objectives. This study examined the numbers of visits at level I and II trauma centers by patients with a diagnosed TBI to determine the prevalence of those meeting physiologic criteria from the ACS-COT/CDC guidelines and to determine the extent of mortality among this patient population. Methods. The data for this study were taken from the 2007 National Trauma Data Bank (NTDB) National Sample Program (NSP). This data set is a nationally representative sample of visits to level I and II trauma centers across the United States and is funded by the American College of Surgeons. Estimates of demographic characteristics, physiologic measures, and death were made for this study population using both chi-square analyses and adjusted logistic regression modeling. Results. The analyses demonstrated that although many people who sustain a TBI and were taken to a level I or II trauma center did not meet the physiologic criteria, those who did meet the physiologic criteria had significantly higher odds of death than those who did not meet the criteria. After controlling for age, gender, race, Injury Severity Score (ISS), and length of stay in the hospital, persons who had a GCS score ≤13 were 17 times more likely to die than TBI patients who had a higher GCS score (odds ratio [OR] 17.4; 95% confidence interval [CI] 10.7–28.3). Other physiologic criteria also demonstrated significant odds of death. Conclusions. These findings support the validity of the ACS-COT/CDC physiologic criteria in this population and stress the importance of prehospital triage of patients with TBI in the hopes of reducing both the morbidity and the mortality resulting from this injury.     

D ETERMINATION OF M EDICAL N ECESSITY FOR A IR AND C RITICAL C ARE M EDICAL T RANSPORTATION

Abstract

Objective. We aimed to assess the diagnostic accuracy of focused assessment with sonography for trauma (FAST) examinations when used by emergency medical technicians (EMTs) to detect the presence of free abdominal fluid. Methods. Six level 1 EMTs (similar to intermediate EMTs in the United States) who worked at a tertiary emergency department in Korea underwent an educational program consisting of two one-hour didactic lectures that included the principles of ultrasonography, the anatomy of the abdomen, and two hours of hands-on practice. After this educational session, the EMTs performed FAST examinations on a convenience sample of patients from July 1 to October 5, 2009. These patients also received an abdominal computed tomography (CT) scan regardless of their chief complaints. The CT findings served as the definitive standard and were interpreted routinely and independently by emergency radiologists who were blinded to the study protocol. In addition, the EMTs were blinded to the CT findings. A positive CT finding was defined as the presence of free fluid, as interpreted by the radiologist. The sensitivity, specificity, predictive values, and their 95% confidence intervals (CIs) were calculated. Informed consent was obtained from all participating patients. Results. Among the 1,060 eligible patients with abdominal CT scans, 403 patients were asked to participate in the study, and 240 patients agreed. Of these 240 patients, 80 (33.3%) had results showing the presence of free fluid. Fourteen patients had a significant amount of peritoneal cavity fluid, 15 had a moderate amount of peritoneal cavity fluid, and 51 had a minimal amount of peritoneal cavity fluid. Compared with the CT findings, the diagnostic performance of the FAST examination had a sensitivity of 61.3% (95% CI, 50.3%–71.2%), specificity of 96.3% (95% CI, 92.1%–98.3%), positive predictive value of 89.1% (95% CI, 77.0%–95.4%), and negative predictive value of 83.2% (95% CI, 76.9%–88.2%). For a significant or moderate amount of peritoneal cavity fluid, the sensitivity was considerably higher (86.2%). Conclusion. EMTs in Korea showed a high diagnostic performance that was comparable to that of surgeons and physicians when detecting peritoneal cavity free fluid in a Korean emergency department setting. The validity of FAST examinations in prehospital care situations should be investigated further.     

T HE D EVELOPMENT OF A R EGISTER OF R ANDOMIZED C ONTROLLED T RIALS IN P REHOSPITAL T RAUMA C ARE

Objectives. To establish a register of randomized controlled trials of interventions in the prehospital care of trauma patients. Methods. A systematic search was conducted for all randomized controlled trials of interventions in the prehospital care of trauma patients. The search included the Cochrane Controlled Trial Register, the Cochrane Injuries Group Specialised Register, Medline, EMBASE, the Cumulative Index to Nursing & Allied Health Literature (CINAHL), Science Citation Index, National Research Register, Dissertation Abstracts, and PubMed for the time period 1966–2000. There were no language restrictions. In addition, full-text hand searching of a range of relevant journals was done, and the authors of included trials were contacted. Results. The combined search strategy identified 16,037 potentially eligible records, of which 28 were reports of randomized controlled trials evaluating prehospital trauma care interventions. After excluding duplicate reports, there were 24 separate randomized controlled trials including 6,806 patients. The largest and smallest trials involved 1,309 and 30 trauma patients, respectively. Conclusions. This register will facilitate the conduct of systematic reviews of the effectiveness of interventions in prehospital trauma care. However, despite the extensive searching, very few randomized trials in this area were found. In view of the absence of evidence for the effectiveness of many of the interventions that are used in the prehospital care of trauma patients, further randomized controlled trials are required.     

T HE W ASHINGTON,DC, Y OUTH C URFEW : E FFECT ON T RANSPORTS OF I NJURED Y OUTH AND H OMICIDES

Objective. Curfews are implemented to curtail youth violence. Trauma systems and emergency medical services (EMS) may need to prepare for changes in patient volume resulting from local ordinances. This study evaluated the impact of the 1995 Washington, DC, Juvenile Curfew Act on EMS transports of injured youth and on youth homicides. Methods. A retrospective, comparative cohort study was performed. Transports of injured youth and youth homicides were counted in corresponding months of 1994 and 1995. Cohorts were formed by year, time of day, age group, and mechanism of injury. Year-to-year statistical comparisons of injury proportions were performed using the chi-square and Fisher's exact tests. Results. One thousand forty-eight transports were included. No significant difference was observed in transports with curfew implementation. Most assaults on youth occurred outside the curfew time. No effect of the curfew on homicides was detected. Of 67 homicides, only two victims were under the curfew. Conclusion. No effect of the curfew on transports for injuries or on homicides was demonstrated. The curfew was not in effect during the period of highest risk.