N ONTRAUMA H ELICOPTER E MERGENCY M EDICAL S ERVICES T RANSPORT : A NNOTATED R EVIEW OF S ELECTED O UTCOMES - RELATED L ITERATURE

While helicopter emergency medical services (HEMS) has its roots in military transport of wounded soldiers, rotor-wing transport is also used for a wide variety of nontrauma indications. Despite this common use of HEMS for noninjured patients, a Medline search found little systematic review of the literature pertinent to HEMS use for nontrauma. With HEMS utilization subject to appropriately increased scrutiny, those seeking to research HEMS utility in noninjured patients could benefit from existence of a collection of the topical literature. This paper aims to provide such a review, in the form of an annotated bibliography of Index Medicus journal studies assessing potential medical risks and benefits of HEMS transport for noninjured patients. The paper's goal is to provide a useful resource for those interested in pursuing more focused review of various sectors of the nontrauma HEMS literature. As such, the main objective of the article summaries is to provide a brief outline of study design and results; there is also limited editorial comment included after each summary.     

Tearing down the walls between O.R. and S.P.D

The focus of this article is the relationship between the Operating Room (O.R.) and the Sterile Processing Department (S.P.D.). The goal is to help readers gain insights into the driving forces which impact on both departments and to help them establish realistic expectations for improving the performance and quality of this relationship. It is important to discuss ways to solve conflict and enhance teamwork between the O.R. and S.P.D. Both departments need to establish a common understanding and ensure that everyone "talks the same language" and "tears down the walls" between them. For the purpose of this article the short form of S.P.D. will be used for Sterile Processing Department (sometimes known as Central Processing), the department where instrument processing takes place and the distribution center for the entire hospital's supplies.     

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.     

A P EDIATRIC S URVEY FOR THE N ATIONAL H IGHWAY T RAFFIC S AFETY A DMINISTRATION : E MERGENCY M EDICAL S ERVICES S YSTEM R E-ASSESSMENTS

Emergency medical services for children, or EMSC, is still a relatively underdeveloped component of most state and local EMS systems. Advocacy and funding for EMSC from the federal EMSC Program, availability of many useful EMSC products, and the rapidly enlarging literature in EMSC have created heightened awareness and interest in improving systems for pediatric emergency, trauma, and critical care. The new National Highway Traffic Safety Administration (NHTSA) EMS Technical Assistance (TA) re-assessment program, the second version of the successful original TA Program from 1988 to 1996, provides an ideal opportunity for state EMS professionals to evaluate EMSC capabilities and to integrate new EMSC products and services. The history of the TA Program reflects the evolution of EMS itself and indicates a historical inattention to children's issues, but re-assessment TA teams now have much useful intervening EMSC history to draw upon and a clear philosophical mandate to integrate children more fully in EMS system planning and management. In order to facilitate state-of-the-art reviews of EMSC within state EMS systems, a pediatric survey for the NHTSA re-assessments is presented. The survey, developed with the input of EMS administrators and physicians and approved by the National Association of State EMS Directors, follows the original ten-component model for EMS system review. It is intended for optional use within the overall EMS review process.     

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

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

T HE L OCATIONS OF N ONRESIDENTIAL O UT-OF -H OSPITAL C ARDIAC A RRESTS IN THE C ITY OF P ITTSBURGH OVER A T HREE-YEAR P ERIOD : I MPLICATIONS FOR A UTOMATED E XTERNAL D EFIBRILLATOR P LACEMENT

Objectives. To determine the locations of nonresidential out-of-hospital cardiac arrests (OHCAs) in the City of Pittsburgh and to determine whether there are “high-risk” locations that might benefit from placement of automated external defibrillators (AEDs). Methods. This was a retrospective case review of paramedic calls for OHCA over a three-year period, in a mid-sized northeastern city. Cardiac arrests that were traumatic or for which the patients were dead on arrival (DOA) or had advanced directives for no resuscitation were excluded. Cardiac arrests that occurred in a public location (i.e., not a private residence) were categorized. Results. A total of 971 OHCAs occurred in the City of Pittsburgh from January 1, 1997, to December 31, 1999. Of these, 575 (59%) occurred in private residences, and 396 (41%) occurred in nonresidential locations. Fifteen locations had at least one cardiac arrest per year for three years, accounting for 166 (43%) of the total nonresidential OHCAs. Twelve locations had two arrests during the three-year period, accounting for 24 (6%) of the total nonresidential OHCAs. One hundred ninety-four locations had a single episode of cardiac arrest, accounting for 51% of the OHCAs. Nursing homes and dialysis centers accounted for 178 (94%) OHCAs in the 27 locations that had two or more cardiac arrests. A local sports/events complex (Three Rivers Stadium) was the only other single location to have more than two cardiac arrests in the three-year study period, with a total of three. However, events at this complex are routinely staffed by paramedics equipped with defibrillators. Conclusion. The majority of nonresidential OHCAs occur as singular, isolated events. Other than nursing homes and dialysis centers, there were no identifiable high-risk locations for nonresidential OHCA within the City of Pittsburgh.     

T HE E FFECTS OF P REHOSPITAL A DVANCED L IFE S UPPORT D RUG T REATMENT ON P ATIENT I MPROVEMENT AND I N-HOSPITAL U TILIZATION

Objective. There is little published evidence to support the benefits of prehospital drug administration by ambulance personnel in reducing subsequent hospital utilization by the medical patients receiving such drugs. The authors studied the outcome of patients treated by Ontario's Emergency Health Services “Symptom Relief Drug Program,” which was developed to relieve patient symptoms in the field for specific medical emergencies. Methods. A retrospective study spanning a three-year period from January 1996 to December 1998 was undertaken in a mid-sized southern Ontario community. From a review of ambulance call reports (ACRs), eligible patients were recruited by mail and divided into two groups: those treated before the introduction of the program (pre) and those treated after (post). Out-of-hospital data were retrieved from ACRs and in-hospital data were gathered from medical chart reviews. Outcomes included emergency department (ED) length of stay (LOS), frequency of admissions, and departmental use. Secondary endpoints included differences in prehospital improvement, ED interventions, and ambulance scene times. Results. For the unpaired analysis, 406 patients provided consent (pre: 215 vs post: 191). Ambulance time on scene was longer in the post group, 14.2 minutes (95% CI 13.7–14.8), versus the pre group, 12.3 minutes (95% CI 11.7–12.9), p < 0.001. A larger proportion of patients receiving prehospital drug treatment were judged to have improved on ED arrival (pre: 19.5% vs post: 48.2%, χ² p < 0.0001). The ED LOSs did not differ between groups (pre: 206.9?min, 95% CI 185.9–230.4, vs post: 220.9?min, 95% CI 196.9–247.7, p = 0.42) but were shorter within the post group for hypoglycemic patients receiving glucagon. The overall proportion of admissions was significantly lower in the post group (pre: 145 [67.4%] vs post: 102 [54.3%], χ² p < 0.01), and this was driven by chest pain patients. Conclusions. The lower rate of admissions for chest pain patients is the first published evidence of prehospital drug treatment's reducing hospital utilization in a subgroup of such medical patients. The “Symptom Relief Drug Program” is effective in improving patients' field conditions and can decrease ED LOS in hypoglycemic persons receiving glucagon injections. More outcome research pertaining to ambulance-administered prehospital drug treatment is warranted.     

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.     

T ERMINATION OF R ESUSCITATION IN THE P REHOSPITAL S ETTING FOR A DULT P ATIENTS S UFFERING N ONTRAUMATIC C ARDIAC A RREST

The National Association of EMS Physicians (NAEMSP) supports out-of-hospital termination of resuscitation for adult, nontraumatic cardiac arrest patients who have not responded to full resuscitative efforts. The following factors should be considered in establishing termination of resuscitation protocols: 1) Termination of resuscitation may be considered for any adult patient who suffers sudden cardiac death that is likely to be medical. 2) Unwitnessed cardiac arrest with delayed initiation of cardiopulmonary resuscitation (CPR) beyond 6 minutes and delayed defibrillation beyond 8 minutes has a poor prognosis. 3) In the absence of “do not resuscitate” or advanced directives, a full resuscitative effort including CPR, definitive airway management, medication administration, defibrillation if necessary, and at least 20 minutes of treatment following Advanced Cardiac Life Support (ACLS) guidelines should be performed prior to declaring the patient dead. 4) A patient whose rhythm changes to, or remains in, ventricular fibrillation or ventricular tachycardia should have continued resuscitative efforts. Patients in asystole or pulseless electrical activity should be strongly considered for out-of-hospital termination of resuscitation. 5) Logistic factors should be considered, such as collapse in a public place, family wishes, and safety of the crew and public. 6) Online medical direction should be established prior to termination of resuscitation. The decision to terminate efforts should be a consensus between the on-scene paramedic and the online physician. 7) The on-scene providers and family should have access to resources, such as clergy, crisis workers, and social workers. 8) Quality review is necessary to ensure appropriate application of the termination protocol, law enforcement notification, medical examiner or coroner involvement, and family counseling.     

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.     

F EW E MERGENCY M EDICAL S ERVICES P ATIENTS WITH L OWER-EXTREMITY F RACTURES R ECEIVE P REHOSPITAL A NALGESIA

Previous literature has identified prehospital pain management as an important emergency medical services (EMS) function, and few patients transported by EMS with musculoskeletal injuries receive prehospital analgesia (PA). Objectives. 1) To describe the frequency with which EMS patients with lower-extremity and hip fracture receive prehospital and emergency department (ED) analgesia; 2) to describe EMS and patient factors that may affect administration of PA to these patients; and 3) to describe the time interval between EMS and ED medication administrations. Methods. This was a four-month (April to July 2000) retrospective study of patients with a final hospital diagnosis of hip or lower-extremity fracture who were transported by EMS to a single suburban community hospital. Data including patient demographics, fracture type, EMS response, and treatment characteristics were abstracted from review of EMS and ED records. Patients who had ankle fractures, had multiple traumatic injuries, were under the age of 18 years, or did not have fractures were excluded. Results. One hundred twenty-four patients met inclusion criteria. A basic life support (BLS)-only response was provided to 20 (16.0%). Another 38 (38.4%) received an advanced life support (ALS) response and were triaged to BLS transport. Of all the patients, 22 (18.3%) received PA. Patients who received PA were younger (64.0 vs. 77.3 years, p < 0.001) and more likely to have a lower-extremity fracture other than a hip fracture (31.8% vs. 10.7%, p < 0.004). Of all patients, 113 (91.1%) received ED analgesia. Patients received analgesia from EMS almost 2.0 hours sooner that in the ED (mean 28.4 ± 36 min vs. 146 ± 74 min after EMS scene arrival, p < 0.001). Conclusion. A minority of the study group received PA. Older patients and patients with hip fracture are less likely to receive PA. It is unclear whether current EMS system design may adversely impact administration of PA. Further work is needed to clarify whether patient need or EMS practice patterns result in low rates of PA.