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Background: Research networks need access to EMS data to conduct pilot studies and determine feasibility of prospective studies. Combining data across EMS agencies is complicated and costly. Leveraging the National EMS Information System (NEMSIS) to extract select agencies’ data may be an efficient and cost-effective method of providing network-level data. Objective: Describe the process of creating a Pediatric Emergency Care Applied Research Network (PECARN) specific NEMSIS data set and determine if these data were nationally representative. Methods: We established data use agreements (DUAs) with EMS agencies participating in PECARN to allow for agency identification through NEMSIS. Using 2019 NEMSIS version 3.4.0 data for EMS events with patients 18 years old and younger, we compared PECARN NEMSIS data to national NEMSIS data. Analyzed variables were selected for their ability to characterize events. No statistical analyses were utilized due to the large sample, instead, differences of ±5% were deemed clinically meaningful. Results: DUAs were established for 19 EMS agencies, creating a PECARN data set with 305,188 EMS activations of which 17,478 (5.7%) were pediatric. Of the pediatric activations, 17,140 (98.1%) were initiated through 9-1-1 and 9,487 (55.4%) resulted in transport by the documenting agency. The national data included 36,288,405 EMS activations of which 2,152,849 (5.9%) were pediatric. Of the pediatric activations 1,704,141 (79.2%) were initiated through 9-1-1 and 1,055,504 (61.9%) were transported by the documenting agency. Age and gender distributions were similar between the two groups, but the PECARN-specific data under-represents Black and Latinx patients. Comparison of EMS provider primary impressions revealed that three of the five most common were similar with injury being the most prevalent for both data sets along with mental/behavioral health and seizure. Conclusion: We demonstrated that NEMSIS can be leveraged to create network specific data sets. PECARN’s EMS data were similar to the national data, though racial/ethnic minorities and some primary impressions may be under-represented. Additionally, more EMS activations in PECARN study areas originated through 9-1-1 but fewer were transported by the documenting agency. This is likely related to the type of participating agencies, their ALS response level, and the diversity of the communities they serve.

Seizures are a common reason why emergency medical services (EMS) transports children by ambulance. Timely seizure cessation prevents neurologic morbidity, respiratory compromise, and mortality. Implementing recommendations from an evidence-based pediatric prehospital guideline may enhance timeliness of seizure cessation and optimize medication dosing.We compared management of pediatric prehospital seizures across several EMS systems after protocol revision consistent with an evidence-based guideline.Using a retrospective, cross-sectional approach, we evaluated actively seizing patients (0-17 years old) EMS transported to a hospital before and after modifying local protocols to include evidence-based recommendations for seizure management in three EMS agencies. We electronically queried and manually abstracted both EMS and hospital data at each site to obtain information about patient demographics, medications given, seizure cessation and recurrence, airway interventions, access obtained, and timeliness of care. The primary outcome of the study was the appropriate administration of midazolam based on route and dose. We analyzed these secondary outcomes: frequency of seizure activity upon emergency department (ED) arrival, frequency of respiratory failure, and timeliness of care.We analyzed data for 533 actively seizing patients. Paramedics were more likely to administer at least one dose of midazolam after the protocol updates [127/208 (61%) vs. 232/325 (71%),Implementation of an evidence-based seizure protocol for EMS increased midazolam administration. Patients frequently received an incorrect weight-based dose. Future research should focus on optimizing administration of the correct dose of midazolam to improve seizure cessation.

BackgroundPrehospital electrocardiogram(s) (ECG) can improve early detection of acute coronary syndrome (ST-segment elevation myocardial infarction [STEMI], non-STEMI, and unstable angina) and inform prehospital activation of cardiac catheterization lab; thus, reducing total ischemic time and improving patient outcomes. Less is known, however, about the association of prehospital ECG ischemic findings and long term adverse clinical events. With this in mind, this study was designed to examine the: 1) frequency of prehospital ECGs for acute myocardial ischemia (ST-elevation, ST-depression, and/or T-wave inversion); and, 2) whether any of these specific ECG features are associated with adverse clinical events within 30day of initial presentation to the emergency department (ED).MethodsWe included consecutive patients≥21years during a five-year period (2013-2017), who were transported by ambulance to the ED with non-traumatic chest pain and/or anginal equivalent(s) and had a prehospital 12‑lead ECG. Two cardiologists (LG, EC), blinded to clinical data, interpreted the 12‑lead ECGs applying current guideline based ischemia criteria. Adverse clinical events, return to ED, and rehospitalization evaluated at 30-days.ResultsWe identified 3646 patients (mean age, 59.7years ±15.7; 45% female) with ECGs, of which N=3587 had data on the three ischemic markers of interest. Of these, 1762 (49.1%) had ECG evidence of ischemia. In adjusted logistic regression models, those with T-wave inversion had a higher odds (OR=1.59) of new onset heart failure, while ST-elevation was associated with lower odds (OR=0.69). Patients with ST-depression had higher odds of new onset heart failure and death within 30days (OR=1.29, 1.49 respectively), but this association attenuated after controlling for other ECG features.ConclusionsST-depression and/or T-wave inversion are independent predictors of new onset heart failure, within 30days of initial ED presentation. Our study in a large cohort of patients, suggests that using ECG ST-elevation alone may not capture patients with ischemia who may benefit from aggressive anti-ischemic therapies to reduce myocardial damage with resultant heart failure.

Introduction: The Field Assessment Stroke Triage for Emergency Destination (FAST-ED) was developed to identify Large Vessel Occlusion Strokes (LVOS) presenting out of hospital, although there is limited prospective research validating its use in this setting. This study evaluated the test characteristics of the FAST-ED to identify LVOS when used as a secondary stroke screen in the prehospital environment. Secondary analysis compared the performance of the CPSS and the FAST-ED in identifying an LVOS. Methods: This prospective, observational study was conducted from April 2018 to December 2019 in a municipal EMS system with all ALS ambulance response. The FAST-ED was implemented as a secondary screening tool for emergent stroke patients who had at least one positive Cincinnati Prehospital Stroke Screen (CPSS) item. CPSS and FAST-ED scores were extracted from prehospital electronic care reports, while the presence of LVOS was extracted from hospital records. Results: A total 1,359 patients were enrolled; 55.3% female, 47.5% white, with a mean age of 69.4 (SD 15.8). In this cohort, 11.3% of patients experienced an LVOS. The mean FAST-ED for a patient experiencing an LVOS was 5.33 (95%CI 4.97-5.69) compared to 3.06 (95%CI 2.95-3.12) (p 0.05), and the FAST-ED had a significantly lower specificity than the CPSS (p

Introduction: The aging population reintroduces the need to establish early identification of falls risk as a means of primary and secondary prevention of falls. While there are several existing to...

Background: Seizures have the potential to cause significant morbidity and mortality, and are a common reason emergency medical services (EMS) are requested for a child. An evidence-based guideline (EBG) for pediatric prehospital seizures was published and has been implemented as protocol in multiple EMS systems. Knowledge translation and protocol adherence in medicine can be incomplete. In EMS, systems-based factors and providers' attitudes and beliefs may contribute to incomplete knowledge translation and protocol implementation. Objective: The purpose of this study was to identify paramedic attitudes and beliefs regarding pediatric seizure management and regarding potential barriers to and enablers of adherence to evidence-based pediatric seizure protocols in multiple EMS systems. Methods: This was a qualitative study utilizing semi-structured interviews of paramedics who recently transported actively seizing 0-17 year-old patients in 3 different urban EMS systems. Interviewers explored the providers' decision-making during their recent case and regarding seizures in general. Interview questions explored barriers to and enablers of protocol adherence. Two investigators used the grounded theory approach and constant comparison to independently analyze transcribed interview recordings until thematic saturation was reached. Findings were validated with follow-up member-checking interviews. Results: Several themes emerged from the 66 interviewed paramedics. Enablers of protocol adherence included point-of-care references, the availability of different routes for midazolam and availability of online medical control. Systems-level barriers included equipment availability, controlled substance management, infrequent pediatric training, and protocol ambiguity. Provider-level barriers included concerns about respiratory depression, provider fatigue, preferences for specific routes, febrile seizure perceptions, and inaccurate methods of weight estimation. Paramedics suggested system improvements to address dose standardization, protocol clarity, simplified controlled substance logistics, and equipment availability. Conclusions: Paramedics identified enablers of and barriers to adherence to evidence-based pediatric seizure protocols. The identified barriers existed at both the provider and systems levels. Paramedics identified multiple potential solutions to overcome several barriers to protocol adherence. Future research should focus on using the findings of this study to revise seizure protocols and to deploy measures to improve protocol implementation. Future research should also analyze process and outcome measures before and after the implementation of revised seizure protocols informed by the findings of this study.

Introduction: Patients experiencing a large vessel occlusion stroke (LVOS) may require endovascular-capable centers and benefit from direct transport to such facilities, creating a need for an accu...

Background Although all emergency departments (EDs) should be ready to treat children, some may have illnesses or injuries that require higher-level pediatric resources that are not available at all hospitals. There are no national guidelines for emergency medical services (EMS) providers about when to directly transport children to hospitals with higher-level pediatric resources, with the exception of severe trauma. Variability exists in EMS protocols about when children warrant transport to hospitals with higher-level pediatric care. Objective The objective was to determine how frequently pediatric patients are transported by EMS to hospitals with higher-level pediatric resources and to evaluate distribution patterns based on illness and injury severity. Methods We conducted a retrospective analysis of all pediatric (age 0-18 years) transports in three large EMS systems between November 2014 and November 2016. Each community had a hospital with higher-level pediatric resources that was within a 30-minute transport time from any location. Patients were included if they were transported by ground ambulance and the request originated in the 9-1-1 system. We assessed the frequency of transports to a hospital with higher-level pediatric resources. Data were stratified by chief complaint of illness or injury and severity. Potential risk for severe injury was defined as meeting the physiologic step of the field triage guidelines and potential risk for severe illness was defined as having an abnormal vital sign after adjusting for patient age. Results A total of 41,345 pediatric patients were transported by a participating EMS agency to an ED and had complete destination data. A total of 55% of all EMS-transported pediatric patients were transported to a hospital with higher-level pediatric resources. There was variation by site (range = 45%-71%) in the percentage of children who went to a hospital with higher-level pediatric resources. Patients over 15 years of age went to general EDs (57%) more often than younger patients. When stratified by severity, 60% of those with potentially severe illness and 74% of those with potentially severe trauma were transported to a hospital with higher-level pediatric resources. Conclusions EMS providers commonly transport children to hospitals with higher-level pediatric resources. However, more than one-quarter of children with potentially severe injuries and illnesses are transported to general EDs.

OBJECTIVE The objective of this study was to characterize key health indicators in Emergency Medical Services (EMS) personnel and identify areas for intervention in order to ensure a strong and capable emergency health workforce. METHODS Participants were EMS personnel delivering patients to 4 regional tertiary care emergency departments within North Carolina (NC). After transferring patient care and agreeing to participate, height, weight, and blood pressure (BP) measurements were recorded and each participant completed a questionnaire regarding demographics, activity levels, alcohol consumption, smoking, and medical history. Data were analyzed descriptively. RESULTS A sample of 452 EMS personnel from across NC was enrolled. The cohort was predominantly male (74.1%) and employed full-time (85.5%). The prevalence of overweight and obesity (80.3%) among EMS personnel was higher than the NC population (65.6%) and the general United States (US) population (70.8%). A previous diagnosis of high BP was reported by only 18.3% of participants, but 65.1% had elevated BP at the time of measurement. Alcohol consumption in the past 30 days among participants (55.4%) was slightly higher than state estimates (48.0%) and similar to national estimates (57.1%). However, heavy drinking (22.2%) and binge drinking (28.8%) were reported at much higher rates than state (5.6% and 15.2%, respectively) and national (6.6% and 18.3%, respectively) estimates. The prevalence of current smoking (21.5%) and quit attempts (48.8%) in the cohort was similar to state (21.8% and 55.0%, respectively) and national (21.2% and 55.7%, respectively) estimates. Likewise, the proportion of EMS providers meeting the Center for Disease Control's activity guidelines (49.6%) was similar to that found in the NC (46.8%) and the general US (48.0%) populations. CONCLUSIONS These findings suggest a high prevalence of overweight and obesity, heavy drinking, binge drinking, and high BP among NC EMS personnel. Similar to fire service personnel, these rates are higher than the general US population. As such, they suggest areas where intervention would have the greatest positive impact on the health and performance of the EMS workforce.

The impact on mortality due to prompt recognition of ST-segment Elevation Myocardial Infarction (STEMI) patients by EMS has not been well described. The objective of this study was to describe the association between the time interval, 9-1-1 call to percutaneous intervention (PCI), and mortality at one year.This retrospective analysis included patients that were transported by EMS as a "code STEMI" and underwent PCI. Total time from 9-1-1 call to PCI was calculated for each patient and was the independent variable of interest. Each patient's mortality status at one year was the outcome variable, collected by querying medical records and the national death index. Confounding variables were abstracted from hospital records. Logistic regression was conducted to determine the likelihood of survival given differences in time to PCI.A total of 550 patients were included in the analyses of which 68% were male with an average age 59.8 (SD 12.8). Mean reperfusion time was 81.8 min (SD 20.0) and was significantly lower in patients alive at one year (80.8 min, SD 19.7) vs. deceased at one year (93.9 min, SD 19.6), respectively. Odds of survival at one year decreased by 3% (OR 0.97; 95% CI 0.96-0.99) for every one minute increase in time to PCI. This relationship practically represents a 30% increase in mortality for every 10 minute delay from 9-1-1 call to PCI.The model produced suggests that a linear relationship exists between time to PCI and mortality in the prehospital environment with the probability of survival decreasing significantly as time to PCI increases.

Objective We compared the tolerability and efficacy of intranasal sub-dissociative ketamine to intranasal fentanyl for analgesia of children with acute traumatic pain and investigated the feasibility of a larger non-inferiority trial that could investigate the potential opioid sparing effects of intranasal ketamine. Methods This randomized controlled trial compared intranasal ketamine 1 mg/kg to intranasal fentanyl 1.5 μg/kg in children 4–17 years old with acute pain from suspected, isolated extremity fractures presenting to an urban level II pediatric trauma center from December 2015 to November 2016. Patients, parents, treating physicians, and outcome assessors were blinded to group allocation. The primary outcome, a tolerability measure, was the frequency of cumulative side effects and adverse events within 60 minutes of drug administration. The secondary outcomes included the difference in mean pain score reduction at 20 minutes, the proportion of patients achieving a clinically significant reduction in pain in 20 minutes, total dose of opioid pain medication in morphine equivalents/kg/hour (excluding study drug) required during the emergency department (ED) stay, and the feasibility of enrolling children presenting to the ED in acute pain into a randomized trial conducted under US regulations. All patients were monitored until 6 hours after their last dose of study drug, or until admission to the hospital ward or operating room. Results Of 629 patients screened, 87 received the study drug and 82 had complete data for the primary outcome (41 patients in each group). The median age (interquartile range) was 8 (3) years and 62% were male. Baseline pain scores were similar among patients randomized to receive ketamine (73 ± 26) and fentanyl (69 ± 26) [mean difference (95% CI): 4 (-7 to 15)]. The cumulative number of side effects was 2.2 times higher in the ketamine group, but there were no serious adverse events and no patients in either group required intervention. The most common side effects of ketamine were bad taste in the mouth (37; 90.2%), dizziness (30; 73.2%), and sleepiness (19; 46.3%). The most common side effects of fentanyl were sleepiness (15; 36.6%), bad taste in the mouth (9; 22%), and itchy nose (9; 22%). No patients experienced respiratory side effects. At 20 minutes, the mean pain scale score reduction was 44 ± 36 for ketamine and 35 ± 29 for fentanyl [mean difference: 9 (95% CI: -4 to 23)]. Procedural sedation with ketamine occurred in 28 ketamine patients (65%) and 25 fentanyl patients (57%) prior to completing the study. Conclusions Intranasal ketamine was associated with more minor side effects than intranasal fentanyl. Pain relief at 20 minutes was similar between groups. Our data support the feasibility of a larger, non-inferiority trial to more rigorously evaluate the safety, efficacy, and potential opioid sparing benefits of intranasal ketamine analgesia for children with acute pain. This article is protected by copyright. All rights reserved.

Therapeutic hypothermia has been shown to improve neurologic outcome in medical cardiac arrest patients, yet little is known about factors that delay target temperature achievement. Our primary aim was to identify factors associated with not achieving our institutional "door-to-cool" (DTC) performance goal (emergency department [ED] arrival to temperature of 34°C) of ≤4 hours. Secondary aims included whether achievement of DTC goal was associated with timing of bolus neuromuscular blockade (NMB), survival, or functional outcome. This was a retrospective cohort study of a medical cardiac arrest quality improvement (QI) database that included patients treated from November 2007 to August 2012. The database was queried for patient demographics, arrest characteristics, specific cooling techniques used, whether patients underwent emergent computed tomography imaging or cardiac catheterization, and patient outcomes. Logistic regression was used to assess the factors associated with DTC goal performance and outcomes. We enrolled 327 patients, median age 58, median return of spontaneous circulation (ROSC) time of 21 minutes (interquartile range [IQR] 14-29 minutes), and shockable initial rhythm in 61%. One hundred forty-four (44%) patients survived to hospital discharge, 133 (41%) with good functional outcome, as defined as cerebral performance category 1-2. Induction with cold IV fluids [OR 0.50 (CI: 0.29-0.85)] and NMB administration within 2 hours of ED arrival [OR 2.95 (CI: 1.17-7.43)] was associated with achieving DTC goal. Logistic regression showed that achievement of DTC goal ≤4 hours [OR 0.59 (0.32-1.09)] was not associated with good functional outcome. In our single-center cohort, initiation of cold intravenous fluids (IVF) and early NMB administration were associated with improved DTC goal performance of 4 hours. However, patients achieving DTC goals were not associated with improved outcomes.

Background: High quality cardiopulmonary resuscitation (CPR) plays a critical role in the success of out-of-hospital resuscitation from sudden cardiac arrest (SCA). AHA guidelines provide protocol to achieve recommended targets for CPR quality metrics including chest compression fraction (CCF), percentage of chest compressions (CCs) with full chest recoil, CC rate and CC depth. Our objective was to report the CPR quality of two emergency medical services (EMS) agencies with different basic life support (BLS) CPR protocols. Methods: Data from 673 patients, 2015 to 2017, suffering out-of-hospital SCA were obtained from Philips FR3 AEDs. The Philips Q-CPR tool was used for real-time CPR feedback, and CC waveforms were recorded for retrospective CPR analysis using Philips Event Review Pro 5.0 and custom software. The two EMS systems had BLS protocol differences: Site 1(King County, WA, n = 93) applied a compression - ventilation ratio of 30:2, while Site 2 (Mecklenburg County, NC, n = 580) applied 200 compressions in each CPR interval and ventilations were performed during CCs. Analyses were performed comparing CPR metrics between sites and to AHA targets. Results: There were 3,460 minutes of resuscitation data analyzed, representing the initial phase of resuscitation prior to ALS. The proportion of cases with shocks was 21.5% (20 of 93) for site 1 and 16.9% (98 of 580) for site 2 (p = 0.3). Both sites achieved guideline metrics though there were statistical differences (Table 1). Compared to site 1, site 2 was associated with a higher CCF, faster CC rate, but less CC depth on average (p < 0.001). Conclusions: High quality CPR defined by AHA guidelines was achieved with both sites during the early phase of AED resuscitation though some differences were observed. Additional investigation should identify equipment, or rescuer characteristics that are important to consistently achieve high quality CPR and how the combination might be tailored to optimize individual patient outcome.

Introduction: The pediatric early warning score (PEWS) and the bedside pediatric early warning score (BPEWS) are validated tools that help determine the need for critical care in children with acute medical conditions. These tools could be used by EMS and have not been evaluated outside of the hospital. This study retrospectively tested the validity of these tools in the prehospital setting to identify children who needed a hospital with higher level pediatric resources. Methods: This was a multi-center retrospective validation of screening tools using prehospital and in-hospital data obtained from 3 EMS agencies. EMS patient records from April 1, 2013 to April 30, 2015 were used to identify subjects for this analysis. Pediatric patients were retrospectively classified using the PEWS based on the clinical information documented in the EMS medical record. Those with PEWS scores greater than 4 were matched to a subject with scores less than 4 based on age, gender, and paramedic primary impression. Hospital medical record review was then used to determine whether the patient required a hospital with higher level pediatric resources. These classifications were used to calculate sensitivity, specificity, and resultant 95% confidence intervals. The analysis was repeated for included subjects who had sufficient data to calculate BPEWS. Results: There were 386 patients enrolled. A PEWS ≥ 4 demonstrated a sensitivity of 62.8 (95% CI 53.6-71.4) and a specificity of 55.9 (95% CI 49.6-61.9) in identifying a patient who required a hospital with higher level pediatric resources. There were 44 pairs of patients that had sufficient EMS data documented to calculate a BPEWS. A BPEWS ≥ 7 demonstrated a sensitivity of 46.4 (95% CI 27.5-66.1) and a specificity of 76.7 (95% CI 64.0-86.6) to correctly classify a patient who required a hospital with higher level pediatric resources. Conclusion: In the prehospital setting neither PEWS nor BPEWS exhibited sufficient sensitivity for clinical use to accurately identify children who need a hospital with higher level pediatric resources. Further research should be conducted to identify variables that are captured by prehospital care providers and are associated with children who need a hospital with higher level pediatric resources.

Introduction The Rapid Emergency Medicine Score (REMS) was developed to predict emergency department patient mortality. Our objective was to utilize REMS to assess initial patient acuity and evaluate clinical change during prehospital care. Methods All non-cardiac arrest emergency transports from April 1, 2013 to March 31, 2014 were analyzed from a single EMS agency. Using age, pulse rate, mean arterial pressure, respiratory rate, oxygen saturation, and Glasgow Coma Scale, initial and final REMS were calculated. Change in REMS was calculated by initial minus final with a positive number indicating clinical improvement. Descriptive analyses were performed calculating means and 95% confidence intervals. Results There were 61,346 patients analyzed with an average initial REMS of 4.3 (95% CI: 4.2–4.3) and an average REMS change of 0.37 (95% CI: 0.36–0.38). Those patients classified with the highest dispatch priority had the highest initial REMS (5.8; 95% CI: 5.5–6.2) and the greatest change (0.95; 95% CI: 0.72–1.17). Patients transported with high priority had greater initial REMS, as well as greater improvement in REMS (high priority 7.3 [95% CI: 7.1–7.4], change 0.61 [95% CI: 0.53–0.69]; middle priority 5.3 [95% CI: 5.2–5.4], change 0.55 [95% CI: 0.51–0.59]; low priority 3.9 [95% CI: 3.8–3.9], change 0.32 [95% CI: 0.31–0.33]). Conclusion Descriptive analyses indicate that as dispatch and transport priorities increased in severity so too did initial REMS. The largest change in REMS was seen in patients with the highest dispatch and transport priorities. This indicates that REMS may provide system level insight into evaluating clinical changes during care.

Greater than half of Emergency Medical Services (EMS) personnel report work-related fatigue, yet there are no guidelines for the management of fatigue in EMS. A novel process has been established for evidence-based guideline (EBG) development germane to clinical EMS questions. This process has not yet been applied to operational EMS questions like fatigue risk management. The objective of this study was to develop content valid research questions in the Population, Intervention, Comparison, and Outcome (PICO) framework, and select outcomes to guide systematic reviews and development of EBGs for EMS fatigue risk management.We adopted the National Prehospital EBG Model Process and Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework for developing, implementing, and evaluating EBGs in the prehospital care setting. In accordance with steps one and two of the Model Process, we searched for existing EBGs, developed a multi-disciplinary expert panel and received external input. Panelists completed an iterative process to formulate research questions. We used the Content Validity Index (CVI) to score relevance and clarity of candidate PICO questions. The panel completed multiple rounds of question editing and used a CVI benchmark of ≥0.78 to indicate acceptable levels of clarity and relevance. Outcomes for each PICO question were rated from 1 = less important to 9 = critical.Panelists formulated 13 candidate PICO questions, of which 6 were eliminated or merged with other questions. Panelists reached consensus on seven PICO questions (n = 1 diagnosis and n = 6 intervention). Final CVI scores of relevance ranged from 0.81 to 1.00. Final CVI scores of clarity ranged from 0.88 to 1.00. The mean number of outcomes rated as critical, important, and less important by PICO question was 0.7 (SD 0.7), 5.4 (SD 1.4), and 3.6 (SD 1.9), respectively. Patient and personnel safety were rated as critical for most PICO questions. PICO questions and outcomes were registered with PROSPERO, an international database of prospectively registered systematic reviews.We describe formulating and refining research questions and selection of outcomes to guide systematic reviews germane to EMS fatigue risk management. We outline a protocol for applying the Model Process and GRADE framework to create evidence-based guidelines.

IntroductionTraditionally, Emergency Medical Services (EMS) educators have divided the pediatric population into age groups to assist in targeting their clinical and didactic curriculum. Currently, the accrediting body for paramedic training programs requires student exposure to pediatric patients based entirely on age without specifying exposure to specific pathologies within each age stratification. Identifying which pathologies are most common within the different pediatric age groups would allow educators to design curriculum targeting the most prevalent pathologies in each age group and incorporating the physiologic and psychological developmental milestones commonly seen at that age.HypothesisIt was hypothesized that there are unique clusterings of pathologies, represented by paramedic student primary impressions, that are found in different age groups which can be used to target provider education.MethodsThis is a retrospective review of prospectively collected data documented by paramedic students in the Fisdap (Field Internship Student Data Acquisition Project; Saint Paul, Minnesota USA) database over a one-year period. For the purposes of this study, pediatric patients were defined arbitrarily as those between the ages of 0-16 years. All paramedic student primary impressions recorded in Fisdap for patients aged 0-16 years were abstracted. Primary impression by age was calculated and graphed. The frequency of primary impression was then assessed for significance of trend by age with an alpha ≤.05 considered significant.ResultsThe following primary impressions showed clinically and statistically significant variability in prevalence among different pediatric age groups: respiratory distress, medical-other, abdominal pain, seizure, overdose/poisoning, behavioral, and cardiac. In patients less than 13 years old, respiratory and other-medical were the most common two primary impressions and both decreased with age. In patients 5-16 years old, the prevalence of abdominal pain and behavioral/psych increased. Bimodal distributions for overdose were seen with one spike in the toddler and another in the adolescent population. Seizures were most common in the age group associated with febrile seizure. Sepsis was seen most often in the youngest patients and its prevalence decreased with age.ConclusionThere are statistically significant variations in the frequency of paramedic student primary impressions as a function of age in the pediatric population. Emphasizing paramedic student exposure to the most common pathologies encountered in each age group, in the context of the psychological and physiological milestones of each age, may improve paramedic student pediatric practice.ErnestEV, BrazeltonTB, CarhartED, StudnekJR, TrittPL, PhilipGA, BurnettAM. Prevalence of unique pediatric pathologies encountered by paramedic students across age groups. Prehosp Disaster Med. 2016; 31(4):386–391.

To assess the clinical and electrocardiographic characteristics of patients diagnosed with ST elevation myocardial infarction (STEMI) that are associated with an increased likelihood of not undergoing percutaneous coronary intervention (PCI) after prehospital Cardiac Catheterization Laboratory activation in a regional STEMI system.We performed a retrospective analysis of prehospital Cardiac Catheterization Laboratory activations in Mecklenburg County, North Carolina, between May 2008 and March 2011. Data were extracted from the prehospital patient record, the prehospital electrocardiogram, and the regional STEMI database. The independent variables of interest included objective patient characteristics as well as documented cardiac history and risk factors. Analysis was performed using descriptive statistics and logistic regression.Two hundred thirty-one prehospital activations were included in the analysis. Five independent variables were found to be associated with an increased likelihood of not undergoing PCI: increasing age, bundle branch block, elevated heart rate, left ventricular hypertrophy, and non-white race. The variables with the most significance were any type of bundle branch block [adjusted odds ratios (AOR), 5.66; 95% confidence interval (CI), 1.91-16.76], left ventricular hypertrophy (AOR, 4.63; 95% CI, 2.03-10.53), and non-white race (AOR, 3.53; 95% CI, 1.76-7.08). Conversely, the only variable associated with a higher likelihood of undergoing PCI was the presence of arm pain (AOR, 2.94; 95% CI, 1.36-6.25).Several of the above variables are expected electrocardiogram mimics; however, the decreased rate of PCI in non-white patients highlights an area for investigation and process improvement. This may guide the development of prehospital STEMI protocols, although avoiding false positive and inappropriate activations.

Early antibiotic administration has been associated with a significant decrease in infection following open fractures. However, antibiotics are most effective at a time when many patients are still being transported for care. There is limited evidence that antibiotics may be safely administered for open fractures when being transported by life-flight personnel. No such data exists for ground ambulance transport of patients with open fractures. The purpose of the study was to assess the safety and feasibility of prophylactic antibiotic delivery in the prehospital setting.We performed a prospective observational study between January 1, 2014 and May 31, 2015 of all trauma patients transferred to a level 1 trauma center by a single affiliated ground ambulance transport service. If open fracture was suspected, the patient was indicated for antibiotic prophylaxis with 2 g IV Cefazolin. Exclusion criteria included penicillin allergy, higher priority patient care tasks, and remaining transport time insufficient for administration of antibiotics. The administration of antibiotics was recorded. Patient demographics, associated injuries, priority level (1 = life threatening injury, 2 = potentially life threatening injury, 3 = non-life threatening injury), and timing of transport and antibiotic administration were recorded as well.EMTs identified 70 patients during the study period with suspected open fractures. Eight reported penicillin allergy and were not eligible for prophylaxis. The patient's clinical status and transport time allowed for administration of antibiotic prophylaxis for 32 patients (51.6%). Total prehospital time was the only variable assessed that had a significant impact on administration of prehospital antibiotics (30 minutes = 29% vs.30 minutes = 66%; p 0.001). There were no allergic reactions among patients and no needle sticks or other injuries to EMT personnel related to antibiotic administration.EMT personnel were able to administer prehospital antibiotic prophylaxis for a substantial portion of the identified patients without any complications for patients or providers. Given the limited training provided to EMTs prior to implementation of the antibiotic prophylaxis protocol, it is likely that further development of this initial training will lead to even higher rates of prehospital antibiotic administration for open fractures.

Background Emergency medical services (EMS) providers must be able to identify the most appropriate destination facility when treating children with potentially severe medical illnesses. Currently, no validated tool exists to assist EMS providers in identifying children who need transport to a hospital with higher-level pediatric care. For such a tool to be developed, a criterion standard needs to be defined that identifies children who received higher-level pediatric medical care. Objective The objective was to develop a consensus-based criterion standard for children with a medical complaint who need a hospital with higher-level pediatric resources. Methods Eleven local and national experts in EMS, emergency medicine (EM), and pediatric EM were recruited. Initial discussions identified themes for potential criteria. These themes were used to develop specific criteria that were included in a modified Delphi survey, which was electronically delivered. The criteria were refined iteratively based on participant responses. To be included, a criterion required at least 80% agreement among participants. If an item had less than 50% agreement, it was removed. A criterion with 50% to 79% agreement was modified based on participant suggestions and included on the next survey, along with any new suggested criteria. Voting continued until no new criteria were suggested and all criteria received at least 80% agreement. Results All 11 recruited experts participated in all seven voting rounds. After the seventh vote, there was agreement on each item and no new criteria were suggested. The recommended criterion standard included 13 items that apply to patients 14 years old or younger. They included IV antibiotics for suspicion of sepsis or a seizure treated with two different classes of anticonvulsive medications within 2 hours, airway management, blood product administration, cardiopulmonary resuscitation, electrical therapy, administration of specific IV/IO drugs or respiratory assistance within 4 hours, interventional radiology or surgery within 6 hours, intensive care unit admission, specific comorbid conditions with two or more abnormal vital signs, and technology-assisted children seen for device malfunction. Conclusion We developed a 13-item consensus-based criterion standard definition for identifying children with medical complaints who need the resources of a hospital equipped to provide higher-level pediatric services. This criterion standard will allow us to create a tool to improve pediatric patient care by assisting EMS providers in identifying the most appropriate destination facility for ill children.

Introduction Quality cardiopulmonary resuscitation (CPR) and timely defibrillation are associated with increasing survival to hospital discharge from out-of-hospital cardiac arrest (OHCA). The objective of this study was to demonstrate that performance coaching during an OHCA would improve compression depth and time to defibrillation (TTD). Methods This study was conducted in a single emergency medical services (EMS) agency and utilized data collected from 815 patients treated between 1/1/2012 and 12/31/2013. The intervention used multiple Plan-Do-Study-Act (PDSA) cycles to train fire captains to translate performance data into active direction. Testing began in simulation with small-scale expansions prior to system-wide implementation. Performance metrics included average (reported as a percentage) and actual compression depth (reported in millimeters), and TTD (an average in seconds). Analysis was conducted using Xbar and S control charts with standard assessment of special cause for performance data. A statistical shift was seen in means and standard deviations for both depth metrics. Results Average depth of compressions improved from 69.8% (SD = 28.0%) to 80.4 (SD = 21.8%). Depth of compressions delivered increased from 43.6 mm (SD = 8.2 mm) to 47.2 mm (SD = 8.1 mm). Analysis of the S charts indicates a statistical shift in process variation for TTD. Conclusion Early results indicate that utilization of a CPR coach during OHCA improves compression depth and TTD. Further data are needed to assess sustainability.

Study objective Emergency medical services (EMS) protocols, which route patients with suspected stroke to stroke centers, rely on the use of accurate stroke screening criteria. Our goal is to conduct a statewide EMS agency evaluation of the accuracies of the Cincinnati Prehospital Stroke Scale (CPSS) and the Los Angeles Prehospital Stroke Screen (LAPSS) for identifying acute stroke patients. Methods We conducted a retrospective study in North Carolina by linking a statewide EMS database to a hospital database, using validated deterministic matching. We compared EMS CPSS or LAPSS results (positive or negative) to the emergency department diagnosis International Classification of Diseases, Ninth Revision codes. We calculated sensitivity, specificity, and positive and negative likelihood ratios for the EMS diagnosis of stroke, using each screening tool. Results We included 1,217 CPSS patients and 1,225 LAPSS patients evaluated by 117 EMS agencies from 94 North Carolina counties. Most EMS agencies contributing data had high annual patient volumes and were governmental agencies with nonvolunteer, emergency medical technician–paramedic service level providers. The CPSS had a sensitivity of 80% (95% confidence interval [CI] 77% to 83%) versus 74% (95% CI 71% to 77%) for the LAPSS. Each had a specificity of 48% (CPSS 95% CI 44% to 52%; LAPSS 95% CI 43% to 53%). Conclusion The CPSS and LAPSS had similar test characteristics, with each having only limited specificity. Development of stroke screening scales that optimize both sensitivity and specificity is required if these are to be used to determine transport diversion to acute stroke centers.

Background Our goal was to determine if a statewide Emergency Medical Services (EMSs) Stroke Triage and Destination Plan (STDP), specifying bypass of hospitals unable to routinely treat stroke patients with thrombolytics (community hospitals), changed bypass frequency of those hospitals. Methods Using a statewide EMS database, we identified stroke patients eligible for community hospital bypass and compared bypass frequency 1-year before and after STDP implementation. Results Symptom onset time was missing for 48% of pre-STDP (n = 2385) and 29% of post-STDP (n = 1612) cases. Of the remaining cases with geocodable scene addresses, 58% (1301) in the pre-STDP group and 61% (2,078) in the post-STDP group were ineligible for bypass, because a community hospital was not the closest hospital to the stroke event location. Because of missing data records for some EMS agencies in 1 or both study periods, we included EMS agencies from only 49 of 100 North Carolina counties in our analysis. Additionally, we found conflicting hospital classifications by different EMS agencies for 35% of all hospitals (n = 38 of 108). Given these limitations, we found similar community hospital bypass rates before and after STDP implementation (64%, n = 332 of 520 vs. 63%, n = 345 of 552; P = .65). Conclusions Missing symptom duration time and data records in our state's EMS data system, along with conflicting hospital classifications between EMS agencies limit the ability to study statewide stroke routing protocols. Bypass policies may apply to a minority of patients because a community hospital is not the closest hospital to most stroke events. Given these limitations, we found no difference in community hospital bypass rates after implementation of the STDP.

The primary objective of this study was to assess the effectiveness of two prehospital stroke screens in correctly classifying patients suspected of having a stroke. Secondarily, differences in the sensitivity and specificity of the two screening tools were assessed.We performed a retrospective assessment of the Cincinnati Prehospital Stroke Scale (CPSS) and the Medic Prehospital Assessment for Code Stroke (Med PACS) between March 1, 2011, and September 30, 2011, in a single emergency medical services (EMS) agency with seven local hospitals all classified as stroke-capable. We obtained data for this analysis from the EMS electronic patient care reports (ePCRs) and the Get With The Guidelines(-)Stroke (GWTG-S) registries maintained by the two local health care systems by matching on patient identifiers. The Med PACS was developed specifically for the EMS agency under study by a local team of neurologists, emergency physicians, and paramedics. All of the physical assessment elements of the CPSS were included within the Med PACS. Two additional physical assessment items, gaze and leg motor function, were included in the Med PACS. We classified patients as CPSS-positive or -negative and Med PACS-positive or -negative if any one of the physical assessment findings was present. We determined the presence of a hospital discharge diagnosis of stroke from GWTG-S. We calculated sensitivity and specificity with resultant 95% confidence intervals.We enrolled 416 patients in this study, of whom 186 (44.7%) were diagnosed with a stroke. The Med PACS scale demonstrated a sensitivity of 0.742 (95% confidence interval [CI] 0.672-0.802), while the sensitivity for the CPSS was 0.790 (95% CI 0.723-0.845). The sensitivity of the CPSS was significantly higher than that of the Med PACS, with a difference of 0.048 (95% CI 0.009-0.088; p = 0.011). The specificities of these two scales were low, Med PACS 0.326 (95% CI 0.267-0.391) vs. CPSS 0.239 (95% CI 0.187-0.300), and the specificity of the Med PACS was significantly higher compared with the CPSS, with a difference in specificity of 0.086 (95% CI 0.042-0.131), p0.001.The two stroke scales under study demonstrated low sensitivity and specificity, with each scale performing marginally better in one of the two metrics assessed.

The primary objective of this study was to estimate the prevalence and severity of depression, anxiety, and stress among a cohort of nationally certified emergency medical services (EMS) professionals. The secondary objective was to determine whether there were differences between individuals who were experiencing depression, anxiety, or stress and those who were not.This was a questionnaire-based, case-control analysis of nationally certified emergency medical technician (EMT)-Basics and paramedics who applied for national recertification in 2009. The three outcome variables of interest included measures of depression, anxiety, and stress, and were assessed using the Depression Anxiety Stress Scale-21 (DASS-21). Descriptive statistics and investigator-controlled backwards-selection logistic regression modeling were utilized to quantify the prevalence of depression, anxiety, and stress and to predict the association of demographic and work-life characteristics with each outcome.A total of 64,032 individuals were eligible to renew their national certification and 34,340 (53.6%) individuals returned a questionnaire. The DASS-21 classified 1,589 (6.8%, 95% confidence interval [CI] = 6.4%-7.1%) EMS professionals as depressed, 1,406 (6.0%, 95% CI = 5.7%-6.3%) as anxious, and 1,382 (5.9%, 95% CI = 5.6%-6.2%) as stressed. Multivariable logistic regression estimates showed that paramedics (odds ratio [OR] = 1.31, 95% CI = 1.22-1.39), those working in county or municipal services (OR = 1.36, 95% CI = 1.16-1.60) or private services (OR = 1.32, 95% CI = 1.14-1.52), and those with ≥16 years of EMS experience (OR = 1.28, 95% CI = 1.01-1.62) had an increased odds of depression. A stepwise increase was found when estimating the effects of self-reported general health on the odds of anxiety (very good, OR = 1.84, 95% CI = 1.53-2.22; good, OR = 3.88, 95% CI = 3.32-4.67; fair/poor, OR = 10.81, 95% CI = 8.14-14.34). Likewise, paramedics (OR = 1.32, 95% CI = 1.23-1.42), those working in a private EMS system (OR = 1.35, 95% CI = 1.16-1.56), and those with ≥16 years of EMS experience (OR = 1.67, 95% CI = 1.28-2.18) had an increased odds of stress.This study was able to estimate the prevalence of depression, anxiety, and stress among a large cohort of nationally certified EMS professionals and identified statistically significant demographic and work-life characteristics that predicted depression, anxiety, and stress. Future research should attempt to follow EMS professionals prospectively to determine specific characteristics associated with occupational traumatic exposure and the development of depression, anxiety, and stress.

ObjectivesThe objective of this paper is to identify factors associated with compensation for Emergency Medical Technician (EMT)-Basics and Paramedics and assess whether these associations have changed over the period 1999-2008.MethodsData obtained from the Longitudinal EMT Attributes and Demographic Study (LEADS) surveys, a mail survey of a random, stratified sample of nationally certified EMT-Basics and Paramedics, were analyzed. For the 1999-2003 period, analyses included all respondents providing Emergency Medical Services (EMS). With the addition of a survey in 2004 about volunteers, it was possible to exclude volunteers from these analyses.ResultsOver 60% of EMT-Basics reported being either compensated or noncompensated volunteers in the 2004-2008 period. This was substantially and significantly greater than the proportion of EMT-Paramedic volunteers (ConclusionsThere are a number of factors associated with compensation disparities within the EMS profession. These include type of service (ie, fire-based vs. other types of agencies) and gender. The reasons for these disparities warrant further investigation.StudnekJR. Compensation of Emergency Medical Technician (EMT)-Basics and Paramedics. Prehosp Disaster Med. 2016;31(Suppl. 1):s87–s95.

Objectives Inducing therapeutic hypothermia using chilled saline in resuscitated cardiac arrest patients has been shown to be feasible and effective. Limited research exists assessing the efficiency of this cooling method. The objective of this study was to assess the change in temperature of 4°C saline upon exiting an infusion set in the laboratory setting while varying conditions of fluid delivery. Methods Efficiency was studied by assessing change in fluid temperature (°C) during the infusion under four laboratory conditions. Each condition was performed four times using 1-L bags of normal saline. Fluid was infused into a 1000-mL beaker through 10 gtt/mL tubing. Flow rate was controlled using a tubing clamp and in-line transducer with a flow meter, while temperature was continuously monitored in a side port at the terminal end of the intravenous (IV) tubing using a digital thermometer. The four conditions included different insulation methods. Descriptive statistics and analysis of variance were performed to assess changes in fluid temperature. Results The mean (±SD) fluid temperature at time 0 was 3.2°C (95% confidence interval [CI] = 3.0 to 3.4 °C) with no significant difference in starting temperature between groups (p = 0.45). When flow rate was constant, it was determined that fluid temperatures were significantly cooler when infused using a chilled, gel-filled sleeve around the saline bag (p

Objective The identification and treatment of critical illness is often initiated by emergency medical services (EMS) providers. We hypothesized that emergency department (ED) patients with severe sepsis who received EMS care had more rapid recognition and treatment compared to non-EMS patients. Methods This was a prospective observational study of ED patients with severe sepsis treated with early goal-directed therapy (EGDT).We included adults with suspected infection, evidence of systemic inflammation, and either hypotension after a fluid bolus or elevated lactate. Prehospital and ED clinical variables and outcomes data were collected. The primary outcome was time to initiation of antibiotics in the ED. Results There were 311 patients, with 160 (51.4%) transported by EMS. Emergency medical services–transported patients had more organ failure (Sequential Organ Failure Assessment score, 7.0 vs 6.1; P = .02), shorter time to first antibiotics (111 vs 146 minutes, P = .001), and shorter time from triage to EGDT initiation (119 vs 160 minutes, P = .005) compared to non–EMS-transported patients. Among EMS patients, if the EMS provider indicated a written impression of sepsis, there was a shorter time to antibiotics (70 vs 122 minutes, P = .003) and a shorter time to EGDT initiation (69 vs 131 minutes, P = .001) compared to those without an impression of sepsis. Conclusions In this prospective cohort, EMS provided initial care for half of the patients with severe sepsis requiring EGDT. Patients presented by EMS had more organ failure and a shorter time to both antibiotic and EGDT initiation in the ED.

Objective: We sought to determine the association between time to initial antibiotics and mortality of patients with septic shock treated with an emergency department-based early resuscitation protocol. Design: Preplanned analysis of a multicenter randomized controlled trial of early sepsis resuscitation. Setting: Three urban U.S. emergency departments. Patients: Adult patients with septic shock. Interventions: A quantitative resuscitation protocol in the emergency department targeting three physiological variables: central venous pressure, mean arterial pressure, and either central venous oxygen saturation or lactate clearance. The study protocol was continued until all end points were achieved or a maximum of 6 hrs. Measurements and Main Results: Data on patients who received an initial dose of antibiotics after presentation to the emergency department were categorized based on both time from triage and time from shock recognition to initiation of antibiotics. The primary outcome was inhospital mortality. Of 291 included patients, mortality did not change with hourly delays in antibiotic administration up to 6 hrs after triage: 1 hr (odds ratio [OR], 1.2; 0.6 –2.5), 2 hrs (OR, 0.71; 0.4 –1.3), 3 hrs (OR, 0.59; 0.3–1.3). Mortality was significantly increased in patients who received initial antibiotics after shock recognition (n 172 [59%]) compared with before shock recognition (OR, 2.4; 1.1– 4.5); however, among patients who received antibiotics after shock recognition, mortality did not change with hourly delays in antibiotic administration. Conclusion: In this large, prospective study of emergency department patients with septic shock, we found no increase in mortality with each hour delay to administration of antibiotics after triage. However, delay in antibiotics until after shock recognition was associated with increased mortality. (Crit Care Med 2011; 39:2066 –2071)

ACADEMIC EMERGENCY MEDICINE 2011; 18:403-412 © 2011 by the Society for Academic Emergency Medicine. Objectives: During disasters, the public expects that emergency care will be available at a moment's notice. As such, an emergency medical services (EMS) workforce that is trained and prepared for disasters is imperative. The primary objectives of this study were to quantify the amount of individual-level training EMS professionals receive in terrorism and disaster-preparedness, as well as to assess EMS professionals' participation in multiagency disaster drills across the United States. Characteristics of those most likely to have received individual-level training or participated in multiagency disaster drills were explored. The secondary objectives were to assess EMS professional's perception of preparedness and to determine whether the amount of training individuals received was correlated with their perceptions of preparedness. Methods: A structured survey was administered to nationally certified EMT-Basics and paramedics as part of their 2008 recertification paperwork. Outcome variables included individual-level preparedness training, participation in multiagency disaster drills, and perception of preparedness. Descriptive statistics and logistic regression modeling were used to quantify the amount of training received. Spearman rank correlation coefficients were used to analyze whether training was correlated with an individual's perception of preparedness. Results: There were 46,127 EMS professionals who had the opportunity to complete the recertification questionnaire; 30,570 (66.3%) responded. A complete case analysis was performed on 21,438 respondents. Overall, 19,551 respondents (91.2%) reported receiving at least 1 hour of individual-level preparedness training, and 12,828 respondents (59.8%) reported participating in multiagency disaster drills, in the prior 24 months. Spearman rank correlation coefficients revealed that hours of individual-level preparedness training were significantly correlated with the perception of preparedness. Conclusions: While areas where EMS should focus attention for improvement were identified, a majority of nationally certified EMT-Basics and paramedics reported participating in both individual and multiagency disaster-preparedness training. A large majority of respondents reported feeling adequately prepared to respond to man-made and natural disasters and the perception of preparedness correlated with hours of training. Language: en

Intraosseous (IO) needle insertion is often utilized in the adult population for critical resuscitation purposes. Standard insertion sites include the proximal humerus and proximal tibia, for which limited comparison data are available.This study compared the frequencies of IO first-attempt success between humeral and tibial sites in out-of-hospital cardiac arrest.This observational study was conducted in an urban setting between August 28, 2009, and October 31, 2009, and included all medical cardiac arrest patients for whom resuscitative efforts were performed. Cardiac arrest protocols stipulate that paramedics insert an IO line for initial vascular access. During the first month of the study, the proximal humerus was the preferred primary insertion site, whereas the tibia was preferred throughout the second month. The primary outcome was first-attempt success, defined as secure IO needle position in the marrow cavity and normal fluid flow. Any needle dislodgment during resuscitation was also recorded. The association between first-attempt IO success and initial IO insertion location was analyzed using a test of independent proportions and 95% confidence intervals (CIs) for the difference in proportions.There were 88 cardiac arrest patients receiving IO placement, with 58 (65.9%) patients receiving their initial IO attempt in the tibia. The rate of first-time IO success at the tibia was significantly higher than that observed at the humerus (89.7% vs. 60.0%; p0.01). There were 18 initial successes at the humerus; for six (33.3%) of these, the needle became dislodged during resuscitation, compared with 52 initial successes at the tibia, with three (5.8%) dislodgments. The rate of total success for initial IO placements was significantly lower for the humerus (40.0%) compared with that for the tibia (84.5%; p0.01) during resuscitation efforts.In this subset of patients, tibial IO needle placement appeared to be a more effective insertion site than the proximal humerus. Success rates were higher with a lower incidence of needle dislodgments. Further randomized studies are required in order to validate these results.

Objectives: The benefit of prehospital endotracheal intubation (ETI) among individuals experiencing out-of-hospital cardiac arrest (OOHCA) has not been fully examined. The objective of this study was to determine if prehospital ETI attempts were associated with return of spontaneous circulation (ROSC) and survival to discharge among individuals experiencing OOHCA. Methods: This retrospective study included individuals who experienced a medical cardiac arrest between July 2006 and December 2008 and had resuscitation efforts initiated by paramedics from Mecklenburg County, North Carolina. Outcome variables were prehospital ROSC and survival to hospital discharge, while the primary independent variable was the number of prehospital ETI attempts. Results: There were 1,142 cardiac arrests included in the analytic data set. Prehospital ROSC occurred in 299 individuals (26.2%). When controlling for initial arrest rhythm and other confounding variables, individuals with no ETI attempted were 2.33 (95% confidence interval [CI] = 1.63 to 3.33) times more likely to have ROSC compared to those with one successful ETI attempt. Of the 299 individuals with prehospital ROSC, 118 (39.5%) were subsequently discharged alive from the hospital. Individuals having no ETI were 5.46 (95% CI = 3.36 to 8.90) times more likely to be discharged from the hospital alive compared to individuals with one successful ETI attempt. Conclusions: Results from these analyses suggest a negative association between prehospital ETI attempts and survival from OOHCA. In this study, the individuals most likely to have prehospital ROSC and survival to hospital discharge were those who did not have a reported ETI attempt. Further comparative research should assess the potential causes of the demonstrated associations. ACADEMIC EMERGENCY MEDICINE 2010; 17:918‐925 a 2010 by the Society for Academic Emergency Medicine

Ensuring the health and productivity of emergency medical services (EMS) professionals is important. However, there has been no known national baseline assessment of the health and wellness of EMS professionals in the United States. According to Healthy People 2010, top indicators of personal health include physical activity, body mass index (BMI), and smoking prevalence.The objectives of this study included quantifying existing health conditions and describing key health indicators among EMS professionals. It was hypothesized that work-life characteristics were associated with existing health conditions and key health indicators.Data utilized for this analysis were obtained from a 2007 questionnaire included in biennial national recertification packets. This questionnaire utilized validated items from the Behavioral Risk Factor Surveillance System (BRFSS) and the Longitudinal EMT Attributes and Demographics Study (LEADS). Along with common demographic characteristics, items inquired about existing health conditions (diabetes, asthma, hypertension, myocardial infarction, angina, stroke, and/or high blood cholesterol level), general health, physical activity, and smoking status. Descriptive analyses were performed utilizing chi-square tests, and logistic regression was utilized to describe associations between existing health conditions and the key health indicators.There were 58,435 individuals who became recertified in 2007, with 30,560 (52%) returning questionnaires. Individuals with missing data were removed, leaving 19,960 individual records. There were 4,681 (23.5%) individuals who reported at least one existing health condition. The mean BMI for the study participants was 27.69 kg/m(2). There were 5,742 (28.8%) individuals classified as having normal weight and 5,146 (25.8%) who were obese. The overwhelming majority of individuals did not meet the Centers for Disease Control and Prevention (CDC) recommendations for physical activity (15,022, 75.3%). There were 3,394 (17.0%) individuals classified as current smokers. Finally, logistic regression analysis indicated that when controlling for work-life characteristics and age, BMI and level of physical fitness were associated with preexisting health conditions.This study was the first known baseline assessment of EMS professionals regarding the key health indicators identified by Healthy People 2010. Investigations regarding the impact of health and wellness in relation to workforce stability should be undertaken. Further research should also be conducted to identify strategies to improve the health of the EMS workforce.

To identify the specific educational strategies used by paramedic educational programs that have attained consistently high success rates on the National Registry of Emergency Medical Technicians (NREMT) examination.NREMT data from 2003-2007 were analyzed to identify consistently high-performing paramedic educational programs. Representatives from 12 programs that have maintained a 75% first-attempt pass rate for at least four of five years and had more than 20 graduates per year were invited to participate in a focus group. Using the nominal group technique (NGT), participants were asked to answer the following question: "What are specific strategies that lead to a successful paramedic educational program?"All 12 emergency medical services (EMS) educational programs meeting the eligibility requirements participated. After completing the seven-step NGT process, 12 strategies were identified as leading to a successful paramedic educational program: 1) achieve and maintain national accreditation; 2) maintain high-level entry requirements and prerequisites; 3) provide students with a clear idea of expectations for student success; 4) establish a philosophy and foster a culture that values continuous review and improvement; 5) create your own examinations, lesson plans, presentations, and course materials using multiple current references; 6) emphasize emergency medical technician (EMT)-Basic concepts throughout the class; 7) use frequent case-based classroom scenarios; 8) expose students to as many prehospital advanced life support (ALS) patient contacts as possible, preferably where they are in charge; 9) create and administer valid examinations that have been through a review process (such as qualitative analysis); 10) provide students with frequent detailed feedback regarding their performance (such as formal examination reviews); 11) incorporate critical thinking and problem solving into all testing; and 12) deploy predictive testing with analysis prior to certification.Twelve specific strategies were identified by representatives from high-performing paramedic education programs. Further study should be conducted to determine whether implementation of these recommendations would improve program pass rates on the NREMT credentialing examination and improve entry-level paramedic field performance.

In emergency medical services (EMS), it has been accepted that continued cognitive competency can be impacted through continuing education (CE).The objective of this study was to assess the continued cognitive competence of emergency medical technicians-basic (EMT-Basics) practicing in low-frequency environments. It was hypothesized that an individual's continued cognitive competence would be associated with hours of continuing education and frequency of patient encounters.Data collection occurred at two state EMS conferences. These states were selected because they were closely matched on many demographic characteristics. Selection criteria required that participants be currently state-licensed/certified EMT-Basics and in attendance at their respective state conference. Individuals were asked to complete a demographic survey and the National Registry of Emergency Medical Technicians' (NREMT's) computer-adaptive EMT-Basic cognitive examination. The outcome variable for this study was an individual's pass or fail of the cognitive portion of the NREMT-Basic certification examination. Independent variables assessed included number of continuing education hours in the preceding 12 months, call volume in a typical week, gender, and level of education. Multivariable logistic regression was used to identify variables significantly associated with the outcome.There were 127 (53.1%) participants from state A and 112 (46.9%) participants from state B. Overall, 151 (63.2%) individuals met or exceeded the passing standard of the NREMT-Basic cognitive examination, with 90 (70.9%) passing in state A and 61 (54.5%) passing in state B. Individuals reported an average of 48.6 continuing education hours. A clear majority of individuals reported responding to 0 or 1 call in a typical week. A logistic regression model was constructed in which level of education and volunteer status were significantly associated with passing the examination. After adjustment, amount of continuing education and call volume were not significantly associated with passing the NREMT-Basic certification examination.This study assessed the cognitive competency of currently state-certified EMT-Basics in a low-frequency practice environment using the current NREMT-Basic cognitive examination. Variables commonly assumed to be associated with continued cognitive competence, hours of CE and practice frequency, were not significantly associated with success on the cognitive examination.

Introduction: This study intended to describe the types of organizations and communities in which Nationally Registered First Responders (NRFR) perform their duties. Also, it aimed to estimate the number of NRFR who received disaster preparedness training. It was hypothesized that NRFR participation in disaster preparedness training was related to the types of organizations and communities in which they performed their duties.Methods: The NRFR re-registering in 2006 were asked to report the organization type and community size in which they work. They also were asked to report the amount and content of preparedness training received during the last 24 months. Multivariable logistic regression modeling was utilized to describe the relationship between NRFR organizational characteristics and the receipt of disaster preparedness training.Results: The analysis included 872 (59%) individuals who completed the survey and reported working for one or more emergency medical services (EMS) organizations. The majority of NRFR performed work in rural areas (75%) and more NRFR reported working for fire departments (61%) than for any other organization type. In all categories of service type, participants who reported working in urban areas had higher odds of receiving disaster preparedness training than those working in rural areas. Additionally, regardless of community size, individuals working in fire departments were more likely to receive disaster preparedness training.Conclusions: This study indicated that the majority of NRFR perform EMS duties for fire departments and work in rural communities. In this sample of NRFR, more than one-quarter did not receive disaster preparedness training within a 24-month period. Finally, a statistical model was constructed that indicated a relationship between service type, community size, and the participation in disaster preparedness training.

The objective of this project was to identify the specific educational strategies used by emergency medical technician (EMT) educational programs that have attained consistently high success rates on the National Registry of Emergency Medical Technicians (NREMT) examination.NREMT data from 2001 to 2005 was analyzed in order to identify consistently high-performing EMT-Basic educational programs. Representatives from each program were invited to participate in a focus group. Using the nominal group technique (NGT), participants were asked to answer the following question: "What are specific strategies that lead to a successful EMT-Basic educational program?"Ten out of the 12 EMS educational programs meeting the eligibility requirements participated. After completing the seven-step NGT process, 12 strategies were identified as leading to a successful EMT-Basic educational program: 1) accept students who are highly motivated to succeed; 2) assure institutional support; 3) administer multiple assessments; 4) develop standardized lesson plans; 5) have a passing standard that is above the minimum competency level; 6) hire qualified/certified instructors; 7) maintain effective communication between didactic, practical, and field instructors; 8) maintain instructional consistency; 9) provide clearly defined objectives; 10) provide immediate feedback for written, practical evaluations to students; 11) require prerequisites; and 12) teach test-taking skills.Twelve specific strategies were identified by high-performing EMT-Basic programs. From these, seven recommendations to improve programmatic pass rates on the NREMT certification exam were derived. Further study should be conducted to determine if implementation of these recommendations improves programmatic pass rates on the NREMT certification exam.

Pediatric prehospital research has been limited, but work in this area is starting to increase particularly with the growth of pediatric-specific research endeavors. Given the increased interest in pediatric prehospital research, there is a need to identify specific research priorities that incorporate the perspective of prehospital providers and other emergency medical services (EMS) stakeholders.To develop a list of specific research priorities that is relevant, specific, and important to the practice of pediatric prehospital care.Three independent committees of EMS providers and researchers were recruited. Each committee developed a list of research topics. These topics were collated and used to initiate a modified Delphi process for developing consensus on a list of research priorities. Participants were the committee members. Topics approved by 80% were retained as research priorities. Topics that were rejected by more than 50% were eliminated. The remaining topics were modified and included on subsequent surveys. Each survey allowed respondents to add additional topics. The surveys were continued until all topics were either successfully retained or rejected and no new topics were suggested.Fifty topics were identified by the three independent committees. These topics were included on the initial electronic survey. There were 5 subsequent surveys. At the completion of the final survey a total of 29 research priorities were identified. These research priorities covered the following study areas: airway management, asthma, cardiac arrest, pain, patient-family interaction, resource utilization, seizure, sepsis, spinal immobilization, toxicology, trauma, training and competency, and vascular access. The research priorities were very specific. For example, under airway the priorities were: "identify the optimal device for effectively managing the airway in the prehospital setting" and "identify the optimal airway management device for specific disease processes."This project developed a list of relevant, specific, and important research priorities for pediatric prehospital care. Some similarities exist between this project and prior research agendas but this list represents a current, more specific research agenda and reflects the opinions of working EMS providers, researchers, and leaders.emergency medical technician; research; emergency medical services; priorities.

Objective To assess the validity of three different computerized electrocardiogram (ECG) interpretation algorithms in correctly identifying STEMI patients in the prehospital environment who require emergent cardiac intervention. Methods This retrospective study validated three diagnostic algorithms (AG) against the presence of a culprit coronary artery upon cardiac catheterization. Two patient groups were enrolled in this study: those with verified prehospital ST-elevation myocardial infarction (STEMI) activation (cases) and those with a prehospital impression of chest pain due to ACS (controls). Results There were 500 records analyzed resulting in a case group with 151 patients and a control group with 349 patients. Sensitivities differed between AGs (AG1 = 0.69 vs AG2 = 0.68 vs AG3 = 0.62), with statistical differences in sensitivity found when comparing AG1 to AG3 and AG1 to AG2. Specificities also differed between AGs (AG1 = 0.89 vs AG2 = 0.91 vs AG3 = 0.95), with AG1 and AG2 significantly less specific than AG3. Conclusions STEMI diagnostic algorithms vary in regards to their validity in identifying patients with culprit artery lesions. This suggests that systems could apply more sensitive or specific algorithms depending on the needs in their community.

Background The objective of this study was to estimate the prevalence and incidence of job-related illness or injury resulting in lost work time among a national cohort of Emergency Medical Services (EMS) professionals. Also, it was hypothesized that individual and work life characteristics were associated with the occurrence of illnesses or injury. Methods Data for this analysis were obtained from the Longitudinal Emergency Medical Technician Attributes and Demographics Study (LEADS), a prospective study of EMS professionals. The outcome variable of interest was self-reported absence from their EMS job due to an EMS work related illness or injury. The prevalence and incidence of injury with lost work time was estimated using cross-sectional and follow-up data. Multivariable logistic regression analyses were performed to determine if individual and work life characteristics were associated with occupational injury. Results The prevalence of job-related illness or injury with time away from work was estimated at 9.4%, while the 1-year incidence was estimated at 8.1 per 100 EMS providers. The results from the logistic regression model fit to follow-up data indicate that increasing call volume (OR = 3.12 for very high vs. moderate, 95% CI 1.40–6.97), an urban work environment (OR = 2.79, 95% CI 1.65–4.72) and a history of back problems (OR = 1.72, 95% CI 1.06–2.78) were associated with reporting job-related illness or injury. Conclusions Results from this analysis provide estimates of the prevalence and incidence of on the job illness and injury resulting in lost work time among a national cohort of EMS professionals. Am. J. Ind. Med. 50:921–931, 2007. © 2007 Wiley-Liss, Inc.

Introduction Back problems are a common complaint among emergency medical technicians (EMTs). It is hypothesized that the likelihood of reporting back problems will be associated with the individual and work-related characteristics of a national sample of EMTs. Methods A case-control analysis was performed on 579 EMTs wherein cases were the 104 subjects who reported new back problems in 2004. Controls were 475 subjects who reported no back problems in 2003 and 2004. Results EMTs dissatisfied with their current assignment were significantly more likely to report back problems (OR = 9.33; 95% CI = 3.04-28.67), as were EMTs reporting good or fair fitness when compared to excellent fitness (OR = 3.39; 95% CI = 1.54-7.45, OR = 3.43; 95% CI = 1.37-8.56). Conclusions Results from this analysis suggest that there are two modifiable factors associated with self-reported back problems among EMTs, satisfaction with current assignment and self-reported physical fitness.

Understanding the geographic distribution of critical illness within a community may provide public health stakeholders with information that can be used to expedite access to specialized care. We hypothesized that severe sepsis patients transported by emergency medical services (EMS) exhibit geospatial clustering and that prehospital providers would recognize sepsis more frequently in patients transported from sepsis clusters. Retrospective review of a prospective, observational study of patients with severe sepsis transported to the emergency department (ED) by EMS and treated with early goal-directed therapy (EGDT).suspected infection, 2 or more criteria for systemic inflammation, and either systolic blood pressure90 mmHg after a fluid bolus or lactate4 mmol/liter.age18 or need for immediate surgery. Patient location at the time of EMS activation was recorded. Analysis of the addresses identified clusters, defined as a location in which EMS transported more than one patient experiencing the above associated signs and symptoms of septic shock. Other data collected included self-reported patient location as private residence or chronic care facility. One hundred sixty severe sepsis patients transported by EMS were eligible for analysis, presenting from 125 locations. Ninety-one patients (57%) presented from a private residence and 69 (37%) from a chronic care facility. Fifty (31%) patients were transported from 15 locations, with 25 of those transported from just 4 locations. Cluster patients tended to be older, come from medical facilities, and were more likely to have sepsis recognized by prehospital providers. Results from this study demonstrate low pre-hospital recognition of sepsis, as well as geospatially clustered presentations, most notably from skilled nursing facilities. Community education, public health initiatives, and EMS interventions could be targeted in such clusters of cases in order to both improve sepsis recognition and potentially expedite time-sensitive interventions.

Objective: Despite growing adoption, the impact of prehospital initiation of therapeutic hypothermia on outcomes of cardiac arrest patients is unknown. The objective of this study was to determine if prehospital administration of cold intravenous fluids improved the time-to-target temperature.Methods: All patients enrolled in an institutional post– cardiac arrest treatment pathway were prospectively registered into a quality assurance database. Patients undergoing cooling induction on hospital arrival were compared to those receiving a new treatment protocol initiated during the study period involving prehospital cooling with 4°C (39.2°F) normal saline. The primary outcome was the time-to-target temperature. Secondary outcomes included emergency medicine system transport time metrics, mortality, and neurologic status at discharge and 1 year.Results: One hundred thirty-two patients were enrolled during the study period. The initial rhythm was ventricular fibrillation/tachycardia in 63% and asystole/pulseless electrical activity in 36%. Eighty patients received prehospital cooling and 52 patients did not and comprised the historical control group. Time-to-target temperatures were not significantly different between prehospital and hospital cooled groups (256 v. 271 minutes, respectively, p=0.64), nor was there any improvement in hospital survival (54% v. 50%, p=0.67), good neurologic outcome (49% v. 44%, p=0.61), or 1- year survival (49% v. 42%, p=0.46) between the two groups. Transport times were longer in the prehospital cooled group.Conclusions: Out-of-hospital cardiac arrest patients treated with prehospital cooling before arrival at our urban hospital did not have faster time-to-target temperature or improvement in outcomes compared to patients cooled immediately on emergency department arrival. Further research is needed to determine if any benefits exist from prehospital cooling prior to its widespread adoption.

Objectives Cardiac arrest is a leading cause of death in the United States, with pulseless electrical activity (PEA) as a common initial arrest rhythm. We sought to determine if rate of electrical activity and QRS width correlate with survival in patients who present with PEA out-of-hospital cardiac arrest. Methods and results This is a retrospective review of patients with PEA out-of-hospital cardiac arrest with first documented cardiac rhythm of PEA from January 2010 to September 2013. Demographic, arrest and initial rhythm characteristics, and patient outcome were abstracted via systematic chart review. The initial 20 seconds of each rhythm strip were used to ascertain electrical rate and QRS width. Primary outcome was survival to hospital discharge. Four hundred fourteen patients were eligible for the study. One hundred fifty-two patients did not have sufficient data for analysis. Two hundred sixty-two patients were included in the final analysis with mean age, 66 years. There were 23 (8.8%) survivors and 17 (6.5%) neurologically intact survivors. Mean heart rate was 58 (confidence interval, 54-63) beats per minute, and mean QRS interval was 100 (confidence interval, 95-106) milliseconds. Twenty-nine point seven percent of patients had wide QRS complexes, and 70.3% were narrow. There was no difference in survival in patients based on heart rate (13.1% vs 7.4%, P = .16) or QRS interval (8.7% vs 7.7%, P = .79). Conclusions In this single emergency medical services agency study, neither PEA electrical rate nor QRS width correlated with survival or neurologic outcome.

Although EMS agencies have been designed to efficiently provide medical assistance to individuals, the overuse of 9-1-1 as an alternative to primary medical care has resulted in the need for new methods to respond to this increasing demand. Our study analyzes the efficacy of classifying specific low-acuity calls that can be transferred to an advice-line nurse for further medical instruction. The objectives of our study were to analyze the impact of implementing this protocol and resultant patient feedback regarding the transfer to an advice-line nurse.We collected data for retrospective review from April 2011 to April 2012 from a single municipal EMS agency with an average annual call volume of approximately 90,000. Medical Priority Dispatch System response codes were assigned to calls based on patient acuity. Patients classified under Omega response codes were assessed for eligibility of transfer to nurse advice lines. Exclusion criteria included the following: if the call was placed by a third-party caller; if the patient refused to be transferred to the advice-line nurse; anytime the MPDS system was not used; if the patient was referred from a skilled nursing facility, school, or university nursing office, or physician's office. Telephone surveys were conducted for those patients who spoke to an advice-line nurse and did not receive an ambulance response 24 hours after calling 9-1-1 to obtain patient feedback.The database included 1660 patients initially classified as Omega and eligible for transfer to an advice-line nurse. After applying the exclusion criteria, 329 (19.8%) patients were ultimately transferred to an advice-line nurse and 204 (12.3%) received no ambulance response. Of those patients who were not transported by ambulance 118 (57.8%), patients completed telephone follow-up, with 104 (88.1%) reporting the nontransport option met their health-care needs and 108 (91.5%) responding they would accept the transfer again for a similar complaint.We identified an average of two patients per day as eligible for transfer to the nurse advice line, with less than one patient successfully completing the Omega protocol per day. While impact was limited, there was a decrease in ambulance response.

Our objective was to determine whether there is an association between a patient's impression of his or her overall quality of care and his or her satisfaction with the pain management provided. We hypothesized that satisfaction with pain management would show a significant positive association with a patient's impression of overall quality of care.This was a retrospective review of patient satisfaction data initially collected by a third-party company from January 1, 2007, to September 1, 2010. Participants were randomly selected from all transported patients, proportional to their paramedic-defined acuity level, with a goal of 100 interviews per month. The proportions of patients sampled from each acuity level were 25% priority 1 (high), 50% priority 2 (medium), and 25% priority 3 (low). Patients were excluded if there was no telephone number recorded in the prehospital patient record, no transportation was recorded, or the call was labeled as a psychiatric complaint. All satisfaction questions used a five-point Likert scale with ratings from excellent to poor, which were dichotomized for analysis. The outcome variable was the patient's perception of his or her overall quality of care. The main independent variable was the patient's rating of his or her pain management by emergency medical services (EMS) staff at the scene. Demographic variables were assessed for potential confounding.There were 2,741 patients with complete data for the outcome and main independent variables; 41.7% of the respondents were male and the average age was 54.1 years (standard deviation = 22.6). The overall quality of care was rated as excellent by 65.9% of the patients, whereas 59.2% rated their pain management as excellent. Of the patients who rated their pain management as excellent, 79.0% rated the overall quality of care as excellent, whereas only 21.0% of the patients rated the overall quality of care as excellent if pain management was not excellent. When the patients rated EMS staff as excellent for both helping to control or reduce pain and explaining the medications given, they were 2.7 (95% confidence interval 1.4-5.4) times more likely to rate their overall quality of care as excellent.Our model indicated that pain management was associated with increased perception of overall quality of care only when EMS providers explained the medications provided and their potential side effects.

Background: A growing number of states are enacting legislation or regulations that direct emergency medical service (EMS) routing to state designated or Joint Commission Certified Stroke Centers, based on prehospital stroke screens performed by EMS providers. Objective: Assess the sensitivity and specificity of the Cincinnati Prehospital Stroke Screen (CPSS) and the Los Angeles Prehospital Stroke Screen (LAPSS) when performed by EMS providers in the context of a state-wide EMS stroke patient transport protocol. Methods: We used a validated method of deterministic matching to link a statewide Prehospital Medical Information System database, that includes prehospital stroke screen results, to a Statewide Emergency Department (ED) Surveillance System database containing ED disposition diagnosis ICD-9 codes. We compared EMS stroke screen results to the ED ICD-9 codes for ischemic and hemorrhagic stroke and TIA. Results: Over a 24 month period, we identified 3,901 linked records with a prehospital impression of acute stroke. This included 2,419 (62%) records with a completed and conclusive stroke screen result. There were 1,202 patients (50%) with a completed CPSS and 1,217 patients (50%) with a completed LAPSS. Ninety-four EMS agencies from 65 of the state’s 100 counties were represented in the complete data. The CPSS was 80% (95% CI 76-83%) sensitive and 46% (95% CI 42-50%) specific, whereas the LAPSS was 73% (95% CI 69-76%) sensitive and 42% (95% CI 38-46%) specific for identifying patients with an ED diagnosis of stroke or TIA. Conclusion: When performed and conclusively recorded by many different EMS agencies across one state, the CPSS and LAPSS had similar test characteristics. If prehospital screening is to be used to determine transport diversion to acute stroke centers, improving the specificity of these screens would be optimum.