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.     

Association of Burnout with Workforce-Reducing Factors among EMS Professionals

Objectives: Emergency medical services (EMS) professionals often work long hours at multiple jobs and endure frequent exposure to traumatic events. The stressors inherent to the prehospital setting may increase the likelihood of experiencing burnout and lead providers to exit the profession, representing a serious workforce and public health concern. Our objectives were to estimate the prevalence of burnout, identify characteristics associated with experiencing burnout, and quantify its relationship with factors that negatively impact EMS workforce stability, namely sickness absence and turnover intentions. Methods: A random sample of 10,620 emergency medical technicians (EMTs) and 10,540 paramedics was selected from the National EMS Certification database to receive an electronic questionnaire between October, 2015 and November, 2015. Using the validated Copenhagen Burnout Inventory (CBI), we assessed burnout across three dimensions: personal, work-related, and patient-related. We used multivariable logistic regression modeling to identify burnout predictors and quantify the association between burnout and our workforce-related outcomes: reporting ten or more days of work absence due to personal illness in the past 12 months, and intending to leave an EMS job or the profession within the next 12 months. Results: Burnout was more prevalent among paramedics than EMTs (personal: 38.3% vs. 24.9%, work-related: 30.1% vs. 19.1%, and patient-related: 14.4% vs. 5.5%). Variables associated with increased burnout in all dimensions included certification at the paramedic level, having between five and 15 years of EMS experience, and increased weekly call volume. After adjustment, burnout was associated with over a two-fold increase in odds of reporting ten or more days of sickness absence in the past year. Burnout was associated with greater odds of intending to leave an EMS job (personal OR:2.45, 95% CI:1.95–3.06, work-related OR:3.37, 95% CI:2.67–4.26, patient-related OR: 2.38, 95% CI:1.74–3.26) or the EMS profession (personal OR:2.70, 95% CI:1.94–3.74, work-related OR:3.43, 95% CI:2.47–4.75, patient-related OR:3.69, 95% CI:2.42–5.63). Conclusions: The high estimated prevalence of burnout among EMS professionals represents a significant concern for the physical and mental well-being of this critical healthcare workforce. Further, the strong association between burnout and variables that negatively impact the number of available EMS professionals signals an important workforce concern that warrants further prospective investigation.     

The Effect of Paramedic Experience on Survival from Cardiac Arrest

Objective. We hypothesized that paramedics with more experience would be more successful at treating patients in ventricular fibrillation (VF) cardiac arrest than those with less experience. We conducted a study examining the relationship between the years of experience of paramedics and survival from out-of-hospital cardiac arrest. Methods. This retrospective cohort study examined all witnessed, out-of-hospital VF cardiac arrests (n = 699) that occurred between January 1, 2002, and December 31, 2006. Logistic regression was used to determine the odds of survival and the 95% confidence intervals (95% CIs) relating to the number of years of experience that each of the treating paramedics had. Results. We found that every additional year of experience of the medic in charge of implementing procedures such as intravenous line insertions, intubations, and provision of medications was associated with a 2% increase in the likelihood of survival of the patient (95% CI: 1.00–1.04). The number of years of experience of the paramedic who did not perform procedures but instead was in charge of treatment decisions was not significantly associated with survival (odds ratio [OR] 1.01, 95% CI: 0.99–1.03). When we combined both paramedics' years of experience, we saw a 1% increase in the odds of survival for every additional year of experience (95% CI: 1.00–1.03). Conclusions. This study suggests that the amount of experience of the paramedic who performed procedures on cardiac arrest patients was associated with increased rates of survival. However, we did not find an association between survival from VF and the number of years of experience of the paramedic who made treatment decisions.     

Association between prehospital prognostic factors and out-of-hospital cardiac arrest: Effect of rural–urban disparities

BackgroundOut-of-hospital cardiac arrest (OHCA) is associated with a poor prognosis and a highly variable survival rate. Few studies have focused on outcomes in rural and urban groups while also evaluating underlying diseases and prehospital factors for OHCAs.ObjectiveTo investigate the relationship between the patient's underlying disease and outcomes of OHCAs in urban areas versus those in rural areas.MethodsWe reviewed the emergency medical service (EMS) database for information on OHCA patients treated between January 2015 and December 2019, and collected data on pre-hospital factors, underlying diseases, and outcomes of OHCAs. Univariate and multivariate logistic regression analyses were used to evaluate the prognostic factors for OHCA.ResultsData from 4225 OHCAs were analysed. EMS response time was shorter and the rate of attendance by EMS paramedics was higher in urban areas (p < 0.001 for both). Urban area was a prognostic factor for >24-h survival (odds ratio [OR] = 1.437, 95% confidence interval [CI]: 1.179–1.761). Age (OR = 0.986, 95% CI: 0.979–0.993). EMS response time (OR = 0.854, 95% CI: 0.811–0.898), cardiac arrest location (OR = 2.187, 95% CI: 1.707–2.795), attendance by paramedics (OR = 1.867, 95% CI: 1.483–2.347), and prehospital defibrillation (OR = 2.771, 95% CI: 2.154–3.556) were independent risk factors for survival to hospital discharge, although the influence of an urban area was not significant (OR = 1.211, 95% CI: 0.918–1.584).ConclusionsCompared with rural areas, OHCA in urban areas are associated with a higher 24-h survival rate. Shorter EMS response time and a higher probability of being attended by paramedics were noted in urban areas. Although shorter EMS response time, younger age, public location, defibrillation by an automated external defibrillator, and attendance by Emergency Medical Technician-paramedics were associated with a higher rate of survival to hospital discharge, urban area was not an independent prognostic factor for survival to hospital discharge in OHCA patients.     

Program Accreditation Effect on Paramedic Credentialing Examination Success Rate

Objectives. Program accreditation is used to ensure the delivery of quality education andtraining for allied health providers. However, accreditation is not mandated for paramedic education programs. This study examined if there is a relationship between completion of an accredited paramedic education program andachieving a passing score on the National Registry Paramedic Certification Examination. Methods. We used data from the National Registry Paramedic Certification Examination for calendar year 2002. Successful completion (passing) of the examination was defined as correctly answering a minimum of 126 out of 180 (70%) of the questions andmeeting or exceeding the individual subtest passing scores. Accredited paramedic training programs were certified by the Committee on Accreditation of Educational Programs for the Emergency Medical Services Professions (CoAEMSP) on or before January 1, 2002. Candidates reported demographic characteristics including age, gender, self-reported race andethnicity, education, andemployer type. We examined the relationship between passing the examination andattendance at an accredited paramedic training program. Results. A total of 12,773 students completed the examination. Students who attended an accredited program were more likely to pass the examination (OR = 1.65, 95% CI: 1.51–1.81). Attendance at an accredited training program was independently associated with passing the examination (OR = 1.58, 95% CI = 1.43–1.74) even after accounting for confounding demographic factors. Conclusion. Students who attended an accredited paramedic program were more likely to achieve a passing score on a national paramedic credentialing examination. Additional studies are needed to identify the aspects of program accreditation that lead to improved examination success.     

EMS Provider Perceptions on Termination of Resuscitation in a Large,Urban EMS System

Objective: Despite the value of out-of-hospital Termination of Resuscitation (TOR) and the scientific evidence in favor of this practice, TOR has not been uniformly adopted or consistently practiced in EMS systems. Previous focus group studies have identified multiple barriers to implementation of out of hospital TOR but existing literature on EMS provider perceptions is limited. We sought to identify EMS providers' perceived barriers to performing out-of-hospital TOR in a large urban EMS system. Methods: The Chicago EMS System is a regional collaborative of EMS physicians, nurses and provider agencies, including the Chicago Fire Department (CFD), which provides exclusive emergency response for 9-1-1 calls in Chicago. CFD is an urban, fire-based EMS agency with a tiered response, with fire-fighter EMTs and paramedics providing initial care, and single role paramedics providing supplemental care and transport. A 2-page written survey was distributed to understand providers' experiences with managing OHCA and perceived barriers to TOR to inform subsequent improvements in protocol development and education. Results: Of 3500 EMS providers that received the survey, 2309 were completed (66%). Survey respondent demographics were fire-fighter/EMTB (69%), fire-fighter/paramedic (14%), and single role paramedic (17%). The most frequent barrier to field TOR was scene safety (86%). The most common safety issue identified was family reaction to TOR (68%) and many providers felt threatened by family when trying to perform

TOR (38%). Providers with a higher career numbers of OHCA were more likely to have felt threatened by the family (OR 6.70, 95% CI 2.99–15.00) and single role paramedics were more likely than FF/EMTBs to have felt threatened (OR 3.34, 95% CI 2.65–4.22). Barriers to delivering a death notification after TOR, include being uncomfortable or threatened with possible family reaction (52%) and family asking to continue the resuscitation (45%). There was lack of formal prior death notification training, the majority learned from colleagues through on the job training. Conclusions: Our study identifies scene safety, death notification delivery, and lack of formal training in death notification as barriers that EMS providers face while performing TOR in a large urban EMS system. These findings informed educational and operational initiatives to overcome the identified provider level issues and improve compliance with TOR policies.     

Paramedic Accuracy Using SALT Triage After a Brief Initial Training

Abstract

Objective. To determine paramedics’ understanding of and accuracy using SALT (sort–assess–lifesaving interventions–treatment/transport) triage, a proposed national guideline for primary triage during mass-casualty incidents, immediately and four months after training. Methods. A 20-minute lecture on SALT triage was provided to all paramedics (n = 320) from a single county during mandatory continuing education. Triage concepts were reemphasized during a 10-minute small-group lecture throughout the study period as part of standard refresher training. After the initial training, all paramedics were asked to complete a posttest consisting of three general knowledge questions about SALT triage and 10 patient scenarios in which they had to assign a triage category. The same test was administered four months after the original educational session. Demographic and job experience information was also obtained. Responses were scored and matched for each paramedic and compared using paired t-test. Results. A total of 290 (91%) paramedics completed the initial posttest. They correctly answered an average (± standard deviation) of 10.7 ± 2.3 of the 13 questions (82%). For the 10 patient scenarios, they correctly triaged an average of 8.1 ± 2.0 patients. A total of 159 paramedics completed both tests. Sixty-seven percent had more than 10 years of emergency medical services (EMS) experience; 72% had prior mass-casualty drill experience; 51% had prior actual mass-casualty experience; and 23% had heard of SALT triage prior to the training. There were no statistically significant differences in initial test scores for any of these demographic groups. For those subjects who completed both tests, the mean overall score for the initial test was 10.9 ± 1.9 (84%) and for the later test was 11.0 ± 1.9 (85%) (p < 0.770; 95% confidence interval [CI] –0.3 to 0.3). For the 10 patient scenarios, the paramedics correctly triaged an average of 8.3 ± 1.7 patients on the initial test and 8.3 ±1.4 patients on the later test (p < 0.565; 95% CI –0.4 to 0.2). Conclusion. Following a short didactic course, paramedics were able to accurately perform SALT triage during a written scenario. Four months after the training, they had retained their understanding of and accuracy using SALT triage. It appears that a brief educational tool was effective for training EMS providers in SALT triage.     

Effect of Paramedic Student Internship on Performance on the National Registry Written Exam

Background. Paramedic students are exposed to numerous patient contacts during their required internship experience. There is no current research examining paramedic student internship experience in relation to performance on the written portion of the National Registry Exam (NRE-W). Methods. A retrospective review from 2001 to 2006 of student records from FISDAP? was completed. Three hundred ninety-six students met the inclusion criteria: 1) graduate of a paramedic program, 2) consent to access data, 3) internship data previously verified, and4) NRE-W results available. Pearson correlation coefficients were used to determine if the number of advanced life support (ALS) runs (run with an IV andECG, or one medication administered), hospital patient contacts (PCs), field PCs, total PCs (hospital PCs + field PCs), student team lead runs (TLs), in-hospital clinical hours, field internship hours, or total hours (in-hospital clinical hours + field internship hours) were associated with passing the NRE-W. Logistic regression was used to determine predictors of success on the NRE-W. Results. The number of ALS runs andtotal PCs were the only variables associated with passing the NRE-W (p = 0.003, 95% CI 0.05–0.24; p = 0.047, 95% CI = 0.00–0.20, respectively). These variables were also predictors for passing the NRE-W (OR = 1.015, 95% CI 1.005–1.025; OR = 1.003, 95% CI 1.000–1.006, respectively). Conclusions. In this sample, the number of ALS runs students completed was the strongest clinical andfield internship predictor of passing the NRE-W. The number of ALS runs andtotal PCs paramedic students complete need to be evaluated by paramedic programs.     

L ACERATIONS AND A CUTE W OUNDS,AN E VIDENCE -B ASED G UIDE

Abstract

Introduction. Few systems worldwide have achieved the benchmark time of less than 90 minutes from emergency medical services (EMS) contact to balloon inflation (E2B) for patients sustaining ST-segment elevation myocardial infarction (STEMI). We describe a successful EMS systems approach using a combination of paramedic and 12-lead electrocardiogram (ECG) software interpretation to activate a STEMI bypass protocol. Objectives. To determine the proportion of patients who met the benchmark of E2B in less than 90 minutes after institution of a regional paramedic activated STEMI bypass to primary PCI protocol. Methods. We conducted a before-and-after observational cohort study over a 24-month period ending December 31, 2009. Included were all patients diagnosed with STEMI by paramedics trained in ECG acquisition and interpretation and transported by EMS. In the “before” phase of the study, paramedics gave emergency departments (EDs) advance notification of the arrival of STEMI patients and took the patients to the ED of the PCI center. In the “after” phase of the study, paramedics activated a STEMI bypass protocol in which STEMI patients were transported directly to the PCI suite, bypassing the local hospital EDs. Transmission of ECGs did not occur in either phase of the study. Results. We compared the times for 95 STEMI patients in the before phase with the times for 80 STEMI patients in the after phase. The proportion for whom E2B was less than 90 minutes increased from 28.4% before to 91.3% after (p < 0.001). Median E2B time decreased from 107 minutes (interquartile range [IQR] = 30) before to 70 minutes (IQR = 24) after. Median D2B time decreased from 83 minutes (IQR = 34) before to 35 minutes (IQR = 19) after. Median E2D time increased from 21 minutes (IQR = 8) before to 32 minutes (IQR = 17) after. Median differences between phases were significant at p < 0.001. The rate of false-positive PCI laboratory activation during the after phase of the study was 12.4%. Conclusions. The proportion of patients with E2B times less than 90 minutes significantly improved through the implementation of a paramedic-activated STEMI bypass protocol. Further study is required to determine whether these benefits are reproducible in other EMS systems.     

Physician Medical Direction andClinical Performance at an Established Emergency Medical Services System

Objective. Few developed emergency medical services (EMS) systems operate without dedicated medical direction. We describe the experience of Hamad Medical Corporation (HMC) EMS, which in 2007 first engaged an EMS medical director to develop andimplement medical direction andquality assurance programs. We report subsequent changes to system performance over time. Methods. Over one year, changes to the service's clinical infrastructure were made: Policies were revised, paramedic scopes of practice were adjusted, evidence-based clinical protocols were developed, andskills maintenance andeducation programs were implemented. Credentialing, physician chart auditing, clinical remediation, andonline medical command/hospital notification systems were introduced. Results. Following these interventions, we report associated improvements to key indicators: Chart reviews revealed significant improvements in clinical quality. A comparison of pre- andpost-intervention audited charts reveals a decrease in cases requiring remediation (11% to 5%, odds ratio [OR] 0.43 [95% confidence interval (CI) 0.20–0.85], p = 0.01). The proportion of charts rated as clinically acceptable rose from 48% to 84% (OR 6 [95% CI 3.9–9.1], p < 0.001). The proportion of misplaced endotracheal tubes fell (3.8% baseline to 0.6%, OR 0.16 [95% CI 0.004–1.06], (exact) p = 0.05), corresponding to improved adherence to an airway placement policy mandating use of airway confirmation devices andsecuring devices (0.7% compliance to 98%, OR 714 [95% CI 64–29,334], (exact) p < 0.001). Intravenous catheter insertion in unstable cases increased from 67% of cases to 92% (OR 1.31 [95% CI 1.09–1.71], p = 0.004). EMS administration of aspirin to patients with suspected ischemic chest pain improved from 2% to 77% (OR 178 [95% CI 35–1,604], p < 0.001). Conclusions. We suggest that implementation of a physician medical direction is associated with improved clinical indicators andoverall quality of care at an established EMS system     

Concordance of field and emergency department assessment in the prehospital management of patients with dyspnea

ObjectiveDyspnea is a common complaint of patients treated by emergency medical services (EMS). Few studies have examined the ability of paramedics to distinguish between etiologies of dyspnea. The authors evaluated the degree of agreement related to cardiac versus noncardiac sources of dyspnea between field and emergency department (ED) assessment of patients transported at the advanced life support level.MethodsThis was a retrospective, cohort study of consecutive patients aged ≥35 years transported by paramedics with dyspnea. The authors compared the concordance between the EMS and ED diagnoses. They also investigated whether patients whose assessments were discordant had worse outcomes.ResultsParamedics correctly assessed the cause of dyspnea in 172 of 222 (77%) patients (kappa = 0.60; 95% confidence interval [CI] = 0.51, 0.69). Among single-source (i.e., cardiac or noncardiac) dyspnea patients, prehospital providers correctly assessed 70 of 84 (83%) noncardiac causes and 98 of 114 (86%) cardiac causes (kappa = 0.69; 95% CI = 0.59, 0.79). When the ED diagnosis included both cardiac and noncardiac etiologies, paramedics treated seven of 24 (29%) patients as noncardiac, 13 of 24 (54%) as cardiac, and four of 24 (17%) as combined-source dyspnea. The authors did not observe any statistically significant differences in in-hospital mortality, intubation frequency, or hospital length of stay in patients whose prehospital dyspnea diagnosis was discordant.ConclusionThe authors conclude that in this EMS system, field assessment of dyspnea by paramedics is in agreement with that arrived at in the ED in a high proportion of patients with dyspnea from a single source. However, field assessment of dyspnea from multiple etiologies is less concordant.     

Is it Appropriate for Patients to be Discharged at the Scene by Paramedics?

Background: Outcomes of patients who are discharged at the scene by paramedics are not fully understood. Objective: We aimed to describe the risk of re-presentation and/or death in prehospital patients discharged at the scene. Methods: We conducted a retrospective cohort study using linked ambulance, emergency department (ED), and death data. We compared outcomes in patients who were discharged at the scene by paramedics with those who were transported to ED by paramedics and then discharged from ED between January 1 and December 31, 2013 in metropolitan Perth, Western Australia. Occurrences of subsequent ambulance requests, ED attendance, hospital admission and death were compared between those discharged at the scene and those discharged from ED. Results: There were 47,330 patients during the study period, of whom 19,732 and 27,598 patients were discharged at the scene and from ED, respectively. Compared to those discharged from ED, those discharged at the scene were more likely to subsequently: request an ambulance (6.1% vs. 1.8%, adjusted odds ratio [adj OR] 3.4; 95% confidence interval [CI] 3.0–3.9), attend ED (4.6% vs. 1.4%, adj OR 3.3; 95% CI 2.8–3.8), be admitted to hospital (3.3% vs. 0.8%, adj OR 4.2; 95% CI 3.4–5.1). Those discharged at the scene tended towards an increased likelihood of death (0.2% vs. 0.1%, adj OR 1.8; 95% CI 0.99–3.2) within 24 hours of discharge compared to those discharged from ED. Conclusion: Patients attended by paramedics who were discharged at the scene had more subsequent events than those who were transported to and discharged from ED. Further consideration needs to be given to who is suitable to be discharged at the scene by paramedics.     

Effect of Body-Worn Cameras on EMS Documentation Accuracy: A Pilot Study

Introduction: Current Emergency Medical Services (EMS) documentation practices usually occur from memory after an event is over. While this practice is fairly standard, it is unclear if it can introduce significant error. Modern technology has seen the increased use of recorded video by society to more objectively document notable events. Stationary mounted cameras, cell-phone cameras, and law enforcement officer Body-Worn Cameras (BWCs) are increasingly used by society for this purpose. Video used in this way can often clarify or contradict recall from memory. BWCs are currently not widely used by EMS. The hypothesis is that current EMS documentation practices are inaccurate and that BWCs will have a positive effect on documentation accuracy. Methods: This prospective, observational study used a convenience sample of paramedics in a simulation lab. The Paramedics wore a BWC and responded to a simulated call of “One Down” (unresponsive from heroin abuse) involving Role Players (RPs). The paramedics received standardized cues from the RPs during the simulation to keep it on track. The simulation contained many factors of concern (e.g., weapons and drugs in plain view, unattended minors, etc.) and intentional stressors (e.g., distraught family member, uncooperative patient, etc.). Upon completion of the scenario, paramedic documentation occurred from memory on an electronic template. After initial documentation, paramedics viewed their BWC recording and were allowed to make tabulated changes. Changes were categorized by a priori criteria as minor, moderate, or major. Results: Ten paramedics participated with an average age of 33.3 years (range 22–43), 8 males and 2 females. The average length of paramedic career experience was 7.7 years (range 2 months to 20 years). There were 71 total documentation changes (7 minor, 51 moderate, 13 major) made after video review. Linear regression (ANCOVA) indicated changes made indirectly correlated with years of experience (coefficient 8.27, 4.22–12.3, 95% CI, p = 0.002), but all made some changes. Conclusion: Current EMS documentation practices demonstrate significant inaccuracy regardless of years of experience. Use of BWC technology appears to significantly improve EMS documentation accuracy in this pilot study.     

Paramedic Performance in Calculating Drug Dosages Following Stressful Scenarios in a Human Patient Simulator

Background. Paramedics face many stressors in their work environment. Studies have shown that stress can have a negative effect on the psychological well-being of health professionals. However, there is little published research regarding the effects of stress on the cognitive skills necessary for optimal patient care. Objectives. The primary purpose of this study was to investigate the effects of acute stress on the emotional response andperformance of paramedics. Furthermore, the authors explored whether a paramedic's level of training or years of experience would mediate the effects of stress on performance. Methods. Paramedic performances in calculating drug dosages were compared in two stress conditions. In the low-stress condition, 30 paramedics calculated the drug dosages in a quiet classroom free of any stressor. In the high-stress condition, the same paramedics calculated comparable drug dosages immediately after working through a challenging scenario with a human patient simulator. Results. The paramedics obtained lower accuracy scores in the high-stress condition than in the low-stress condition [43% (95% confidence interval [CI]: 36.9–49.2) vs. 58% (95% CI: 48.6–67.1), p < 0.01 based on univariate analysis]. Neither work experience nor level of training predicted the individual differences in the stress-induced performance decrements. Conclusion. These results suggest that the types of stressors encountered in clinical situations can increase medical errors, even in highly experienced individuals. These findings underline the need for more research to determine the mechanisms by which stress influences clinical performance, with the ultimate goal of targeting education or technologic interventions to those tasks, situations, andindividuals most likely to benefit from such interventions.     

Medical Conditions Associated with Out-of-Hospital Endotracheal Intubation

Abstract

Background. While prior studies describe the clinical presentation of patients requiring paramedic out-of-hospital endotracheal intubation (ETI), limited data characterize the underlying medical conditions or comorbidities. Objective. To characterize the medical conditions and comorbidities of patients receiving successful paramedic out-of-hospital ETI. Methods. We used Pennsylvania statewide emergency medical services (EMS) clinical data, including all successful ETIs performed during 2003–2005. Using multiple imputation triple-match algorithms, we probabilistically linked EMS ETI to statewide death and hospital admission data. Each hospitalization record contained one primary and up to eight secondary diagnoses, classified according to the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). We determined the proportion of patients in each major ICD-9-CM diagnostic group and subgroup. We calculated the Charlson Comorbidity Index score for each patient. Using binomial proportions with confidence intervals (CIs), we analyzed the data and combined imputed results using Rubin's method. Results. Across the imputed sets, we linked 25,733 (77.7% linkage) successful ETIs to death or hospital records; 56.3% patients died before and 43.7% survived to hospital admission. Of the 14,478 patients who died before hospital admission, most (92.7%; 95% CI: 92.5–93.3%) had presented to EMS in cardiac arrest. Of the 11,255 hospitalized patents, the leading primary diagnoses were circulatory diseases (32.0%; 95% CI: 30.2–33.7%), respiratory diseases (22.8%; 95% CI: 21.9–23.7%), and injury or poisoning (25.2%; 95% CI: 22.7–27.8%). Prominent primary diagnosis subgroups included asphyxia and respiratory failure (15.2%), traumatic brain injury and skull fractures (11.3%), acute myocardial infarction and ischemic heart disease (10.9%), poisonings and drug and alcohol disorders (6.7%), dysrhythmias (6.7%), hemorrhagic and nonhemorrhagic stroke (5.9%), acute heart failure and cardiomyopathies (5.6%), pneumonia and aspiration (4.9%), and sepsis, septicemia, and septic shock (3.2%). Most of the admitted ETI patients had a secondary circulatory (70.8%), respiratory (61.4%), or endocrine, nutritional, or metabolic (51.4%) secondary diagnosis. The mean Charlson Index score was 1.6 (95% CI: 1.5–1.7). Conclusions. The majority of successful paramedic ETIs occur on patients with cardiac arrest and circulatory and respiratory conditions. Injuries, poisonings, and other conditions compromise smaller but important portions of the paramedic ETI pool. Patients undergoing ETI have multiple comorbidities. These findings may guide the systemic planning of paramedic airway management care and education.     

Paramedic Perceptions of Challenges in Out-of-Hospital Endotracheal Intubation

Objective. Paramedics often perform endotracheal intubation (ETI), insertion of a breathing tube, on critically ill out-of-hospital patients. Recent studies highlight important paramedic ETI shortcomings including adverse events, errors, andpoor outcomes resulting from this procedure. Little is known about workforce perceptions of these events. We sought to identify paramedic andphysician perceptions regarding the challenges andpitfalls of out-of-hospital ETI. Methods. We conducted a qualitative study involving paramedic focus groups sessions andindividual interviews with Emergency Medical Services (EMS) physician medical directors. We recorded andtranscribed all sessions. We used inductive theory construction to examine, organize, andclassify thematic patterns. Results. Fourteen paramedics and6 physicians participated. Although paramedics andphysicians recognized problems with paramedic ETI, all participants strongly felt that paramedics should continue to perform the procedure. Physicians andparamedics disagreed about the ability of paramedics to perform neuromuscular blockade-assisted intubation. Both groups identified aspects of paramedic education, skills acquisition, andmaintenance as core issues. Participants also identified broader factors about the structure of emergency services, the role of the medical director, andworkforce culture andprofessionalism. Conclusion. Paramedics andEMS physicians attribute paramedic ETI performance to a myriad of factors involving EMS education, organization, oversight, retention, andprofessionalism. Efforts to improve ETI must include strategies to address multiple aspects of EMS operations andculture.