Patient outcome using medical protocol to limit "lights and siren" transport

INTRODUCTION: Emergency medical services vehicle collisions (EMVCs) associated with the use of warning "lights and siren" (L&S) are responsible for injuries and death to emergency medical services (EMS) personnel and patients. This study examines patient outcome when medical protocol directs L&S transport. DESIGN: During four months, all EMS calls initiated as an emergency request for service and culminating in transport to an emergency department (ED) were included. Medical criteria determined emergent (L&S) versus non-emergent transport. Patients with worsened conditions, as reported by EMS providers, were reviewed. SETTING: Countywide suburban/rural EMS system. RESULTS: Ninety-two percent (1,495 of 1,625) of patients were transported nonemergently. Thirteen (1%) of these were reported to have worsened during transport, and none of them suffered any worsened outcome related to the non-L&S transport. CONCLUSION: This medical protocol directing the use of warning L&S during patient transport results in infrequent L&S transport. In this study, no adverse outcomes were found related to non-L&S transports.     

Ambulance transport to the emergency department: A patient-selected signal of acuity and its effect on resource provision

ObjectiveTo determine whether ambulance arrival to the emergency department has remained an unidentified signal of perceived medical acuity. Informed by economic signaling theory, does arrival via ambulance affect resource utilization given varying levels of patient acuity?MethodsThe analysis examined a nationally representative sample of de-identified emergency department patient encounters from 2011 to 2015, gathered from the National Hospital Ambulatory Medical Care Survey (NHAMCS). Multivariate logistic regression analysis was employed using regional and time-fixed effects. The provision of twenty diagnostic and imaging services was analyzed. Patient encounters were also categorized into five acuity-levels.ResultsDrawing from the NHAMCS dataset, 98,888 emergency department records were analyzed, weighted to represent 504.5 million estimated emergency department patient encounters. Findings suggest that patients transported to the hospital via ambulance are more likely than those who arrive by other means to receive 19 of the 20 analyzed diagnostic testing and imaging services. Furthermore, when analyzed by acuity-level, the disparity of service provision is the greatest among low-acuity patients, where medical complaints are argued to be the most subjective.ConclusionsThe results are consistent with the notion that emergency department medical providers readily accept ambulance transport as a valid signal of patient acuity, regardless of true acuity level. Consequently, patients transported to the hospital via ambulance may be receiving a disproportionate amount of medical resources in an increasingly cost-conscious environment.     

The use of outcome feedback by emergency medicine physicians: Results of a physician survey

BACKGROUND: Feedback on patient outcomes is invaluable to the practice of emergency medicine but examples of effective forms of feedback have not been well characterized in the literature. We describe one system of emergency department (ED) outcome feedback called the return visit report (RVR) and present the results of a survey assessing physicians’ perceptions of this novel form of feedback. METHODS: An Opinio web-based survey was conducted in 81 emergency physicians (EPs) at three EDs.RESULTS: Of the 81 physicians surveyed, 40 (49%) responded. Most participants indicated that they frequently review their RVRs (83%), that RVRs are valuable to their practice of medicine (80%), and that RVRs alter their practice in future encounters (57%). Respondents reported seeking other forms of outcome feedback including speaking with other EPs (83%) and reviewing discharge summaries of admitted patients (87%). There was no correlation between demographic data and use of RVRs. CONCLUSION: EPs value RVRs as a form of feedback. RVRs could be improved by reducing the observational interval and optimizing report relevance and differential weighting.     

Peer evaluation of the professional behaviors of emergency medical technicians

INTRODUCTION: Professional behavior is one of the cornerstones of effective emergency medical services (EMS) practice and is a required part of the National Standard Curricula for advanced levels of EMS education. However, peer rating of emergency medical technicians with respect to the 11 categories of professional behavior never has been quantified. This study uses a peer evaluation methodology to assess the affective competencies of practicing EMS providers. METHODS: A professional behavior evaluation form was included as part of a survey that was sent to 2,443 randomly selected, nationally registered emergency medical technicians (EMTs). Participants were asked to rate the EMT partner with whom they worked most closely in the past year using 11 different categories of professional behavior using a Likert scale. RESULTS: One thousand, five hundred, ten (61.8%) surveys were returned and analyzed. Both nationally registered EMTs at the Basic and Paramedic levels rated their partners with respect to 11 categories of professional behavior. The overall average score was 0.68 on a 0-1 scale, with one being the highest. The rating of each of the categories was: (1) integrity (0.77); (2) appearance/personal hygiene (0.74); (3) patient advocacy (0.73); (4) empathy (0.72); (5) self-confidence (0.70); (6) careful delivery of service (0.70); (7) respect (0.65); (8) communication skills (0.64); (9) time management skills (0.63); (10) teamwork/diplomacy skills (0.62); and (11) self-motivation (0.61). Overall, the NREMT-Paramedics rated their partners significantly lower than did the NREMT-Basics (p = 0.0156) and experienced EMT-Basics rated their partners significantly lower than did the newer EMT-Basics (p = 0.0002). Those EMTs who indicated high satisfaction with their current EMS assignment rated their partner more highly on professional behaviors than did those EMTs who were not as satisfied. CONCLUSION: Overall, EMTs peer evaluation of professional behavior was "good." The behaviors most highly rated were integrity and appearance/personal hygiene. The behaviors rated lowest were self-motivation and team work/diplomacy. It appears that paramedics are more critical of their colleagues than are EMT-Basics, that experienced EMT-Basics are harsher critics than are newer EMT-Basics, and that there is a relationship between job satisfaction and peer evaluation.     

Factors Associated with Emergency Medical Services Scope of Practice for Acute Cardiovascular Events

Abstract

Objectives. To examine prehospital emergency medical services (EMS) scope of practice for acute cardiovascular events and characteristics that may affect scope of practice; and to describe variations in EMS scope of practice for these events and the characteristics associated with that variability. Methods. In 2008, we conducted a telephone survey of 1,939 eligible EMS providers in nine states to measure EMS agency characteristics, medical director involvement, and 18 interventions authorized for prehospital care of acute cardiovascular events by three levels of emergency medical technician (EMT) personnel. Results. A total of 1,292 providers responded to the survey, for a response rate of 67%. EMS scope of practice interventions varied by EMT personnel level, with the proportion of authorized interventions increasing as expected from EMT-Basic to EMT-Paramedic. Seven of eight statistically significant associations indicated that EMS agencies in urban settings were less likely to authorize interventions (odds ratios <0.7) for any level of EMS personnel. Based on the subset of six statistically significant associations, fire department–based EMS agencies were two to three times more likely to authorize interventions for EMT-Intermediate personnel. Volunteer EMS agencies were more than twice as likely as nonvolunteer agencies to authorize interventions for EMT-Basic and EMT-Intermediate personnel but were less likely to authorize any one of the 11 interventions for EMT-Paramedics. Greater medical director involvement was associated with greater likelihood of authorization of seven of the 18 interventions for EMT-Basic and EMT-Paramedic personnel but had no association with EMT-Intermediate personnel. Conclusions. We noted statistically significant variations in scope of practice by rural vs. urban setting, medical director involvement, and type of EMS service (fire department–based/non–fire department–based; volunteer/paid). These variations highlight local differences in the composition and capacity of EMS providers and offer important information for the transition towards the implementation of a national scope of practice model.     

Systematic review of alcohol screening tools for use in the emergency department

To ascertain which alcohol screening tool is most accurate in identifying alcohol misuse in patients in the emergency department a systematic review of diagnostic cohort studies of appropriate alcohol screening tools was performed. A thorough search of medical databases and relevant peer journals was conducted. Citation and author tracking was also utilised due to an initial paucity of relevant literature. Seven relevant papers were identified from this search, which allowed a review of the quality of the following alcohol screening tools: the fast alcohol screening tool (FAST), the Paddington alcohol test (PAT), the rapid alcohol problem screen (RAPS-4) and the TWEAK (where TWEAK is an acronym of the first letter of the key words in the questions of this screening tool: tolerance, worried, eye-opener, amnesia, K (cut-down)). The most sensitive screening tool within this review appears to be the FAST (93-94%), which has a specificity of 86-88% with a positive predicted value of 86-87%. Although the FAST appears to be the best for accurately identifying alcohol misuse within emergency department patients, it was assessed as a universal screening tool, and it may not be feasible (time or cost) to screen all who present to this service. In contrast, the PAT has been developed to be used on a select population within the emergency department and has already been shown to be cost-effective.     

Emergency medical service providers' experience with family presence during cardiopulmonary resuscitation

OBJECTIVE: To describe emergency medical service providers' experiences with family member presence during resuscitation, and to determine whether those experiences are similar within urban and suburban settings. METHODS: We conducted a personally distributed survey of a convenience sample of urban and suburban emergency medical service (EMS) providers presenting to two Midwestern Emergency Departments. Providers were questioned as to their experiences with resuscitating patients in the presence of family members. RESULTS: There were 128 respondents to the survey (59 urban and 69 suburban), of which 70.1% were EMT-Paramedics. No provider who was approached refused participation. Nearly all (122) had performed CPR in the presence of family members, with most (77%) performing greater than 20. Subjects averaged 12.3 years of experience. The majority of urban and suburban providers felt it was inappropriate for family to witness resuscitations (75.9% versus 60.3%, respectively; p=0.068). Many providers reported feeling uncomfortable with family presence (31.5% urban versus 44.8% suburban; p=0.136), and few preferred that family witness the resuscitation (13.2% urban versus 15.4 suburban; p=0.738). A minority of providers believed that family were better prepared to accept the death of the patient (37.0% urban versus 37.6% suburban; p=0.939). Approximately half felt comfortable providing emotional support (66.0% urban versus 53.7% suburban; p=0.173). Many felt that family caused a negative impact during resuscitation (53.7% urban and 36.8% suburban; p=0.061). Urban providers more often reported feeling threatened by family members during resuscitation (66.7% versus 39.7%; p=0.003), and felt that family often interfered with their ability to perform resuscitations (35.6% versus 16.4%, p=0.014). CONCLUSIONS: EMS providers have substantial experience with family witnessed resuscitations, are uncomfortable about their presence, and often must provide support for families. While urban providers tended to report more negative experiences and perceptions, there were minimal differences between the two groups.     

Emergency medical services in the reconstruction phase following a major earthquake: a case study of the 1988 Armenia earthquake

STUDY OBJECTIVE: To use the clinical activities of an ambulance service as a tool to assess the residual and unmet medical needs of a city in the aftermath of a major earthquake and to apply that assessment to the development of a training curriculum for the prehospital personnel. METHODS: The researchers conducted structured interviews with health care workers at all levels of the emergency health care delivery system in Gyumrii, Armenia, and carried out a retrospective frequency analysis of 29,010 ambulance runs for an 11-month period from February through December 1992. Runs first were assigned into the broad categories of: 1) Adult Medical; 2) Pediatric Medical; or 3) Trauma, and then, according to diagnosis. The runs then were classified further as: 1) Primary Care; 2) Basic Life Support (BLS); or 3) Advanced Life Support (ALS). RESULTS: Adult Medical calls represented 24,684 (85%), Pediatric Medical calls 459 (1.6%), and Trauma calls 3,867 (13%). Only 12% of all ambulance calls resulted in transport to a medical facility, although this percentage was higher in children. Thirty percent of Adult Medical patients were diagnosed by the emergency medical providers as having exclusively a psychiatric problem. CONCLUSION: In the late aftermath of a devastating earthquake, the ambulance service in Gyumrii, Armenia has been delivering a substantial proportion of non-emergency, primary care services. They have adopted this unconventional role to compensate for the deficit in health care facilities and personnel created by the disaster. The training program that the investigators developed reflected the actual work activities of the prehospital personnel demonstrated in their assessment.     

Mistaken identity: the effect of badges on EMT recognition

INTRODUCTION: Many emergency medical services (EMS) providers wear badges with their uniforms. This study was undertaken to determine whether emergency medical technicians (EMTs) who wear badges with their uniforms are more likely to be mistaken for law enforcement personnel than are those who do not wear badges. HYPOTHESIS: Emergency medical services providers who wear badges are more likely to be mistaken for law enforcement personnel than are those who do not wear badges. METHODS: High school students, college students, civic organizations, and church groups were shown slides of different uniforms and badges/insignia and asked to identify the person portrayed. Responses were categorized as "EMS," "law enforcement," or "other." Frequency of responses for each uniform and insignia were compared with chi-square analysis. RESULTS: Fifty-nine percent of the uniforms with badges were identified as law enforcement personnel. Only 5.5% of the uniforms with badges were identified as "EMS," compared with 74% of the uniforms with a Star of Life (p < 0.001). CONCLUSION: Individuals wearing uniforms with badges are more likely to be identified as law enforcement personnel than are EMS personnel. Emergency medical services providers who do not wish to be mistaken for law enforcement personnel should wear the Star of Life, not a badge, with their uniform.     

EMS providers do not accurately note motor-vehicle crash patients with positive serum alcohol concentrations

INTRODUCTION: Alcohol use is associated with many motor-vehicle crashes and may increase the severity of injury. Because alcohol use also may mask injury, prehospital emergency care providers (PHECPs) may make inaccurate assessments. To assess and triage crash victims accurately, PHECPs must identify recent alcohol use. STUDY OBJECTIVE: This study examines the accuracy of PHECPs in identifying motor-vehicle crash victims who had positive serum alcohol concentrations. DESIGN: Retrospective cohort study. POPULATION: Included in the study were motor-vehicle crash victims more than 17 years of age who were conveyed directly to a university medical center emergency department by ground ambulance (n = 372). TIME PERIOD: 15 July 1990 to 15 July 1991. METHODS: Data sources included ambulance report forms and hospital records. Variables that were abstracted included the Revised Trauma Score (RTS), the PHECPs' impression of alcohol use, and serum alcohol concentrations. Sensitivity, specificity, predictive-value positive, predictive-value negative, and 0.95 confidence intervals (0.95 CI) were calculated for the PHECPs' ability to identify patients with a serum alcohol concentration > 0. The relationship between the RTS and the impressions of alcohol use was analyzed with chi-square testing: a p-value of < 0.05 was considered statistically significant. CONCLUSION: This study suggests that PHECPs cannot accurately identify crash victims with positive serum alcohol concentrations. Selection bias and retrospective design are significant limitations of this study. Future studies should develop and evaluate methods to improve PHECPs' accuracy in assessing alcohol use in motor-vehicle crash victims.     

A self-assessment of Wisconsin prehospital provider needs

INTRODUCTION: The pressures facing emergency medical services (EMS) in Wisconsin and their effects on the delivery of prehospital emergency medical care were not known by the Wisconsin EMS Board. In an effort to assess these pressures and the needs of the emergency medical services in the State as perceived by the services, the Board undertook a survey of the EMS providers in Wisconsin. METHODS: A survey instrument was developed and approved by the EMS Board and distributed to all of the licensed emergency medical services in Wisconsin. RESULTS: Of the 453 survey instruments distributed, 323 (71.3%) were completed and returned. Intermediate- and paramedic-level services were more likely to respond than were the basic services, but 235 (72.8%) of the respondents identified their service levels as basic. In addition to providing information about the service characteristics, each responding service also rated the importance of their perceived needs. Lack of medical direction was perceived as the greatest need by all levels of service. However, the second greatest area of need for basic and intermediate services related to difficulty in recruiting new staff. For paramedic services, the second greatest need was associated with dispatching. When comparing services by rural versus urban, difficulty in recruiting new staff and collecting ambulance fees were seen as second and third to lack of a medical director by rural services, whereas urban services noted local training to be in the top three. In the assessment of educational needs, patient-care issues dominated. A review of written comments also demonstrated a difference between rural and urban services, but both noted Medicare and Medicaid reimbursement issues more commonly than any other problem. CONCLUSIONS: In the restructuring of health care, it will be important to consider the various needs of prehospital providers and recognize that such needs may be unique to the providers' location and level of service.     

Hypoglycemia Patients and Transport by EMS in Alameda County, 2013–15

Objective: To estimate the rate, characteristics, and dispositions of hypoglycemia events among persons who received care from Alameda County, California, Emergency Medical Services (EMS). Methods: This study was based on data for 601,077 Alameda County EMS encounters during 2013–15. Subjects were defined as having hypoglycemia if EMS personnel recorded a primary impression of hypoglycemia or low blood glucose (<60 mg/dl or “unspecified low”). The outcome of interest was patient transport or non-transport to an emergency department or other care setting; we excluded 33,177 (6%) encounters which lacked clear disposition outcomes. Results: Among 567,900 eligible encounters, 8,332 (1.47%) were attributed to hypoglycemia, of which 1,125 (13.5%) were not transported. Non-transport was more likely among males, adult patients age <60, initial blood glucose >60 mg/dl or EMS arrival time 18:00–6:00. Conclusions: Without an understanding of EMS encounters and non-transport rates, surveillance based solely on emergency department and hospital data will significantly underestimate rates of severe hypoglycemia. Additionally, given that hypoglycemia is often safely and effectively treated by non-physicians, EMS protocols should provide guidance for non-transport of hypoglycemic patients whose blood glucose levels have normalized.     

Feedback

The emergency department provides a rich environment for diverse patient encounters, rapid clinical decision making, and opportunities to hone procedural skills. Well-prepared faculty can utilize this environment to teach residents and medical students and gain institutional recognition for their incomparable role and teamwork. Giving effective feedback is an essential skill for all teaching faculty. Feedback is ongoing appraisal of performance based on direct observation aimed at changing or sustaining a behavior. Tips from the literature and the author's experience are reviewed to provide formats for feedback, review of objectives, and elements of professionalism and how to deal with poorly performing students. Although the following examples pertain to medical student education, these techniques are applicable to the education of all adult learners, including residents and colleagues. Specific examples of redirection and reflection are offered, and pitfalls are reviewed. Suggestions for streamlining verbal and written feedback and obtaining feedback from others in a fast-paced environment are given. Ideas for further individual and group faculty development are presented.     

精神科与综合科医护人员应激因素比较研究

目的探讨精神科与临床综合科医护人员应激因素的差异。方法对209名精神科与临床综合科室医护人员,采用“工作应激量表”进行问卷调查分析。结果不同科室和工龄间对应激没有交互作用,不同工龄间的人际关系、所需体力和工作应激因素有显著差异（P=0．032,P=0．024）;不同科室和性别间的交互作用对工作兴趣也有显著影响（F=3．740．P=0．05）;不同科室和专业的交互作用在人际关系上有极显著性差异（F=10．823,P=0．001）。结论精神科与临床综合科医护人员的应激源不是单一性的,其影响因素是多方面,且各不相同的．需给他们提供更多的正性反馈。     

Determination of prehospital blood glucose: A prospective, controlled study

Study Objective: To determine if emergency medical personnel can effectively rule out hypoglycemia in the prehospital setting. Design: During a 10-week period, emergency medical personnel determined the fingerstick glucose on all prehospital patients with altered mental status using the Chemstrip bG®. Statistical comparisons were made to serum glucose levels performed by hospital laboratory personnel on blood samples obtained prior to glucose administration. A serum glucose level less than 60 mg/dL was considered a positive test for hypoglycemia. Participants: 170 consecutive patients with altered mental status (AMS) ranging in age from 13 to 90 years were enrolled. Measurements and Main Results: Of these patients, 158 were normal or hyperglycemic, 12 were hypoglycemic, and one patient was hypoglycemic but had only a borderline negative fingerstick test. Thus, a sensitivity of 91.7% and a negative predictive value of 99.3% were obtained. The specificity was 92.4%, and positive predictive value was 47.8%. Conclusion: The Chemstrip bG may be used safely in the prehospital setting to rule out hypoglycemia.     

Reduced length of stay in medical emergency department patients: a prospective controlled study on emergency physician staffing.

OBJECTIVE: Patients, emergency department staff and hospital managers are often confronted with a prolonged length of stay of emergency department patients, with resulting overcrowding in the emergency department. We hypothesized that additional medical personnel would reduce the length of stay. METHODS: We prospectively studied consecutive patients managed in a medical emergency department by internal medicine residents during the evening shift. Data were collected on patients managed before (n=200) and after (n=160) the addition of a second physician on the shift. RESULTS: The addition of a physician in the busy evening shift decreased the length of stay from 176+/-137 to 141+/-86 min (mean+/-SD, P=0.012) for outpatients discharged after evaluation and management in the emergency department. The length of stay for emergency department inpatients admitted for hospitalization was not significantly reduced. CONCLUSION: An additional physician significantly reduced the length of stay of medical emergency department outpatients.     

Triage, transportation, and destination decisions by out-of-hospital emergency care providers.

INTRODUCTION: The effectiveness of a tiered emergency medical services system often hinges upon the ability of initial care providers with little or no formal training to identify emergent patient needs and determine the best means to meet those needs. OBJECTIVES: To determine if out-of-hospital emergency care providers consistently make appropriate triage, transportation, and destination decisions; and to determine if experience and training have an effect on these decisions. METHODS: A survey consisting of 14 patient-care scenarios was administered to certified and non-certified out-of-hospital emergency-care providers (n = 311) from 20 randomly selected EMS agencies. These agencies were part of EMS systems that utilize one, two, and three tiered responses by ambulance and fire-based commercial, municipal, and volunteer agencies. Participants were asked to select the most appropriate mode of transport and destination facility using the assumption that they had responded to each scenario in a basic life support ambulance. Answers included transporting the patient to various receiving facilities or requesting a more advanced-level unit to respond to the scene. Transport times to receiving facilities and estimated times of arrival for advanced-level units were provided with each choice. Eight emergency physicians unanimously had agreed upon the most appropriate answer for each scenario. A two-tailed t-test was used to compare the scores of the certified and non-certified groups; and Spearman's Correlation Coefficients were used to test the effects of experience and training. RESULTS: Non-certified providers (n = 108) had a mean score of 32.6% or 4.6 (SD = 1.84) correct answers; certified providers (n = 203) had a mean score of 41.1% or 5.76 (SD = 2.12) correct answers (p < 0.000001). Spearman's Correlation Coefficients were: 1) individual provider level--(0.3978); 2) agency provider level--(0.2741); 3) hours worked per week--(0.2505); 4) years in EMS--(-0.0821); 5) commercial or volunteer provider--(0.2398); 6) agency call volume--(0.2012); 7) agency location--(0.0685), and 8) transporting versus non-transporting agency--(0.2523). CONCLUSIONS: A need exists for further education of out-of-hospital emergency care providers with respect to triage, transportation, and destination decisions. Provider experience and level of certification do not appear to affect these critical patient-care decisions.     

Emergency department-based telemedicine.

Although many studies have been published concerning clinical telemedicine, little information is available about emergency department (ED)-based telemedicine programs. An ED-based telemedicine program was initiated in April 1996 involving the National Cheng Kung University Hospital (NCKUH) and the Provincial Peng-Hu Hospital (PPHH) under a pilot project supported by the Department of Health. This is the first telemedicine program for remote offshore island service in Taiwan. The program is synchronous in nature to the practice of telemedicine. The role of the emergency physician includes giving initial suggestions, arranging consultations, coordination, and the organization of other medical tasks, such as accompanying some of the transfers. During the 12-month period, this system was used in 275 consultations, including 24 specialty and/or subspecialty department/sections, and more than 100 members of the medical staff have participated in this project since. In a survey, 89.4% of physicians in the PPHH and 82.2% of the physicians in NCKUH rated the system as very comfortable to work with and satisfactory. According to these observations, an ED-based telemedicine program is a feasible method for carrying out remote consultations. Successful development of the partnership and program of telemedicine is based on the active participation and coordination of the medical personnel and technicians between the cooperating hospitals.     

Evaluation of agricultural rescue course by providers

STUDY OBJECTIVE: To assess the characteristics of rural emergency medical services providers involved in the prehospital care of victims of agricultural injuries and determine which aspects of an agricultural rescue course were perceived as most useful. DESIGN: A questionnaire was sent to participants of a course designed for agricultural prehospital providers who had attended a farm accident rescue course between 1986 and 1993. SETTING: A rural referral center in central Wisconsin. PARTICIPANTS: The questionnaire was sent to all persons who had participated in the course. Respondents to the questionnaire characterized their service experience and rated the topic areas in usefulness and whether the subject should be included in future courses. RESULTS: A total of 459 surveys (44% of potential respondents) was returned. Of the respondents, 316 (74.4%) were men, and the mean age was 39.4 years. There were 247 (60.8%) who were volunteers, and an additional 126 (31%) were paid, on-call workers. There were 232 (56.4%) basic providers, and 365 (87.5%) were from a rural area. Many (n = 149; 36.9%) had not responded to farm accidents during the past year. Training course topics rated most useful were machinery extrication, tractor overturn, and enclosed-space rescue. CONCLUSIONS: Respondents to an evaluation of an agricultural rescue course primarily were rural, basic providers. Future development of courses for emergency medical technicians involved in agriculture rescue must account for this level of training. Such courses should be short and modular with an emphasis on continuing education, practice, and focus on the identified needs of the participants.