A T WO - HOUR I NTERVENTION U SING START I MPROVES P REHOSPITAL T RIAGE OF M ASS C ASUALTY I NCIDENTS

Objective. There are few data concerning the ability of prehospital providers to triage patients in a mass casualty incident (MCI). The authors evaluated the effectiveness of a brief educational intervention on MCI triage with a written scenario and test. The START method (simple triage and rapid treatment) was used. Methods. The authors enrolled and tested 109 prehospital providers consisting of 31 paramedics and prehospital registered nurses (PHRNs) and 78 emergency medical technicians (EMTs) and first responders. A written scenario of an MCI was used to test participants before, immediately after, and again at one month after a two-hour educational intervention consisting of a slide and video presentation utilizing START. Results. The 109 participants completed the pre-intervention and post-intervention test; 72 (66%) completed the one-month post-intervention as well. Mean work experience was 9 years (ranging from 1 to 27 years). The mean immediate post-test score (75% correct) was significantly improved compared with the mean pre-test score (55% correct) for the 109 providers completing both tests (p < 0.001). Among advanced life support providers (EMT-Ps and PHRNs) completing all three surveys, the mean immediate post-test score (76% correct) and mean one-month post-test score (75% correct) were not significantly different. Among the basic life support providers completing all three surveys, a modest but statistically significant decay in mean scores from immediate post-test (74% correct) to one-month post-test (68% correct) was observed (p < 0.01). Prior training in MCI had no statistically significant effect on changes in mean test scores. Conclusion. The ability of prehospital providers of all levels of training and experience to triage patients in an MCI is less than optimal. However, this ability improved dramatically after a single didactic session, and improvement persisted one month later.     

A GITATED D ELIRIUM AND S UDDEN D EATH : T WO C ASE R EPORTS

Objective. To determine the chemicals involved in fire department hazardous materials (hazmat) responses and analyze the concomitant emergency medical services' patient care needs. Methods. The setting was a mid-sized metropolitan area in the southwestern United States with a population base of 400,000 and an incorporated area of 165 square miles. The authors conducted a retrospective evaluation of all fire department hazmat reports, with associated emergency medical services patient encounter forms, and in-patient hospital records from January 1, 1992, through December 31, 1994. Results. The fire department hazardous materials control team responded to 468 hazmat incidents, involving 62 chemicals. The majority of incidents occurred on city streets, with a mean incident duration of 46 minutes. More than 70% of the responses involved flammable gases or liquids. A total of 32 incidents generated 85 patients, 53% of whom required transport for further evaluation and care. Most patients were exposed to airborne toxicants. Only two patients required hospital admission for carbon monoxide poisoning. Conclusion. Most hazmat incidents result in few exposed patients who require emergency medical services care. Most patients were exposed to airborne toxicants and very few required hospitalization. Routine data analysis such as this provides emergency response personnel with the opportunity to evaluate current emergency plans and identify areas where additional training may be necessary.     

R EDUCTION OF THE C ALL -R ESPONSE I NTERVAL WITH A MBULANCE B ASE P AGING

Objective. To determine whether the call-response interval for an emergency medical services (EMS) system would be decreased through the introduction of ambulance base paging. Methods. The study community included a mixture of urban and rural areas with a total population of approximately 400,000. The EMS system is composed of two ambulance services and one central ambulance communication center with computer-aided dispatching capabilities. Approximately 30,000 calls are responded to yearly by the combined ambulance services. A before-and-after study design was used. In a retrospective review of one ambulance service, there were 224 calls collected in the period before base paging and 200 calls collected in the period after base paging was introduced. In the other ambulance service, there were 571 calls captured in the period before base paging and 515 calls captured in the period after base paging. Results. The call-receipt-to-crew-notified interval was reduced from the before period to the after period in both ambulance services: Cambridge—61.8 to 49.8 seconds (p < 0.0001); Kitchener—66.6 to 46.2 seconds (p < 0.0001). The crew-notified-to-vehicle-mobile interval was reduced from the before period to the after period in both ambulance services: Cambridge—91.8 to 73.2 seconds (p < 0.0001); Kitchener—80.4 to 66.0 seconds (p < 0.0001). Conclusions. The introduction of ambulance base paging reduced components of the call-response interval in this EMS system. Overall, the reduction in time was approximately 30 seconds, which was found to be statistically significant.     

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.     

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.     

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.     

P ERFORMANCE OF R ETROGRADE I NTUBATION IN A M ULTIPLE-TRAUMA P ATIENT

Introduction: Emergency response plans often call on health care providers to respond to the workplace outside of their normal working pattern. Hypothesis. Providers will report to work during a mass casualty emergency regardless of family duties, type of incident, or availability of treatment. Methods. Survey of emergency personnel needed to respond to a mass casualty incident. Two scenarios were presented: one involving the release of a nontransmissible biological agent with proven treatment andthe other the release of a transmissible biological agent with no treatment. At critical time points, participants were asked whether they would report to work. Additional questions considered the effect of commonly used treatment dissemination methods. Results. A total of 186 surveys were issued andreturned. (45 physicians, 29 nurses, 86 EMS personnel, and20 support staff); 6 were incomplete andexcluded. Initial commitment rates were 78%. The highest commitment rate identified was 84% andthe lowest was 18%. Any treatment dissemination method excluding providers' family members led to decreases in commitment rate, as did agents identified to be transmissible. Conclusions. As an event develops, fewer health care providers will report to work andat no time will all providers report when asked. This conclusion may be generalizable to several types of incidents ranging from pandemic influenza to bioterrorism. Identification of the causative agent is a major decision point for providers to return to or stay away from work. Offering on-site treatment of providers' family increases commitment to work. These factors should be considered in emergency planning.     

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.     

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.     

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.     

U TILIZATION AND I MPACT OF A MBULANCE D IVERSION AT THE C OMMUNITY L EVEL

Objective. To evaluate the utilization and impact of ambulance diversion in the metropolitan area of Syracuse, New York. Methods. This was a retrospective review of the ambulance diversion system operated by the hospitals of Syracuse, New York. This system allows each emergency department to divert incoming ambulances during periods of extreme overcrowding. Data collected included numbers of hours on ambulance diversion by hospital, numbers of hours when all four hospitals were on diversion simultaneously, and numbers of ambulances received while the hospitals were on and off diversion. Results. For three of the five years evaluated, ambulance diversion hours were most numerous during the period between January and March. For the most recent year studied (2000), ambulance diversion hours did not decline after the first quarter. During periods of diversion, hospital emergency departments received 30%–50% fewer ambulances than they did while open. Conclusion. This study demonstrated that, in Syracuse, New York, ambulance diversion was once a seasonal phenomenon, but is increasingly occurring throughout the year because of staff and resource limitations. It also demonstrated that ambulance diversion can be employed to reduce numbers of incoming transports.     

C OST -E FFECTIVENESS A NALYSIS OF A R URAL /U RBAN F IRST - RESPONDER D EFIBRILLATION P ROGRAM

Objective. To analyze the cost-effectiveness of a proposed first-responder defibrillation program in a small rural area in comparison with a recently initiated first-responder program in an adjoining urban center in southwestern Ontario. The purpose of the analysis was to quantify the expected benefits of the proposed program to determine whether the costs are justified. Methods. This analysis was conducted on the city of Waterloo (population 80,000 over 25 square miles) and the adjoining rural township of Wellesley (population 8,000 over 105 square miles). The township has volunteer fire department first responders with basic life support (BLS), and basic life support/defibrillation (BLS-D) ambulances as the second tier; whereas the city's full-time fire department has recently adopted a first-responder defibrillation (BLS-D) program backed up by the same BLS-D ambulance service. The most relevant costs identified were the capital costs of the defibrillators, ancillary equipment, and biomedical service for preventive maintenance and routine nonwarranty work. Response intervals and percentage of patients found in ventricular fibrillation were projected and sensitivity analysis was applied. Results. The projected cost per life saved is $6,776 (C) in the urban area and $49,274 (C) in the rural area using an incremental save rate of 6%. Applying sensitivity analysis to the data, the save rate varied from 2% to 10%, resulting in a cost per life saved of $20,328 (C) and $4,066 (C), respectively, in the urban community. For the rural area, the cost per life saved ranged from $147,821 (C) (2%) to $29,564 (C) (10%). Even the worst-case save rate for the urban center [2%; $20,328 (C)] is significantly less than the best-case save rate [10%; $29,564 (C)] for the rural area. Conclusions. The cost per life saved for a rural first-responder defibrillation program is significantly more expensive than one for an urban center. However, the cost per life saved is still economical compared with common treatments for other life-threatening illnesses.     

A PPROPRIATENESS OF I NTRAVENOUS C ANNULATION BY P ARAMEDICS : A L ONDON S TUDY

Introduction. The number of patients undergoing intravenous (IV) cannulation by paramedics has increased dramatically over recent years in the UK. Treatment protocols for cannulation in the field are loosely defined. Variation in practice may lead to patients' receiving differential treatment according to customary practice, rather than according to their clinical conditions. Objectives. To explore variations in practice and assess level of appropriatenesss of IV cannulation by London Ambulance Service (LAS) paramedics; to revise treatment protocols and work toward clinical guidelines, if indicated by study findings. Methods. Skill usage data were analyzed for all LAS paramedics for 1995–96. All patients who were IV-cannulated and transported to three hospitals by LAS during March 1996 were identified. A panel of accident and emergency (A&E) and prehospital specialists judged each case for appropriateness. Results. Variation during the year was wide, with a range of 1 to 221 (mean 47) patients cannulated per paramedic, although the majority showed some consistency in frequency of skill usage. A sample of 183 cases was reviewed. The majority judged 149 (81.4%) to be appropriate, although there was considerable disagreement between reviewers (κ = 0.43, p < 0.001). Data suggested that those paramedics who cannulate more frequently cannulated less appropriately during the study period (lowest 30%: 73.9% appropriate; highest 30%: 45.8% appropriate, p = 0.05). Conclusion. Despite wide variation between paramedics, the panel judged overall appropriateness of cannulation to be high. The audit advisory group judged that new clinical guidelines might not achieve an improvement in practice and were not supported by study findings. It was recommended that variations be addressed through individual practice review.     

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.     

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.     

P HYSICIAN F IELD R ESPONSE : A N ATIONAL S URVEY

Objective. To assess the availability, scope of practice, and training of physician field response (PFR) units for emergency medical services (EMS) systems in the United States. Methods. The physician medical directors of EMS systems in the 125 most populous U.S. cities were surveyed by mail, with a second mailing and phone follow-up to nonresponders. In cities that listed multiple services, a survey was sent to each. Results. One hundred sixty-eight surveys were mailed, and 121 responses were received (72%), representing 109 of the 125 cities (87%). Seventy-seven cities (71%) reported having no PFR capability. Of the 32 (29%) with some type of PFR, two reported having a dedicated field response unit, while 30 had an “on-call” system from the hospital or home. Staffing patterns were highly variable, with no dominant pattern. The number of annual PFR responses ranged from 0 to 10,000 (median 15, IQR 3-200). All systems reported that their PFR unit was well accepted by EMS providers. The following scope-of-practice items were reported (n = 30): physician triage, 30 teams (94%); on-scene medical direction, 14 (47%); amputation, six (20%); tube thoracostomy, 12 (40%); and blood administration, 29 (97%). The following training requirements for physician team members were reported (n = 32): incident command system, 15 (47%); emergency vehicle operations, 12 (38%); hazardous materials, 13 (41%); vehicle rescue/extrication, seven (22%); confined space medicine, four (13%); and none 12 (38%). Conclusion. There is a wide variability in the availability, training, and scope of practice of PFR units across the country. No standardization or trends could be detected.