The Resuscitation Outcomes Consortium Epistry-Trauma: design, development, and implementation of a North American epidemiologic prehospital trauma registry

Injury is a major public health problem generating substantial morbidity, mortality, and economic burden on society. The majority of seriously injured persons are initially evaluated and cared for by prehospital providers, however the effect of emergency medical services (EMS) systems, EMS clinical care, and EMS interventions on trauma patient outcomes is largely unknown. Outcome-based information to guide future EMS care has been hampered by the lack of comprehensive, standardized, multi-center prehospital data resources that include meaningful patient outcomes. In this paper, we describe the background, design, development, implementation, content, and potential uses of the first North American comprehensive epidemiologic prehospital data registry for injured persons. This data registry samples patients from 264 EMS agencies transporting to 287 acute care hospitals in both the United States and Canada.     

Pain management in the prehospital environment

Pain measurement and relief is complex and should be a priority for prehospital providers and supervisors. The literature continues to prove that we are poor pain relievers, despite the high prevalence of pain in the out-of-hospital patient population. Lack of education and research, along with agent availability, controlled substance regulation, and many myths given credence by health care providers, hinder our ability to achieve adequate pain assessment and treatment in the prehospital setting. Protocols must be established to help guide providers through proper acknowledgment, measurement, and treatment for prehospital pain. Nonpharmacologic therapies must also be taught and reinforced as important adjuncts to pain management. Finally, formation of quality improvement pain programs that evaluate patient outcomes and provider practice patterns will help EMS systems understand the pain management process and outline areas for improvement. Only through emphasis on pain education, research, protocol and program monitoring development will the quality of pain assessment and management in the prehospital setting improve.     

Deadly defects. Managing the pediatric patient with a congenital heart defect

CHD-specific emergencies may be managed quite effectively in the prehospital environment. The key to successful prehospital management of CHDs is identifying the cardiac anomaly, obtaining an effective history and physical assessment, and providing supportive care. When obtaining a history, it is important to remember that parents know their children and their children's diseases very well. An EMS provider who ignores information from a parent is doomed to failure. Realizing that most EMS providers are not well-versed in the various CHDs and are not likely to have a great deal of experience in working with CHD patients, conferring with medical control prior to initiation of any treatments is strongly encouraged. Finally, remember that patients with CHDs are sick and have traditionally been sick for quite a while. Because of the chronic illness, it is easy to focus on the congenital defect when called to the scene for an ill child and neglect the potential for a noncardiac-related pathology. Although the most commonly seen congenital heart defects have been reviewed here, there are others that have not been addressed. Garnering an understanding of each individual defect is not nearly as important as understanding the difference between cyanotic and acyanotic defects. Prehospital care for the CHD patient is primarily supportive, but, in certain cases, may require substantial intervention. EMS providers should not be concerned with diagnosing specific defects, but should be aware of the global effects that various defects have on normal perfusion. EMS providers' comprehension of the pathophysiology of CHDs and prompt actions will play a vital role in the outcome of the acutely ill CHD patient.     

Recognition of Stroke by EMS is Associated with Improvement in Emergency Department Quality Measures

Objective: Hospital arrival via Emergency Medical Services (EMS) and EMS prenotification are associated with faster evaluation and treatment of stroke. We sought to determine the impact of diagnostic accuracy by prehospital providers on emergency department quality measures. Methods: A retrospective study was performed of patients presenting via EMS between September 2009 and December 2012 with a discharge diagnosis of transient ischemic attack (TIA), ischemic stroke (IS), or intracerebral hemorrhage (ICH). Hospital and EMS databases were used to determine EMS impression, prehospital and in-hospital time intervals, EMS prenotification, NIH stroke scale (NIHSS), symptom duration, and thrombolysis rate. Results: 399 cases were identified: 14.5% TIA, 67.2% IS, and 18.3% ICH. EMS providers correctly recognized 57.6% of cases. Compared to cases missed by EMS, correctly recognized cases had longer median on-scene time (17 vs. 15 min, p = 0.01) but shorter transport times (12 vs. 15 min, p = 0.001). Cases correctly recognized by EMS were associated with shorter door-to-physician time (4 vs. 11 min, p < 0.001) and shorter door-to-CT time (23 vs. 48 min, p < 0.001). These findings were independent of age, NIHSS, symptom duration, and EMS prenotification. Patients with ischemic stroke correctly recognized by EMS were more likely to receive thrombolytic therapy, independent of age, NIHSS, symptom duration both with and without prenotification. Conclusion: Recognition of stroke by EMS providers was independently associated with faster door-to-physician time, faster door-to-CT time, and greater odds of receiving thrombolysis. Quality initiatives to improve EMS recognition of stroke have the potential to improve hospital-based quality of stroke care.     

Documentation: why is it so important?

Persons who activate an EMS system expect a timely response from people who will be able to help them. When they don't get the service they are expecting, they may look for legal recourse. Hospital staff and healthcare providers expect prehospital care providers to follow protocols and standing orders in providing interventions to help stabilize conditions found during patient assessments. The results of these interventions must be conveyed via both oral and written documentation. Documentation of patient care, equipment maintenance, inventory control and training can help protect the assets of an EMS organization. It can help prove (in a court of law, if necessary) that the organization acted in a prudent manner. Documentation becomes the history of the organization. Does your history show that you are a professional organization?     

Mass casualty incident. Integration with prehospital care

Mass casualty incident involves the use of limited resources for multiple casualties. The emergency physician must be familiar with both prehospital and hospital plans for mass casualty care in order to facilitate optimal care and to maintain the continuum from field care to definitive treatment. It is essential that the emergency physician become involved in the disaster planning processes to ensure that the victims receive the best care available under the circumstances and that the safety and emotional well-being of both prehospital and hospital personnel are assured. Emergency physicians involved in prehospital care should be certain that the local EMS system has adequate training and chances to update their skills and knowledge. Disaster drills of the EMS system are excellent ways to practice, to identify weaknesses, and for preplanning to enhance disaster medical care.     

T ACTICAL E MERGENCY C ARE,M ILITARY AND O PERATIONAL O UT-OF -H OSPITAL M EDICINE

To improve the outcomes of stroke patients, public awareness of stroke must be increased and emergency medical services (EMS) response to stroke calls optimized. Rapid response to stroke is key, as emphasized in the American Stroke Association's “Stroke Chain of Survival,” which consists of four components—rapid recognition of and reaction to stroke warning signs through immediate use of the 9-1-1 system; rapid EMS assessment; priority transport with prenotification of the receiving hospital; and rapid and accurate diagnosis and treatment at the hospital. Neither the risk factors for stroke nor the most common warning signs are adequately known to the public in general, and in particular, to the groups at highest risk for stroke. Effective education through mass media and health care professionals is paramount in increasing the public's awareness of stroke. Whether tools to aid dispatchers and paramedics in stroke diagnosis, assessment, and management can improve stroke patients' outcomes requires further study, as does the value of designated stroke centers. Overall, according stroke the same urgency as acute myocardial infarction, from both the public and the prehospital provider perspectives, might improve stroke patient outcomes.     

Ethical challenges in emergency medical services. A special contribution of the Ethics Committee, National Association of Emergency Medical Services Physicians

Patient autonomy, beneficence, and justice are the fundamental ethical principles of an emergency medical service. Ethical conflicts are present in the daily practice of prehospital care. These conflicts surround issues of resuscitation, futile therapy, consent, and refusal of care, duty, and confidentiality. Emergency medical services must remain fair and equitable, equally available to those it is designed to serve, regardless of the patient's social or economic status. Establishing priorities for patient care is dictated by medical and operational concerns. Education and information regarding ethical issues are important for the providers of prehospital medical care as well as the medical director. Policies and protocols must continue to be developed to address requests to limit resuscitation, such as refusal of care and patient confidentiality. Policies should be developed in conjunction with experienced legal advice. Current training does not equip even the most advanced prehospital care provider to deal easily with every potential situation. Many learn by experience, some are guided by clear policy. Ideally, medical control personnel will be educated, interested, and available to address dilemmas which arise. Where possible, policies and procedures should be developed to address ethical issues which are likely to be faced by EMS personnel.     

Patient ventilation and oxygenation. A new day is dawning

Maintaining an airway and providing adequate ventilation and oxygenation to the patient can be challenging in the prehospital environment. Ventilation and oxygenation are a complex series of interactions between the patient, EMS providers and emergency airway equipment. Routine ventilation techniques carry significant risk of long-term complications. New ventilatory equipment is available to perform this function and provide verification of its effectiveness. This opportunity for improved patient care is available to all EMS providers and sets new standards for delivery of ventilation and oxygenation. The technical methods available to EMS personnel vary considerably and are reviewed in this article.     

Ensuring the chain of recovery for stroke in your community

Until recently, the prehospital and emergency department management of nonhemorrhagic stroke was largely supportive care. Studies now have demonstrated the potential of certain therapeutic interventions to reverse the debilitating consequences of such strokes. But despite the potential benefit, there exists a clear time dependency for such interventions, not only to ensure therapeutic efficacy, but also to diminish the likelihood of significant therapeutic complications. In turn, to optimize the chances of a better outcome for the patient with stroke, each community must establish and continue to refine a chain of recovery for stroke patients. The chain of recovery is a metaphor that describes a series of sequential actions that must take place in a timely fashion to optimize the chances of recovery from stroke. Each of these sequential actions forms an individual link in the chain, and each link must be intact. The links include: identification of the onset of stroke symptoms by the patient or bystanders; dispatch life support services, which preferably include enhanced 9-1-1 and medically supervised and trained dispatchers who can rapidly deploy the closest responders and transport units; emergency medical services (EMS) personnel who can rapidly assess and transport the stroke patient to the closest appropriate center capable of providing advanced stroke diagnostics and interventions; en route notification of the receiving facility so that appropriate personnel can be readied for rapid diagnosis and intervention; and receiving facilities capable of providing rapid diagnosis and advanced treatment of stroke, including the availability of specialists who can evaluate underlying etiologies as well as plan future therapies and rehabilitation. To ensure that the chain of recovery is in place, aggressive public education campaigns should be implemented to increase the probability that stroke symptoms and signs will be recognized as soon as possible by patients and bystanders. In addition, because most of the current training programs for EMS dispatchers and prehospital care personnel are lacking with regard to stroke, it is recommended that such personnel and their EMS system managers be updated on current management and treatment strategies for stroke.     

Occupational considerations for the prehospital care provider

Contemporary prehospital personnel are facing the major issues of infectious disease exposure, malpractice, attrition, and career opportunities in their challenging and demanding profession. Successful prehospital emergency medicine is contingent not only on the effective and efficient functioning of the entire EMS system, but most important, on the sound performance of each prehospital care provider. For the emergency physician, awareness, understanding, and appreciation of the important occupational considerations confronting prehospital care providers are essential.     

Physician at the scene of an emergency

Growth and maturation in the delivery of prehospital emergency medical care has been dramatic in the past 15 years. The increased availability and use of emergency medical services (EMS) has led to more frequent interactions between providers of prehospital care and the medical practitioner. This paper reviews the training and capabilities of emergency medical personnel and introduces the issue of medical control at the scene of an emergency. Also presented are the basics of emergency scene and victim stabilization. Physicians can help improve prehospital care by becoming familiar with local EMS capabilities and personnel.     

Vital signs records omissions on prehospital patient encounter forms

INTRODUCTION: A reported in-field, prospective evaluation of 227 prehospital patient assessments by advanced life support (ALS) emergency medical technicians (EMTs) found a frequent failure to measure vital signs. The objective of this retrospective review was to report the omission frequency of vital signs found in a centralized emergency medical services (EMS) data collection system. METHODS: The EMS database contained information from 90,480 optically scanned, prehospital patient encounter forms. Each record identified EMT skill levels, response times, dispatch type, vital signs, medical and trauma information, treatment, and patient disposition. Records for 1989 and 1990 were collected from 92 rural EMS providers who responded to emergency medical and trauma events. RESULTS: Of 90,480 emergency responses, 14,129 (15.6%) were false alarms, deceased, or canceled without vital patient contact. Valid encounters were documented for 76,351 (84.4%) patient contacts. Systolic blood pressure measurements were not recorded for 13,262 (17.4%) patients. Diastolic blood pressure was not recorded for 14,272 (18.7%) patients. A pulse record was not recorded for 12,125 (15.9%) patients. A ventilatory rate was absent in 12,958 (17.0%) patient records. CONCLUSION: This study found a frequent failure by non-metropolitan basic life support (BLS) and advanced life support (ALS) EMTs to record vital signs on prehospital emergency patient encounter forms. It supports a previous report of direct in-field observations of ALS EMTs failing to measure vital signs during patient assessment. The impact of vital sign omissions upon individual patient care can be assessed only by receiving medical control physicians. In the absence of effective emergency physician networking, the statewide magnitude of the problem among BLS and ALS EMTs has not been recognized as a system issue.     

Financial considerations in emergency medical services systems

EMS providers have raised the public's perception and acceptance of paramedic-level care. Both rural and urban EMS policy makers will continue to feel the financial pressure to maintain and upgrade EMS services. The issue of who pays for health care has captured the interest of all and will continue to be scrutinized like no other part of providing quality prehospital medicine.     

E MERGENCY M EDICAL S ERVICES C APACITIES IN THE D EVELOPING W ORLD : P RELIMINARY E VALUATION AND T RAINING IN A DDIS A BABA,E THIOPIA

In December 1999, a group of emergency physicians from the United States, Israel, and Ethiopia met for the Second Annual Symposium on Emergency Medicine and to perform an initial evaluation of the prehospital care system in Addis Ababa. The symposium was structured into a workshop on prehospital care and a clinical seminar for emergency medicine providers. This article describes the current prehospital infrastructure in Addis Ababa, Ethiopia. This serves as the basis for more specific needs assessments and training interventions, which are ongoing. The authors present a list of priorities for the development of an emergency medical services (EMS) system for Addis Ababa that was generated in partnership with local government and the World Health Organization. The article contrasts these initial recommendations with those found in the literature on the development of EMS systems in developing nations.     

EMS Providers and Exception from Informed Consent Research: Benefits, Ethics, and Community Consultation

Abstract Background. As attention to, and motivation for, emergency medical services (EMS)-related research continues to grow, particularly exception from informed consent (EFIC) research, it is important to understand the thoughts, beliefs, and experiences of EMS providers who are actively engaged in the research. Objective. We explored the attitudes, beliefs, and experiences of EMS providers regarding their involvement in prehospital emergency research, particularly EFIC research. Methods. Using a qualitative design, 24 participants were interviewed including nationally registered paramedics and Virginia-certified emergency medical technicians employed at Richmond Ambulance Authority, the participating EMS agency. At the time of our interviews, the EMS agency was involved in an EFIC trial. Transcribed interview data were coded and analyzed for themes. Findings were presented back to the EMS agency for validation. Results. Overall, there appeared to be support for prehospital emergency research. Participants viewed research as necessary for the advancement of the field of EMS. Improvement in patient care was identified as one of the most important benefits. A number of ethical considerations were identified: individual risk versus public good and consent. The EMS providers in our study were open to working with EMS researchers throughout the community consultation and public disclosure process. Conclusion. The EMS providers in our study valued research and were willing to participate in studies. Support for research was balanced with concerns and challenges regarding the role of providers in the research process.