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.     

P REHOSPITAL R APID-SEQUENCE I NTUBATION

Prehospital pain management has become an important emergency medical services (EMS) patient care issue. Objectives. To describe the frequency of EMS andemergency department (ED) analgesic administration to injured children; to describe factors associated with the administration of analgesia by EMS; andto assess whether children with lower-extremity fractures receive analgesia as frequently as do adults with similar injuries. Methods. This was a retrospective study of children (age < 21 years) who were transported by EMS between January 2000 andJune 2002 andhad a final hospital diagnosis of extremity fractures or burns. Secondarily, children with lower-extremity fractures were compared with a cohort of EMS-transported adults with similar injuries andtransported during the same study period. Receipt of andtime of parenteral analgesia were recorded. Results. Seventy-three children met the inclusion criteria. The mean (range) age of this sample was 12.4 (0.9–21) years, with only four patients aged < 5 years. A majority of the patients were male (49/73, 67.1%) andsustained femur (20/73, 27.4%) or tibia/fibula (26/73, 35.6%) fractures. Few pediatric patients received prehospital analgesia (16/73, 21.9%), while a majority received analgesia in the ED (58/73, 79.4%). Prehospital analgesia was associated with earlier patient treatment than that administered in the ED (22.3 ± 5.9 min vs. 88.3 ± 38.2 min). Comparing children (n = 33) with adults (n = 76) with similar lower-extremity fractures, a small insignificant difference was found in the rate of prehospital analgesia between children andadults (7/33, 21.2%, vs. 20/56, 26.3%). Conclusion. Few pediatric patients receive prehospital analgesia, although most ultimately received ED analgesia. Few factors were identified that could be associated with EMS oligoanalgesia. No difference was found between children andadults in the rates of EMS analgesia.     

Prehospital care and outcome of pediatric out-of-hospital cardiac arrest

Cardiac arrest in children outside the hospital is associated with high mortality rates. Recent investigations have suggested that the use of advanced life support (ALS) measures by emergency medical services (EMS) personnel may decrease survival. These studies have used the pediatric Utstein style of defining ALS and basic life support (BLS) measures. The pediatric Utstein style defines BLS as “an attempt to restore effective ventilation and circulation” using noninvasive means to open the airway but specifically excludes the use of bag-valve-mask devices. Advanced life support is defined as the “addition of invasive maneuvers to restore effective ventilation and circulation.” The authors of the study described below believe that using this definition would categorize some patients into an ALS group who would otherwise be categorized as having received BLS (i.E., “bag-valve-mask only”). Objective: To compare survival rates among children receiving BLS or ALS following out-of-hospital cardiac arrest using amended definitions of prehospital life support measures. Specifically, the definition of BLS was expanded to include the use of bag-valve-mask devices only. Methods: This was a retrospective chart review in an urban, pediatric emergency department. Patients included all children presenting to the emergency department between January 1, 1986, and December 31, 1999, following out-of-hospital cardiac arrest. The main outcome measure was survival to hospital discharge. Results: Two hundred ten children were identified. Twenty-one patients were excluded from further analysis because of absent or incomplete medical records. One hundred eighty-nine patients were studied. Five children (2.6%) survived to discharge from the hospital. Of 189 children, 39 (20.6%) were provided BLS measures by prehospital personnel; 150 (79.4%) received ALS. There was no significant difference between groups in survival to hospital discharge. Patients who survived to hospital discharge were more likely to be in sinus rhythm upon arrival in the emergency department (p < 0.001) and to have received fewer doses of standard-dose epinephrine in the emergency department (p < 0.001). Conclusion: The use of ALS by prehospital personnel for children with out-of-hospital cardiac arrest did not improve survival to discharge from the hospital when compared with the use of BLS. PREHOSPITAL EMERGENCY CARE 2002;6:283-290     

Utilization of Intravenous Catheters by Prehospital Providers during Pediatric Transports

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

Accuracy of Paramedic Broselow Tape Use in the Prehospital Setting

Introduction. Previous literature has documented that prehospital 12-lead electrocardiography (ECG) decreases the time to reperfusion in patients with an acute ST-segment elevation myocardial infarction (STEMI). Objective. To compare time to ECG, time to angioplasty suite (laboratory), andtime to reperfusion in emergency medical services (EMS) STEMI patients, who received care through three different processes. Methods. The setting was a large suburban community teaching hospital with emergency department (ED)-initiated single-page acute myocardial infarction (AMI) team activation for STEMI patients. The population was STEMI patients transported by EMS from January 2003 to October 2005. Not all EMS agencies had prehospital 12-lead ECG capability. Paramedics interpret andverbally report clinical assessment andECG findings via radio. The AMI team is activated at the discretion of the emergency physician 1) before patient arrival to the ED based on EMS assessment, 2) after ED evaluation with EMS ECG, or 3) after ED evaluation andED ECG. Time intervals were calculated from ED arrival. To assess the impact of interventions on performance targets, we also report the proportion of patients who arrived in laboratory within 60 minutes andreperfusion within 90 minutes of arrival. Parametric andnonparametric statistics are used for analysis. Results. During the study period, there were 164 STEMI patients transported by EMS; mean age was 66.1 years, and56% were male. Of these, 93 (56.7%) had an EMS ECG and31 (33%) had AMI team activation before ED arrival. Mean time to laboratory for all patients was 49.8 ± 34.4 minutes andtime to reperfusion was 93.2 +/? 34.5 min. Patients with prearrival activation were transported to laboratory sooner (mean, 24.3 vs. 53. 4 minutes; p < 0.001) andreceived reperfusion sooner than all other patients (mean, 70.4 vs. 96.3 minutes; p = 0.007). More prearrival activation patients met performance targets to laboratory (96.7% vs. 73.7%; p = 0.009) andreperfusion (85.2% vs. 51.0%; p = 0.003). There was no difference in time to laboratory or to reperfusion for patients who received EMS ECG but no prearrival activation compared with those who received EMS transport alone. Conclusions. A minority of patients with EMS ECGs had prearrival AMI team activation. EMS ECGs combined with systems that activate hospital resources, but not EMS ECGs alone, decrease time to laboratory andreperfusion.     

Prehospital use of analgesia for suspected extremity fractures

Introduction. Pain and its control have been studied extensively in the emergency department. Numerous studies indicate that inadequate treatment of pain is common, despite the availability of myriad analgesics. It has been suggested that oligoanesthesia is also a common practice in the prehospital setting. Objective. To assess the use of prehospital analgesia in patients with suspected extremity fracture. Methods. Emergency medical services (EMS) call reports were reviewed for all patients with suspected extremity fractures treated from June 1997 to July 1998 in a midwestern community with a population base of 223,000. Data collected included demographic information, mechanism of injury, medications given, and field treatment. Standing orders for administration of analgesia were available and permitted paramedics to give either morphine sulfate or nitrous oxide per protocol. Results. The EMS call reports were analyzed for 1,073 patients with suspected extremity fractures. The mean patient age was 47 years. Accidental injuries comprised 86.5% of those reviewed. Suspected leg fractures were most common (20%), followed by hips (18%), arms (11%), knees (10%), ankles (9%), shoulders (7.2%), hands (5.5%), and wrists (5.3%). Multiple trauma and assorted broken digits accounted for the remaining 14%. The most common mechanisms of injury were: fall (43%), motor vehicle collision (21%), and human assault (10%). Intravenous lines were placed in 9.4% of patients; 17% received ice packs; 16% received bandage/dressings; 25% received air splints; and 19% were fully immobilized. Analgesia was administered to 18 patients (1.8%): 16 patients received nitrous oxide and two received morphine. Conclusion. Administration of analgesics to prehospital patients with suspected fractures was rare. Prehospital identification and treatment of pain for patients with musculoskeletal trauma could be improved. PREHOSPITAL EMERGENCY CARE 2000;4:205-208     

Comparison of children receiving emergent sepsis care by mode of arrival

ObjectiveTo determine if differences in patient characteristics, treatments, and outcomes exist between children with sepsis who arrive by emergency medical services (EMS) versus their own mode of transport (self-transport).MethodsRetrospective cohort study of patients who presented to the Emergency Department (ED) of two large children's hospitals and treated for sepsis from November 2013 to June 2017. Presentation, ED treatment, and outcomes, primarily time to first bolus and first parental antibiotic, were compared between those transported via EMS versus patients who were self-transported.ResultsOf the 1813 children treated in the ED for sepsis, 1452 were self-transported and 361 were transported via EMS. The EMS group were more frequently male, of black race, and publicly insured than the self-transport group. The EMS group was more likely to have a critical triage category, receive initial care in the resuscitation suite (51.9 vs. 22%), have hypotension at ED presentation (14.4 vs. 5.4%), lactate >2.0 mmol/L (60.6 vs. 40.8%), vasoactive agents initiated in the ED (8.9 vs. 4.9%), and to be intubated in the ED (14.4 vs. 2.8%). The median time to first IV fluid bolus was faster in the EMS group (36 vs. 57 min). Using Cox LASSO to adjust for potential covariates, time to fluids remained faster for the EMS group (HR 1.26, 95% CI 1.12, 1.42). Time to antibiotics, ICU LOS, 3- or 30-day mortality rates did not differ, yet median hospital LOS was significantly longer in those transported by EMS versus self-transported (6.5 vs. 5.3 days).ConclusionsChildren with sepsis transported by EMS are a sicker population of children than those self-transported on arrival and had longer hospital stays. EMS transport was associated with earlier in-hospital fluid resuscitation but no difference in time to first antibiotic. Improved prehospital recognition and care is needed to promote adherence to both prehospital and hospital-based sepsis resuscitation benchmarks.     

Potential time savings by prehospital administration of activated charcoal

Objective. Activated charcoal (AC) has been proven useful in many toxic ingestions. Theoretically, administration of AC in the prehospital environment could save valuable time in the treatment of patients who have sustained potentially toxic oral ingestions. The purpose of this study was to determine the frequency of prehospital AC administration and to identify time savings that could potentially result from field AC administration.

Methods. Adult patients with a chief complaint of toxic ingestion who had complete emergency medical services (EMS) and emergency department (ED) records and no medical treatment (gastric emptying, AC administration) prior to EMS arrival were eligible for inclusion. Data obtained from EMS and ED records included time of EMS departure from the scene, time of EMS arrival at the ED, and time of administration of AC in the ED. Since most EMS agencies in this system do not insert gastric tubes, patients requiring gastric tube placement for administration of AC were excluded.

Results. Twenty-nine of 117 (24.8%) adult patients received oral AC with no other intervention. None of the 117 patients received AC in the prehospital setting. The EMS transport time for these patients ranged from 5 to 43 minutes (mean 16.2 ± 9.7 minutes). The delay from ED arrival to AC administration ranged from 5 to 94 minutes (mean 48.8 ± 24.1 minutes), and was more than 60 minutes for 14 (48.2%) of the patients. The total time interval from scene departure to ED AC administration ranged from 17 to 111 minutes (mean 65.0 ± 25.9 minutes). Conclusions. In a selected subset of patients who tolerate oral AC, prehospital administration of AC could result in earlier and potentially more efficacious AC therapy. Prospective study of the benefits and feasibility of prehospital AC administration is indicated.     

An Analysis of EMS and ED Detection of Stroke

Background and Purpose: Studies have shown a reduction in time-to-CT and improved process measures when EMS personnel notify the ED of a “stroke alert” from the field. However, there are few data on the accuracy of these EMS stroke alerts. The goal of this study was to examine diagnostic test performance of EMS and ED stroke alerts and related process measures. Methods: The EMS and ED records of all stroke alerts in a large tertiary ED from August 2013–January 2014 were examined and data abstracted by one trained investigator, with data accuracy confirmed by a second investigator for 15% of cases. Stroke alerts called by EMS prior to ED arrival were compared to stroke alerts called by ED physicians and nurses (for walk-in patients, and patients transported by EMS without EMS stroke alerts). Means ± SD, medians, unpaired t-tests (for continuous data), and two-tailed Fisher's exact tests (for categorical data) were used. Results: Of 260 consecutive stroke alerts, 129 were EMS stroke alerts, and 131 were ED stroke alerts (70 called by physicians, 61 by nurses). The mean NIH Stroke Scale was higher in the EMS group (8.1 ± 7.6 vs. 3.0 ± 5.0, p < 0.0001). The positive predictive value of EMS stroke alerts was 0.60 (78/129), alerts by ED nurses was 0.25 (15/61), and alerts by ED physicians was 0.31 (22/70). The PPV for EMS was better than for nurses or physicians (both p < 0.001), and more patients in the EMS group had final diagnoses of stroke (62/129 vs. 24/131, p < 0.001). The positive likelihood ratio was 1.53 for EMS personnel, 0.45 for physicians, and 0.77 for nurses. The mean time to order the CT (8.5 ± 7.1 min vs. 23.1 ± 18.2 min, p < 0.0001) and the mean ED length of stay (248 ± 116 min vs. 283 ± 128 min, p = 0.022) were shorter for the EMS stroke alert group. More EMS stroke alert patients received tPA (16/129 vs. 6/131, p = 0.027). Conclusions: EMS stroke alerts have better diagnostic test performance than stroke alerts by ED staff, likely due to higher NIH Stroke Scale scores (more obvious presentations) and are associated with better process measures. The fairly low PPV suggests room for improvement in prehospital stroke protocols.     

The National Trend in Quality of Emergency Department Pain Management for Long Bone Fractures

Background
Despite national attention, there is little evidence that the quality of emergency department (ED) pain management is improving.
Objectives
To compare the quality of ED pain management before and after implementation of the Joint Commission on the Accreditation of Healthcare Organizations' standards in 2001.
Methods
The authors performed a retrospective cohort study by using the National Hospital Ambulatory Medical Care Survey from 1998–2003. Patients who presented to the ED with a long bone fracture (femur, humerus, tibia, fibula, radius, or ulna) were compared. The authors extracted data on patient, visit, and hospital characteristics. The primary outcomes were the proportion of patients who received assessment of pain severity and who received analgesic treatment.
Results
There were 2,064 patients with a qualifying fracture in the study period, 834 from 1998–2000 and 1,230 from 2001–2003. Compared with the early period, a higher proportion of patients in the late period had their pain assessed (74% vs. 57%), received opiates (56% vs. 50%), and received any analgesic (76% vs. 56%). Patients in the late period had higher odds of receiving any analgesia (adjusted odds ratio [OR], 1.43) and opioid analgesia (adjusted OR, 1.27) compared with the early period. Patients in the middle age group (adjusted OR, 2.28) or those seen by physician assistants (adjusted OR, 2.05) were more likely, whereas those with Medicaid (adjusted OR, 0.58) and those in the Northeast were less likely, to receive opiates.
Conclusions
Although the quality of ED pain management for acute fractures appears to be improving, there is still room for further improvement.     

Racial disparity in analgesic treatment for ED patients with abdominal or back pain

Objective

Research on how race affects access to analgesia in the emergency department (ED) has yielded conflicting results. We assessed whether patient race affects analgesia administration for patients presenting with back or abdominal pain.

Methods

This is a retrospective cohort study of adults who presented to 2 urban EDs with back or abdominal pain for a 4-year period. To assess differences in analgesia administration and time to analgesia between races, Fisher exact and Wilcoxon rank sum test were used, respectively. Relative risk regression was used to adjust for potential confounders.

Results

Of 20?125 patients included (mean age, 42 years; 64% female; 75% black; mean pain score, 7.5), 6218 (31%) had back pain and 13?907 (69%) abdominal pain. Overall, 12?109 patients (60%) received any analgesia and 8475 (42%) received opiates. Comparing nonwhite (77 %) to white patients (23%), nonwhites were more likely to report severe pain (pain score, 9-10) (42% vs 36%; P < .0001) yet less likely to receive any analgesia (59% vs 66%; P < .0001) and less likely to receive an opiate (39% vs 51%; P < .0001). After controlling for age, sex, presenting complaint, triage class, admission, and severe pain, white patients were still 10% more likely to receive opiates (relative risk, 1.10; 95% confidence interval, 1.06-1.13). Of patients who received analgesia, nonwhites waited longer for opiate analgesia (median time, 98 vs 90 minutes; P = .004).

Conclusions

After controlling for potential confounders, nonwhite patients who presented to the ED for abdominal or back pain were less likely than whites to receive analgesia and waited longer for their opiate medication.     

R EVIEW AND S ELF -A SSESSMENT TO A CCOMPANY EMERGENCY MEDICINE

Cardiac arrest in children outside the hospital is associated with high mortality rates. Recent investigations have suggested that the use of advanced life support (ALS) measures by emergency medical services (EMS) personnel may decrease survival. These studies have used the pediatric Utstein style of defining ALS and basic life support (BLS) measures. The pediatric Utstein style defines BLS as “an attempt to restore effective ventilation and circulation” using noninvasive means to open the airway but specifically excludes the use of bag-valve-mask devices. Advanced life support is defined as the “addition of invasive maneuvers to restore effective ventilation and circulation.” The authors of the study described below believe that using this definition would categorize some patients into an ALS group who would otherwise be categorized as having received BLS (i.E., “bag-valve-mask only”). Objective: To compare survival rates among children receiving BLS or ALS following out-of-hospital cardiac arrest using amended definitions of prehospital life support measures. Specifically, the definition of BLS was expanded to include the use of bag-valve-mask devices only. Methods: This was a retrospective chart review in an urban, pediatric emergency department. Patients included all children presenting to the emergency department between January 1, 1986, and December 31, 1999, following out-of-hospital cardiac arrest. The main outcome measure was survival to hospital discharge. Results: Two hundred ten children were identified. Twenty-one patients were excluded from further analysis because of absent or incomplete medical records. One hundred eighty-nine patients were studied. Five children (2.6%) survived to discharge from the hospital. Of 189 children, 39 (20.6%) were provided BLS measures by prehospital personnel; 150 (79.4%) received ALS. There was no significant difference between groups in survival to hospital discharge. Patients who survived to hospital discharge were more likely to be in sinus rhythm upon arrival in the emergency department (p < 0.001) and to have received fewer doses of standard-dose epinephrine in the emergency department (p < 0.001). Conclusion: The use of ALS by prehospital personnel for children with out-of-hospital cardiac arrest did not improve survival to discharge from the hospital when compared with the use of BLS.     

Witnessed arrest, but not delayed bystander cardiopulmonary resuscitation improves prehospital cardiac arrest survival

Methods: This prospective, randomised, double blinded clinical intervention trial enrolled 874 prehospital cardiopulmonary arrest patients encountered in a prehospital urban, suburban, and rural regional emergency medical service (EMS) area. This group underwent conventional advanced cardiac life support intervention followed by empiric early administration of sodium bicarbonate (1 mEq/l), monitoring conventional resuscitation parameters. Survival was measured as presence of vital signs on emergency department (ED) arrival. Data were analysed using χ² with Pearson correlation and odds ratio where appropriate.

Results: The overall survival rate was 13.9% (110 of 792) of prehospital cardiac arrest patients. The mean (SD) time until provision of bystander cardiopulmonary resuscitation (ByCPR) by laymen was 2.08 (2.77) minutes, and basic life support (BLS) by emergency medical technicians was 6.62 (5.73) minutes. There was improved survival noted with witnessed cardiac arrest—a 2.2-fold increase in survival, 18.9% (76 of 402) versus 8.6% (27 of 315) compared with unwitnessed arrests (p<0.001) with a decreased risk ratio of mortality of 0.4534 (95% CI, 0.0857 to 0.1891). The presence of ByCPR occurred in 32% (228 of 716) of patients, but interestingly did not correlate with survival. The survival rate was 18.2% (33 of 181) if ByCPR was performed within two minutes and 12.8% (6 of 47), if performed >two minutes (p = 0.3752).

Conclusions: Survival after prehospital cardiac arrest is more likely when witnessed, but not necessarily when ByCPR was performed by laymen.

     

Characterization of Children with Septic Shock Cared for by Emergency Medical Services

Objective: To inform the future development of a pediatric prehospital sepsis tool, we sought to 1) describe the characteristics, emergent care, and outcomes for children with septic shock who are transported by emergency medicine services (EMS) and compare them to those self-transported; and 2) determine the EMS capture rate of common sepsis screening parameters and the concordance between the parameters documented in the EMS record and in the emergency department (ED) record. Methods: This is a retrospective cohort study of children ages 0 through 21 years who presented to a pediatric ED with septic shock between 11/2013 and 06/2016. Data, collected by electronic and manual chart review of EMS and ED records, included demographics, initial vital signs in both EMS and ED records, ED triage level, site of initial ED care, ED disposition, ED therapeutic interventions, outcomes, and times associated with processes. Potential screening parameters were dichotomized as normal vs. abnormal based on age-dependent normative data. Results: Of the children with septic shock treated in our ED, 19.3% arrived via EMS. These children as compared to those self-transported were more likely (i.e., p?<?0.05) to be male, have public insurance, receive initial care in the ED resuscitation suite, be hypotensive on arrival, receive their first ED fluid bolus sooner (33 vs. 58?minutes), receive vasoactive agents, be mechanically ventilated in the first 24?hours, and have slightly longer length of hospital stays. Both groups had similar times to antibiotics. While poor outcomes were rare, the 3- and 30-day mortalities were similar for both groups. EMS capture rates were highest for heart rate and respiratory rate and lowest for temperature, glucose, and blood pressure. Interrater reliability was highest for heart rate. Conclusions: Children presenting to the ED with septic shock transported by EMS represent a critically ill subset of modest proportions. Realization of a sepsis screening tool for this vulnerable population will require both creation of a tool containing a limited subset of objective parameters along with processes to ensure capture.     

I S T HERE G ENDER B IAS IN THE P REHOSPITAL M ANAGEMENT OF P ATIENTS WITH A CUTE C HEST P AIN ?

Objective. Prior emergency department (ED) and inpatient studies have found that women with coronary artery disease are more frequently misdiagnosed and undertreated compared with men. This study was performed to determine whether there is a gender bias in the prehospital management of patients with acute chest pain. Methods. This study was performed in a large urban county emergency medical services (EMS) agency with approximately 40,000 patient contacts/year. The study population comprised consecutive patients ≥45 years old with a chief complaint of atraumatic chest pain. Using χ² analysis and the unpaired Student's t-test, male and female patient encounters were compared. This study had >80% power (alpha 0.05) to detect a 3% difference between populations. Results. Data from 2,858 consecutive patient encounters were analyzed, with females comprising 1,508 (53%). Females were significantly older than males (67 ± 13.1 vs. 62.7 ± 12.3 years, p < 0.001). Male patients were more likely to receive aspirin (42.3% vs. 35.4%, p < 0.001) and 12-lead electrocardiograms (ECGs) (46.8% vs. 39.3%, p < 0.001) compared with female patients. The rates of transport refusal, oxygen, nitroglycerin, and narcotic administration did not differ between populations. Conclusion. Although females presenting to this urban EMS system with acute chest pain were older, they received significantly less aspirin and fewer 12-lead ECGs in the field. These results suggest strategies must be developed to ensure that appropriate therapy is provided to women presenting to EMS systems with acute cardiac ischemia.     

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.