Out-of-hospital Treatment of Hypoglycemia: Refusal of Transport and Patient Outcome

Abstract. Objectives: Patient refusal of transport after treatment of hypoglycemia is common in urban emergency medical services (EMS) systems. The rate of relapse is unknown. The goal of this study was to compare the outcomes of diabetic patients initially refusing transport (refusers) and those transported to an ED. Methods: All paramedic runs from January to July 1995 were retrospectively reviewed. Inclusion criteria were adult patients with a field assessment of hypoglycemic signs/symptoms, and a fingerstick glucose < 80 mg/dL. Data for analysis included paramedic run duration, patient demographics, and refusal or acceptance of transport. Patient outcome was obtained from a review of hospital and medical examiner records. Relapse was defined as hypoglycemia necessitating EMS activation or an ED visit within 48 hours of the initial episode. Student's t-test and x² analysis were used to compare means and rates, respectively. Results: Over the 7 months, 374 patients made 571 calls to 9-1-1 that met inclusion criteria (5.2% of all paramedic runs). Of these, 412 were refusers (72.2%) and 159 were transported patients (27.8%). The hospital records of 4 transported patients were unavailable. Sixty-three transported patients were admitted (11.2%), with 1 death from prolonged hypoglycemia. The rates of relapse did not differ between the refusers and the transported patients (p < 0.05). Twenty-five relapses occurred among the refusers (6.1%), with 14 repeat refusals, 11 transports, 5 admissions, and no deaths. There were 7 relapses among the transported patients (4.4%), with 2 refusals, 5 transports, 2 admissions, and no deaths. The paramedic run time was significantly shorter for the refusers than for the transported patients (p < 0.05). Conclusions: The out-of-hospital treatment of hypoglycemic diabetic patients appears to be effective and efficient. Independent of the patient's refusal or acceptance of transport, the out-of-hospital treatment of hypoglycemic patients in this system appears to be safe.     

Prehospital Glucose Testing for Children with Seizures: A Proposed Change in Management

Objective: Many Emergency Medicine Services (EMS) protocols require point-of-care blood glucose testing (BGT) for any pediatric patient who presents with seizure or altered level of conscious. Few data describe the diagnostic yield of BGT when performed on all pediatric seizures regardless of presenting mental status. We analyzed a large single center dataset of pediatric patients presenting with prehospital seizures to determine the prevalence of hypoglycemic seizures and the utility of repeat BGT in the emergency department (ED). Methods: This was a retrospective, IRB-approved chart analysis of all pediatric patients (≤14 years) transported by EMS to the Harbor-UCLA pediatric ED over a 2-year period with a chief complaint of seizure. Cases were selected in which witnessed seizures had occurred in the field by family or EMS. Chart review included prehospital, nursing and physician records. Hypoglycemia was defined as blood glucose <60 mg/dL. Analysis included blood glucose, witnessed field seizure, initial mental status assessed by Glasgow Coma Scale (GCS), and further mental status assessments, along with age, sex, and medical history. Medical records were reviewed for subsequent BGT and patient outcome. Results: A total 770 children were transported by EMS due to seizures. Four patients (0.5%) had recorded hypoglycemia in the field, yet only two received treatment to raise blood glucose. Additionally, one child (0.1%) was normoglycemic (81 mg/dL) in the field with hypoglycemia (43 mg/dL) in the ED but required no intervention. Two were found by EMS to have an ALOC (GCS ≤ 12) and hypoglycemia. Only the patient with hypoglycemia secondary to a suspected glipizide ingestion received ED glucose administration. The most common discharge diagnosis was simple febrile seizure (38.6%). Conclusion: Hypoglycemia in the pediatric seizure patient is extremely rare, thus universal field BGT has low utility and potential downstream effects. We propose a novel algorithm for the initial evaluation and management of prehospital pediatric seizures. Although limited to a retrospective analysis of a single medical center, our findings suggest the importance of reassessing prehospital seizure protocols. A larger patient sample should be studied to validate these findings and identify unique cases where glucose testing might be useful.     

Utilization of Intravenous Catheters by Prehospital Providers during Pediatric Transports

Introduction: Prehospital intravenous (IV) access in children may be difficult and time-consuming. Emergency Medical Service (EMS) protocols often dictate IV placement; however, some IV catheters may not be needed. The scene and transport time associated with attempting IV access in children is unknown. The objective of this study is to examine differences in scene and transport times associated with prehospital IV catheter attempt and utilization patterns of these catheters during pediatric prehospital encounters. Methods: Three non-blinded investigators abstracted EMS and hospital records of children 0–18 years of age transported by EMS to a pediatric emergency department (ED). We compared patients in which prehospital IV access was attempted to those with no documented attempt. Our primary outcome was scene time. Secondary outcomes include utilization of the IV catheter in the prehospital and ED settings and a determination of whether the catheter was indicated based on a priori established criteria (prehospital IV medication administration, hypotension, GCS < 13, and ICU admission). Results: We reviewed 1,138 records, 545 meeting inclusion criteria. IV catheter placement was attempted in 27% (n = 149) with success in 77% (n = 111). There was no difference in the presence of hypotension or median GCS between groups. Mean scene time (12.5 vs. 11.8 minutes) and transport time (16.9 vs. 14.6 minutes) were similar. Prehospital IV medications were given in 38.7% (43/111). One patient received a prehospital IV medication with no alternative route of administration. Among patients with a prehospital IV attempt, 31% (46/149) received IV medications in the ED and 23% (34/396) received IV fluids in the ED. Mean time to use of the IV in the ED was 70 minutes after arrival. Patients with prehospital IV attempt were more likely to receive IV medication within 30 minutes of ED arrival (39.1% vs. 19.0%, p = 0.04). Overall, 34.2% of IV attempts were indicated. Conclusions: Prehospital IV catheter placement in children is not associated with an increase in scene or transport time. Prehospital IV catheters were used in approximately one-third of patients. Further study is needed to determine which children may benefit most from IV access in the prehospital setting.     

Hypoglycemia Emergencies: Factors Associated with Prehospital Care,Transportation Status,Emergency Department Disposition,and Cost

Objectives: The objectives of this study were to evaluate demographic/clinical characteristics and treatment/transportation decisions by emergency medical services (EMS) for patients with hypoglycemia and link EMS activations to patient disposition, outcomes, and costs to the emergency medical system. This evaluation was to identify potential areas where improvements in prehospital healthcare could be made. Methods: This was a retrospective analysis of the National Emergency Medical Services Information System (NEMSIS) registry and three national surveys: Nationwide Emergency Department Sample (NEDS), National Hospital Ambulatory Medical Care Survey (NHAMCS), and Medical Expenditure Panel Survey (MEPS) from 2013, to examine care of hypoglycemia from the prehospital and the emergency department (ED) perspectives. Results: The study estimated 270,945 hypoglycemia EMS incidents from the NEMSIS registry. Treatments were consistent with national guidelines (i.e., oral glucose, intravenous [IV] dextrose, or glucagon), and patients were more likely to be transported to the ED if the incident was in a rural setting or they had other chief concerns related to the pulmonary or cardiovascular system. Use of IV dextrose decreased the likelihood of transportation. Approximately 43% of patients were not transported from the scene. Data from the NEDS survey estimated 258,831 ED admissions for hypoglycemia, and 41% arrived by ambulance. The median ambulance expenditure was $664?±?98. From the ED, 74% were released. The average ED charge that did not lead to hospital admission was $3106?±?86. Increased odds of overnight admission included infection and acute renal failure. Conclusions: EMS activations for hypoglycemia are sizeable and yet a considerable proportion of patients are not transported to or are discharged from the ED. Seemingly, these events resolved and were not medically complex. It is possible that implementation and appropriate use of EMS treat-and-release protocols along with utilizing programs to educate patients on hypoglycemia risk factors and emergency preparedness could partially reduce the burden of hypoglycemia to the healthcare system.     

Feasibility of Paramedic Performed Prehospital Lung Ultrasound in Medical Patients with Respiratory Distress

Objective: Prehospital ultrasound is not yet widely implemented. Most studies report on convenience samples and trauma patients, often by prehospital physicians or critical care clinicians. We assessed the feasibility of paramedic performed prehospital lung ultrasound in medical patients with respiratory distress. Methods: Paramedics at 2 ambulance stations in the city of Pittsburgh, Pennsylvania, USA underwent a 2-hour training session in prehospital lung ultrasound using the SonoSite iViz, a handheld ultrasound device. Emergency medical services (EMS) command center (EMS-CC) physicians were instructed in the interpretation of lung ultrasound images. Paramedics enrolled patients presenting with signs and symptoms of respiratory distress over a 3-month period. The ultrasound exam included anterior and lateral views from both sides of the chest. Images were transmitted wirelessly using a mobile hotspot device and uploaded into an online image archiving system. Images were interpreted remotely by the EMS-CC physicians, and 2 expert sonographers provided an overread. We assessed agreement between EMS-CC physicians and experts, as well as between chart-review derived ED diagnosis and both EMS-CC physician and expert interpretation. We defined four a priori hypotheses that would need to be met for the intervention to be considered “feasible.” Results: A total of 34 of 78 (43.6%) eligible patients had an ultrasound exam completed. Image transmission was successful in 25 (73.5%) of cases where ultrasound was performed. The primary reason for not enrolling an otherwise eligible patient was equipment failure (25.0%), followed by patient acuity and patient refusal (18.2% each). A total of 20 (58.8%) completed scans were deemed uninterpretable upon expert review. Agreement between EMS physicians and experts was poor. Agreement between EMS-CC physicians and ED diagnosis, as well as between experts and ED diagnosis, was fair. The predetermined thresholds for feasibility were not met. Conclusions: Paramedic performed prehospital lung ultrasound for patients with respiratory distress and remote interpretation by EMS physicians did not meet the predetermined thresholds to be considered “feasible” in a real-world environment with currently available technologies. This study identified important barriers to the implementation of prehospital lung ultrasound, which should be addressed in future studies.     

Prehospital time intervals and management of ischemic stroke patients

ObjectiveQuantify prehospital time intervals, describe prehospital stroke management, and estimate potential time saved if certain procedures were performed en route to the emergency department (ED).MethodsAcute ischemic stroke patients who arrived via emergency medical services (EMS) between 2012 and 2016 were identified. We determined the following prehospital time intervals: chute, response, on-scene, transport, and total prehospital times. Proportions of patients receiving the following were determined: Cincinnati Prehospital Stroke Scale (CPSS) assessment, prenotification, glucose assessment, vascular access, and 12-lead electrocardiography (ECG). For glucose assessment, ECG acquisition, and vascular access, the location (on-scene vs. en route) in which they were performed was described. Difference in on-scene times among patients who had these three interventions performed on-scene vs. en route was assessed.ResultsData from 870 patients were analyzed. Median total prehospital time was 39 min and comprised the following: chute time: 1 min; response time: 9 min; on-scene time: 15 min; and transport time: 14 min. CPSS was assessed in 64.7% of patients and prenotification was provided for 52.0% of patients. Glucose assessment, vascular access initiation, and ECG acquisition was performed on 84.1%, 72.6%, and 67.2% of patients, respectively. 59.0% of glucose assessments, 51.2% of vascular access initiations, and 49.8% of ECGs were performed on-scene. On-scene time was 9 min shorter among patients who had glucose assessments, vascular access initiations, and ECG acquisitions all performed en route vs. on-scene.ConclusionsOn-scene time comprised 38.5% of total prehospital time. Limiting on-scene performance of glucose assessments, vascular access initiations, and ECG acquisitions may decrease prehospital time.     

Physician-Investigator Phone Elicitation of Consent in the Field: A Novel Method To Obtain Explicit Informed Consent For Prehospital Clinical Research

Objective. To describe andreport the feasibility of a novel field telephonic strategy to elicit explicit informed consent in prehospital trials for conditions in which patients retain decision-making capacity. Methods. In a pilot prehospital neuroprotective stroke therapy trial, ambulances carried written informed consent forms anddedicated trial cellular phones permitting rapid connection to on call physician-investigators. The physician-investigator discussed the trial with the consent provider [patient if competent, on scene legally authorized representative (LAR) if patient not competent] by phone, while paramedics carried out prehospital care duties unimpeded. Results. 32 patients met consent elicitation criteria. 20 (63%) were enrolled. The most frequent reasons for non-enrollment were: patient not competent andno available on-scene LAR–5; patient/LAR declined participation–4. Among enrollees, 15 (75%) were competent andself-enrolled; 5 (25%) were not competent andwere enrolled by LAR family members. Site of consent initiation was: patient home–15 (74 = 5%), work–2(10)%, other–3(15)%. Consent was elicited via cell phone in 11 (55%) andsite landline in 9 (45%). Compared with patients enrolled in prior studies employing standard in-hospital consent, prehospital consent procedures reduced time from paramedic arrival on–scene to start of study agent (26 vs 139 mins, p < 0.0001), anddid not prolong the on-scene to ED arrival time (37 vs 34 min, p = 0.50). No patient/family withdrew consent during the 3-month follow-up period. Conclusion. Physician phone elicitation of prehospital research consent from individuals with retained competency or on-scene legally authorized representatives is feasible, permits rapid patient study entry, anddoes not delay field transport times.     

Impact of High-Fidelity Pediatric Simulation on Paramedic Seizure Management

Background: A simulation-based course, Pediatric Simulation Training for Emergency Prehospital Providers (PediSTEPPs), was developed to optimize pediatric prehospital care. Seizures are common in Emergency Medical Services (EMS), and no studies have evaluated pediatric outcomes after EMS simulation training. Objectives: The primary objective was to determine if PediSTEPPs enhances seizure protocol adherence in blood glucose measurement and midazolam administration for seizing children. The secondary objective was to describe management of seizing patients by EMS and Emergency Departments (EDs). Methods: This is a two-year retrospective cohort study of paramedics who transported 0–18 year old seizing patients to ten urban EDs. Management was compared between EMS crews with at least one paramedic who attended PediSTEPPs and crews that had none. Blood glucose measurement, medications administered, intravenous (IV) access, seizure recurrence, and respiratory failure data were collected from databases and run reports. Data were compared using Pearson's χ² test and odds ratios with 95% confidence intervals (categorical) and the Mann-Whitney test (continuous). Results: Of 2200 pediatric transports with a complaint of seizure, 250 (11%) were actively seizing at the time of transport. Of these, 65 (26%) were treated by a PediSTEPPs-trained paramedic. Blood glucose was slightly more likely to be checked by trained than untrained paramedics (OR = 1.35, 95% CI 0.72–2.51). Overall, 58% received an indicated dose of midazolam, and this was slightly more likely in the trained than untrained paramedics (OR = 1.39, 95% CI 0.77–2.49). There were no differences in secondary outcomes between groups. The prevalence of hypoglycemia was low (2%). Peripheral IVs were attempted in 80%, and midazolam was predominantly given by IV (68%) and rectal (12%) routes, with 51% receiving a correct dose. Seizures recurred in 22%, with 34% seizing on ED arrival. Respiratory failure occurred in the prehospital setting in 25 (10%) patients in the study. Conclusion: Simulation-based training on pediatric seizure management may have utility. Data support the need to optimize the route and dose of midazolam for seizing children. Blood glucose measurement in seizure protocols may warrant reprioritization due to low hypoglycemia prevalence.     

The Positive Predictive Value of Paramedic Versus Emergency Physician Interpretation of the Prehospital 12-Lead Electrocardiogram

Background. Obtaining a prehospital 12-lead ECG may improve triage andexpedite care of patients with acute myocardial infarction (AMI). Whether the ECG should undergo physician review prior to activation of a percutaneous intervention (PCI) team is unclear. Objective. To document the positive predictive value (PPV) of the prehospital 12-lead ECG when interpreted by paramedics versus emergency physicians. Methods. This was a prospective, observational study. In November 2003, our local health care andemergency medical services (EMS) systems implemented a prehospital “cardiac alert” program in which patients suspected of having ST-elevation myocardial infarction (STEMI) based on the prehospital 12-lead ECG were diverted away from receiving facilities without emergent PCI capability andthe PCI team was mobilized. For the first year, a cardiac alert was activated by paramedics (Phase I). After the first year, the ECG was transmitted to the ED, with the emergency physician (EP) responsible for activation (Phase II). The PPV for cardiac alerts in Phases I andII were compared by using three different “gold standards”: cardiologist interpretation of the prehospital 12-lead ECG, disposition to emergent PCI, andcoronary lesions on angiography or arrest prior to emergent PCI. Results. A total of 110 patients were enrolled (54 in Phase I, 56 in Phase II). Cardiologist confirmation of a STEMI on the prehospital 12-lead EKG was 42/54 (78%) in Phase I and54/56 (96%) in Phase II. Disposition to emergent PCI occurred in 38/54 (70%) Phase I patients and51/56 (91%) Phase II patients. Lesions at catheterization or arrest prior to emergent PCI were observed in 41/54 (69%) of Phase I patients and50/56 (89%) of Phase II patients. All of these comparisons achieved statistical significance (p < 0.01). Conclusions. Transmission to the ED for EP interpretation improves the PPV of the prehospital 12-lead ECG for triage andtherapeutic decision-making.     

Prehospital use of activated charcoal: A pilot study

Activated charcoal (AC) is most effective when administered soon after the ingestion of certain substances. Delays are recognized to occur at times in the administration of AC after arrival of poisoned patients in the emergency department (ED). In addition, it has been recognized that these delays may be avoided if AC administration is begun in selected patients by paramedics while en route to the ED. We present a pilot study evaluating the administration of AC to poisoned patients in the ambulance prior to arrival in the ED. We performed a retrospective review of Emergency Medical System (EMS) run sheets and ED records of poisoned patients during a 6-month period from two area hospitals. Cases were identified that met criteria for the prehospital administration of AC. Cases were divided into two groups: those who received prehospital AC, and those who did not. Groups were compared for ambulance transport time, time from first paramedic contact to AC administration, and whether AC was tolerated by the patient. A total of 14 patients received prehospital AC (group 1). This group was compared to 22 cases that would have qualified under County protocol to receive prehospital AC, but for whatever reason did not (group 2). Group 2 patients all received AC after arriving in the ED. Average ambulance transport times did not statistically differ among groups. The average time from first encounter with paramedics to administration of AC was 5.0 minutes when AC administration was given in the ambulance as compared to 51.4 minutes when delayed until arrival in the ED. Tolerance was similar among the groups. The time to initiate AC administration may be significantly shortened when begun by prehospital personnel. All EMS should consider including AC in protocols addressing the prehospital management of certain poisoned patients.     

Prehospital care in Indonesia

Current system: Hospitals of varying standards are widespread but have no system of emergency ambulance or patient retrieval. Indonesia's only public emergency ambulance service, 118, is based in five of the biggest cities and is leading the way in paramedic training and prehospital care.

Challenges and developments: There are many challenges faced including the culture of acceptance, vast geographical areas, traffic, inadequate numbers of ambulances, and access to quality training resources. Recently there have been a number of encouraging developments including setting up of a disaster response brigade, better provision of ambulances, and development of paramedic training.

Conclusions: An integrated national regionalised hospital and prehospital system may seem fantastic but with the enthusiasm of those involved and perhaps some help from countries with access to training resources it may not be an unrealistic goal.

     

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.     

Implementation of Specialty Centers for Patients with ST-Segment Elevation Myocardial Infarction

Background. Early percutaneous coronary intervention (PCI) has been shown to be superior to fibrinolytic therapy andis associated with reduced morbidity andmortality for patients with ST-segment elevation myocardial infarction (STEMI). Objective. To determine the performance of a regional system with prehospital 12-lead electrocardiogram (ECG) identification of STEMI patients anddirect paramedic transport to STEMI receiving centers (SRCs) for provision of primary PCI. Methods. This was a prospective study evaluating the first year of implementation of a regional SRC network to determine the key time intervals for patients identified with STEMI in the prehospital setting. Results. During the 12-month study period, 1,220 patients with a suspected STEMI were identified on prehospital 12-lead ECG, of whom 734 (60%) underwent emergency PCI. A door-to-balloon time of 90 minutes or less was achieved for 651 (89%) patients, and459 (62.5%) had EMS–patient contact-to-balloon times ≤ 90 minutes. Transport of suspected STEMI patients to an SRC resulted in ambulance diversion from a closer ED for 31% of patients anda median increase in transport time of 3.8 minutes. Conclusion. Door-to-balloon times within the 90-minute benchmark were achieved for almost 90% of STEMI patients transported by paramedics after implementing our regionalized SRC system     

Paramedics Accurately Apply the Pediatric Assessment Triangle to Drive Management

Abstract

Objective. To provide an evaluation of the Pediatric Assessment Triangle (PAT) as an assessment tool for use by paramedic providers in the prehospital care of pediatric patients. Methods. Paramedics from Los Angeles Fire Department (LAFD) received training in the Pediatric Education for Prehospital Professionals (PEPP) course, PAT study procedures, and completed training in applying the PAT to assess children 0–14 years of age. A convenience sample of LAFD paramedic assessments of the pediatric patients transported to 29 participating institutions, over an 18-month period ending July 2010, were eligible for inclusion. Patients who were not transported were excluded from the study, as were the assessments of children with special health-care needs (CSHCN). PAT Study Forms, emergency medical services (EMS) report forms, and emergency department (ED) and hospital charts were entered into a secure database. Two study investigators, blinded to paramedic PAT assessment, reviewed hospital charts and determined the category of illness or injury. Results. A total of 1,552 PAT Study Forms were collected. Overall, 1,168 of the patient (75%) assessments met inclusion criteria, were transported, and had all three data points (PAT Study Form, paramedic EMS report form, and ED/hospital chart) available for analysis. When paramedics used the PAT to identify abnormalities in the three arms of the triangle (PAT Paramedic Pattern) and applied that pattern to form a general impression (PAT Paramedic Impression), the agreement resulted in a κ coefficient of 0.93 [95% CI: 0.91–0.95]. The PAT paramedic impression was congruent with field management, as the majority of patients received consistent interventions with local EMS protocols. The PAT Paramedic Impression for instability demonstrated a sensitivity of 77.4% [95% CI: 72.6–81.5%], a specificity of 90.0% [95% CI: 87.1–91.5%] with a positive likelihood ratio (LR+) of 7.7 [95% CI: 5.9–9.1] and a negative likelihood ratio (LR-) of 0.3 [95% CI: 0.2–0.3]. Conclusion. The PAT is a rapid assessment tool that can be readily and reliably used by paramedics in the prehospital setting. The PAT should be used in conjunction with other assessments but can safely drive initial field management.