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Evidence-Based Performance Measures for Emergency Medical Services Systems: A Model for Expanded EMS BenchmarkingA Statement Developed by the 2007 Consortium U.S. Metropolitan Municipalities' EMS Medical Directors (Appendix)
Prehospital Emergency Care
Abstract
There are few evidence-based measures of emergency medical services (EMS) system performance. In many jurisdictions, response-time intervals for advanced life support units andresuscitation rates for victims of cardiac arrest are the primary measures of EMS system performance. The association of the former with patient outcomes is not supported explicitly by the medical literature, while the latter focuses on a very small proportion of the EMS patient population andthus does not represent a sufficiently broad selection of patients. While these metrics have their place in performance measurement, a more robust method to measure andbenchmark EMS performance is needed. The 2007 U.S. Metropolitan Municipalties' EMS Medical Directors' Consortium has developed the following model that encompasses a broader range of clinical situations, including myocardial infarction, pulmonary edema, bronchospasm, status epilepticus, andtrauma. Where possible, the benefit conferred by EMS interventions is presented in the number needed to treat format. It is hoped that utilization of this model will serve to improve EMS system design anddeployment strategies while enhancing the benchmarking andsharing of best practices among EMS systems.
... 10 Although these early studies established a time-outcome relationship for OHCA, the idea of an 8-minute response time benchmark became an inviolable standard in many jurisdictions. In most EMS systems today, meeting the 8-minute advanced life support response in a minimum of 90% of calls is the benchmark of EMS quality 11 and is frequently tied to reimbursement. The evolution of this benchmark no doubt reflects the need of municipalities to quantify EMS quality, justify resources, and meet public expectation. ...
... Yet, we believe the time has come to emphasize a marker that measures proficiency earlier in the chain of survival and more closely addresses what matters most in the physiological aspects of cardiac arrest: the time from collapse to the initiation of CPR and defibrillation. 11,13,14 Studies worldwide speak to the value emergency medical telecommunicators can bring to facilitating bystander CPR. [15][16][17][18][19] If properly trained, these professionals can promptly recognize OHCA over the telephone and direct callers to start and continue CPR until professional rescuers assume care. ...
... The evaluation of clinical metrics, a key component of PEC system performance, is inherently dependent on timely and accurate data collection and sharing of hospital outcome data. 9 Inability to obtain hospital outcome data has previously been associated as a barrier to implementing QI programmes in EMS in other settings. 10 Given the variety of countries represented in our study, we also note differences in cultural perceptions of data sharing as well as the regulatory use of data, which were raised as important points by some participants. ...
Objectives
Strengthening of emergency care systems, including prehospital systems, can reduce death and disability. We aimed to identify perspectives on barriers and facilitators relating to the development and implementation of a prehospital emergency care system assessment tool (PEC-SET) from prehospital providers representing several South and Southeast (SE) Asian countries.
Design
We conducted a qualitative study using focus group discussions (FGD) informed by the Consolidated Framework for Implementation Research (CFIR). FGDs were conducted in English, audioconferencing/videoconferencing was recorded, transcribed verbatim and coded using an inductive and deductive approach. Participants suggested specific elements to be measured within three main ‘pillars’ of disease conditions proposed by the research team of the tool being developed (cardiovascular, trauma and perinatal emergencies).
Setting
We explored the perspectives of medical directors in six low-income and middle-income countries (LMICs) in South and SE Asia.
Participants
A total of 16 participants were interviewed (1 Vietnam, 4 Philippines, 4 Thailand, 5 Malaysia, 1 Indonesia and 1 Pakistan) as a part of 4 focus groups.
Results
Themes identified within the four CFIR constructs included: (1) Intervention characteristics: importance of developing an contextually specific tool, need for generalisability, trialling in one geographical area or with one pillar before expanding; (2) Inner setting: data transfer barriers, workforce shortages; (3) Outer setting: underdevelopment of EMS nationally; need for further EMS system development prior to implementing a tool and (4) Individual characteristics: lack of buy-in by prehospital personnel. Elements proposed by participants included both process and outcome measures.
Conclusions
Through the CFIR framework, we identified several themes which can provide a basis for codeveloping a PEC-SET for LMICs with local stakeholders. This work may inform development of quality improvement tools in LMIC PEC systems.
... The quick arrival of emergency vehicles (ambulances, fire trucks, etc.) on the scene is crucial to protect human life and safety (Sarı, 2017). Especially ambulance vehicles are essential to solving vital problems such as accident trauma or heart attack (Myers et al., 2008). In this context, the health centre's response time to emergency vehicle signals must be reduced to decrease the death risk (H. ...
Urban population and expansion continue to rise, as have emergencies, and emergency response times are becoming longer in the city. Response times are critical in urban emergency management. Traditional navigation systems do not consider the preferential road usage rights and requirements crucial for emergency teams such as ambulances, fire departments, and police. In traditional navigation systems, features such as safety lanes and road width are not incorporated as routing criteria. Past emergency navigation studies do not contain many variables and this causes delays in emergency response processes. As a result, applications that process real-time traffic information and provide guidance according to different vehicle types are needed for emergency management.. This study aims to develop an application capable of routing for different vehicles according to criteria such as working hours, holidays, weather conditions, and seasonal effects. The application is developed with a novel approach in this context using machine learning methods and produces alternate routes with GPS navigation based on the real-time traffic situation. Moreover, the software also provides routing solutions for trucks, freight distribution, and automobiles and recommends unique routes for emergency vehicles based on factors including safety lanes, road width, corner turning angles, and right of way. The expected outcomes upon implementing this application include easy and fast access to the emergency locations, reduced response times, and improvement in urban emergency management services.
... The work of paramedics requires a high level of technical competence and involves both quick decision-making and the ability to act accurately and swiftly (Bitan, 2017;Myers et al., 2008). Paramedics provide immediate life support such as Cardiopulmonary Resuscitation (CPR) during out-of-hospital cardiac arrest. ...
This study investigates how the positions of paramedic equipment bags affect paramedic performance and biomechanical loads during out-of-hospital Cardiopulmonary Resuscitation (CPR). An experiment was conducted in which 12 paramedic teams (each including two paramedics) performed in-situ simulations of a cardiac-arrest scenario. CPR quality was evaluated using five standard resuscitation measures (i.e., pre- and post-shock pauses, and compression rate, depth and fraction). The spinal loads while lifting, pulling and pushing the equipment bags were assessed using digital human modeling software (Jack) and prediction equation from previous studies. The results highlight where paramedics are currently choosing to position their equipment. They also demonstrate that the positions of the equipment bags affect CPR quality as well as the paramedics' work efficiency, physiological effort and biomechanical loads. The spinal loads ranged from 1901 to 4030N; furthermore, every occasion on which an equipment bag was lifted resulted in spinal forces higher than 3400N, thus exceeding the maximum threshold stipulated by the National Institute for Occupational Safety and Health. 72% of paramedics' postures were categorized as high or very high risk for musculoskeletal disorders by the Rapid Entire Body Assessment. Guidelines related to bag positioning and equipment handling might improve CPR quality and patient outcomes, and reduce paramedics' risk of injury.
... These findings do not necessarily imply that EMS should simply drive faster, but rather that trauma systems should be organized to achieve a quick response to MVCs. Approaches to shortening response time intervals include ensuring adequate numbers 43 and optimizing the distribution of first-responding units in a dynamic and predictive fashion. 44 In regions where geographic and resource constraints are especially limiting, improvements to on-board telematics systems that predict the risk of severe injury may serve to better triage deployment. ...
Importance
Motor vehicle crashes (MVCs) are a leading public health concern. Emergency medical service (EMS) response time is a modifiable, system-level factor with the potential to influence trauma patient survival. The relationship between EMS response time and MVC mortality is unknown.
Objectives
To measure the association between EMS response times and MVC mortality at the population level across US counties.
Design, Setting, and Study Population
This population-based study included MVC-related deaths in 2268 US counties, representing an estimated population of 239 464 121 people, from January 1, 2013, through December 31, 2015. Data were analyzed from October 1, 2017, through April 30, 2018.
Exposure
The median EMS response time to MVCs within each county (county response time), derived from data collected by the National Emergency Medical Service Information System.
Main Outcomes and Measures
The county rate of MVC-related death, calculated using crash fatality data recorded in the Fatality Analysis Reporting System of the National Highway Traffic Safety Administration.
Results
During the study period, 2 214 480 ambulance responses to MVCs were identified (median, 229 responses per county [interquartile range (IQR), 73-697 responses per county]) in 2268 US counties. The median county response time was 9 minutes (IQR, 7-11) minutes. Longer response times were significantly associated with higher rates of MVC mortality (≥12 vs <7 minutes; mortality rate ratio, 1.46; 95% CI, 1.32-1.61) after adjusting for measures of rurality, on-scene and transport times, access to trauma resources, and traffic safety laws. This finding was consistent in both rural/wilderness and urban/suburban settings, where a significant proportion of MVC fatalities (population attributable fraction: rural/wilderness, 9.9%; urban/suburban, 14.1%) were associated with prolonged response times (defined by the median value, ≥10 minutes and ≥7 minutes, respectively).
Conclusions and Relevance
Among 2268 US counties, longer EMS response times were associated with higher rates of MVC mortality. A significant proportion of MVC-related deaths were associated with prolonged response times in both rural/wilderness and urban/suburban settings. These findings suggest that trauma system–level efforts to address regional disparities in MVC mortality should evaluate EMS response times as a potential contributor.
... Data that we have collected indicates that this physical strain may be due, in part, to the fact that the paramedic's equipment is arbitrarily placed around the patient (Bitan & Jaffe, 2017). In addition to the physical effort, inadequate access to the equipment may diminish a paramedic's performance by decreasing the quality of the treatment and increasing the chance of errors (Myers et al., 2008;Harari et al., 2017;Harari et al., 2018). The objective of this study is to investigate the influence of equipment position on the paramedic's performance and level of effort during out-of-hospital resuscitation. ...
... These variables have been adopted from the quarterly report card published from 12 National Health Service (NHS) Ambulance Trusts in U.K. and from 2007 consortium of US metropolitan municipalities' EMS medical directors. [20,21] The time period for evaluating individual performance in this study was taken as three months. The three months was derived from human resource policy of probationary period for new job commencement which assumes that three months provides sufficient time to evaluate an individual's performance. ...
Background:
The purpose of the study was to explore the association between post-traumatic stress disorder (PTSD) and work performance of emergency medical services personnel in Karachi, Pakistan.
Methods:
Emergency medical service personnel were screened for potential PTSD using Impact of Event Scale-Revised (IES-R). Work performance was assessed on the basis of five variables: number of late arrivals to work, number of days absent, number of days sick, adherence to protocol, and patient satisfaction over a period of 3 months. In order to model outcomes like the number of late arrivals to work, days absent and days late, negative binomial regression was applied, whereas logistic regression was applied for adherence to protocol and linear for patient satisfaction scores.
Results:
Mean scores of PTSD were 24.0±12.2. No association was found between PTSD and work performance measures: number of late arrivals to work (RRadj 0.99; 0.98-1.00), days absent (RRadj 0.98; 0.96-0.99), days sick (RRadj 0.99; 0.98-1.00), adherence to protocol (ORadj 1.01; 0.99-1.04) and patient satisfaction (β 0.001%-0.03%) after adjusting for years of formal schooling, living status, coping mechanism, social support, working hours, years of experience and anxiety or depression.
Conclusion:
No statistically significant association was found between PTSD and work performance amongst EMS personnel in Karachi, Pakistan.
... A 2007 consensus statement from the U.S. Metropolitan Municipalities' Emergency Medical Services (EMS) Medical Directors titled Evidence-Based Performance Measures for Emergency Medical Services Systems: A Model for Expanded EMS Benchmarking identified "crude measures of stakeholder satisfaction and other anecdotal measures" as the primary evaluation source of EMS system performance. 1 A lack of standardized evidence-based metrics limits local EMS system analysis. 2 Several agencies, including the Commission on the Accreditation of Ambulance Services and National Park Service (NPS) and North Carolina College of Emergency Physicians, have created objective criteria to evaluate EMS systems. ...
Introduction:
As part of a Military Emergency Medical Services (EMS) system process improvement initiative, the authors sought to objectively evaluate the U.S. military EMS system for the island of Okinawa. They applied a program evaluation tool currently utilized by the U.S. National Park Service (NPS).
Methods:
A comprehensive needs assessment was conducted to evaluate the current Military EMS system in Okinawa, Japan. The NPS EMS Program Audit Worksheet was used to get an overall "score" of our assessment. After all the data had been collected, a joint committee of Military EMS physicians reviewed the findings and made formal recommendations.
Results:
From 2011 to 2014, U.S. military EMS on Okinawa averaged 1,345 ± 137 patient transports annually. An advanced life support (ALS) provider would have been dispatched on 558 EMS runs (38%) based on chief complaint in 2014 had they been available. Over 36,000 man-hours were expended during this period to provide National Registry Emergency Medical Technician (EMT)-accredited instruction to certify 141 Navy Corpsman as EMT Basics. The NPS EMS Program Audit Worksheet was used and the program scored a total of 31, suggesting the program is well planned and operating within standards.
Conclusion:
This evaluation of the Military EMS system on Okinawa using the NPS program assessment and audit worksheet demonstrates the NPS evaluation instruments may offer a useful assessment tool for the evaluation of Military EMS systems.
... Does integrating evidence with clinical and policy decision-making make a difference to important outcomes? Importantly, previous work from the United States proposed EMS performance measures that were grounded in research evidence, 39 which has been expanded in the recent COMPASS project. 40 This shifts reliance from traditional performance indicators, such as response times, to indicators that reflect important outcomes, including clinical patient care and safety outcomes. ...
Nationally, emphasis on the importance of evidence-based practice (EBP) in emergency medicine and emergency medical services (EMS) has continuously increased. However, meaningful incorporation of effective and sustainable EBP into clinical and administrative decision-making remains a challenge. We propose a vision for EBP in EMS: Canadian EMS clinicians and leaders will understand and use the best available evidence for clinical and administrative decision-making, to improve patient health outcomes, the capability and quality of EMS systems of care, and safety of patients and EMS professionals. This vision can be implemented with the use of a structure, process, system, and outcome taxonomy to identify current barriers to true EBP, to recognize the opportunities that exist, and propose corresponding recommended strategies for local EMS agencies and at the national level. Framing local and national discussions with this approach will be useful for developing a cohesive and collaborative Canadian EBP strategy.
Zusammenfassung
Hintergrund
Qualitätsvergleiche mittels Qualitätsindikatoren sind ein bewährtes Verfahren im Qualitätsmanagement.
Ziel der Arbeit
Im Auftrag des Ausschusses Rettungswesen der Bundesländer erarbeitete und konsentierte eine Arbeitsgruppe (AG) Qualitätsindikatoren für ein länderübergreifendes Benchmarking im deutschen Rettungsdienst.
Material und Methoden
Ausgehend von übergeordneten Qualitätszielen trug die AG Indikatorkandidaten zusammen, welche in einem iterativen Gruppenprozess anhand von systematischen Gütebewertungen nach der QUALIFY-Methode verfeinert und selektioniert wurden. Im Anschluss fand eine Konsentierung durch die AG statt.
Ergebnisse
Neunzig Indikatorkandidaten wurden erstellt, diskutiert und bewertet, wovon 22 Kandidaten vertieft ausgearbeitet wurden. Zwanzig Indikatoren erreichten im Konsensusverfahren die notwendige Zustimmung. Nach weiteren Ausarbeitungen zur praktischen Umsetzung des Benchmarkings einschließlich Rechen- und Operationalisierungsregeln erfolgte eine Überarbeitung und Aktualisierung der Indikatoren gefolgt von einer Neukonsentierung, wobei ein Element in 6 spezifischere Indikatoren aufgesplittet wurde. Die AG schlägt nunmehr einen konsentierten Katalog von 25 Qualitätsindikatoren für den länderübergreifenden Qualitätsvergleich in der Notfallrettung (inklusive Beitrag der Leitstelle) vor.
Diskussion
Erstmals stehen länderübergreifend konsentierte Qualitätsindikatoren für den Rettungsdienst in der Bundesrepublik zur Verfügung, die sich jedoch für die länderübergreifende Verwendung noch bewähren müssen. Die organisatorischen Voraussetzungen für eine flächendeckende Umsetzung müssen vielerorts noch geschaffen werden.
The National Association of Emergency Medical Services Physicians (NAEMSP) advocates for Emergency Medical Services (EMS) to play an integral role in all phases of disaster management -preparedness, mitigation, response, and recovery. An inherently strong EMS system mitigates some of the negative impacts of disaster by supporting a more resilient population and a robust response capability. EMS must be a sustainable resource that is able to continue to provide care to the community even after a disaster response. This resource document will outline the basis for the corresponding NAEMSP position statement on the role of EMS in disaster management.
Background
An increasing number of patients receive ambulance care without being conveyed to a definitive care provider. This process has been described as complex, challenging, and lacking in guideline support by EMS clinicians. The use of quality- and outcome measures among non-conveyed patients is an understudied phenomenon.
Aim
To identify current quality- and outcome measures for the general population of non-conveyed patients in order to describe major trends and knowledge gaps.
Methods
A scoping review of peer-reviewed original articles was conducted to identify quality- and outcome measures for non-conveyance within emergency medical services. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews statement (PRISMA-ScR) was followed. The PROSPERO and OSF database were checked for pending reviews or protocols. PubMed, CINAHL, Scopus, Web of Science and the Cochrane Library database were searched for relevant articles. Searches were performed in November 2023.
Results
Thirty-six studies fulfilled the inclusion criteria and were included in the review. Mortality was the most used outcome measure, reported in 24 (67%) of the articles. Emergency department attendance and hospital admission were the following most used outcome measures. Follow-up durations varied substantially between both measures and studies. Mortality rates were found to have the longest follow-up times, with a median follow-up duration a little bit over one week.
Conclusions
This scoping review shows that studies report a wide range of quality and outcome measures in the ambulance setting to measure non-conveyance. Reported quality and outcome measures were also heterogeneous with regard to their follow-up timeframe. The variety of approaches to evaluate non-conveyance poses challenges for future research and quality improvement. A more uniform approach to reporting and measuring non-conveyance is needed to enable comparisons between contexts and formal meta-analysis.
Improving health and safety in our communities requires deliberate focus and commitment to equity. Inequities are differences in access, treatment, and outcomes between individuals and across populations that are systemic, avoidable, and unjust. Within health care in general, and Emergency Medical Services (EMS) in particular, there are demonstrated inequities in the quality of care provided to patients based on a number of characteristics linked to discrimination, exclusion, or bias. Given the critical role that EMS plays within the health care system, it is imperative that EMS systems reduce inequities by delivering evidence-based, high-quality care for the communities and patients we serve. To achieve equity in EMS care delivery and patient outcomes, the National Association of EMS Physicians recommends that EMS systems and agencies:make health equity a strategic priority and commit to improving equity at all levels.assess and monitor clinical and safety quality measures through the lens of inequities as an integrated part of the quality management process.ensure that data elements are structured to enable equity analysis at every level and routinely evaluate data for limitations hindering equity analysis and improvement.involve patients and community stakeholders in determining data ownership and stewardship to ensure its ongoing evolution and fitness for use for measuring care inequities.address biases as they translate into the quality of care and standards of respect for patients.pursue equity through a framework rooted in the principles of improvement science.
Introduction
Standards for Emergency Medical Services [EMS] have recently been introduced in South Africa in a movement towards the promotion of quality improvement. While these standards identify a minimum set of criteria for EMS quality they do not differentiate between services just meeting them and those exceeding them. Benchmarking may be a helpful exercise in beginning to address the question of comparative levels of capability in EMS beyond a set of minimum standards. The aim of this study was to develop a consensus-based capability benchmarking tool for EMS organizations within the South African context.
Methods
A total of 12 experts in the field of EMS in South Africa consented to participate in two Delphi Surveys in order to achieve consensus on the core components of an EMS organization as well as relevant level descriptors for those components. The resulting data was used to develop a consensus-based capability benchmarking tool for EMS organizations in South Africa.
Results
A consensus-based capability benchmarking tool was developed that allows organizations to distinguish whether the organization's capability, as a whole, is underdeveloped, developing, or well-developed. This is in addition to identifying how capable they are in all individual components or sub-components.
Conclusion
It is recommended that further research be conducted to assess this tool's implementation within different EMS organizations in South Africa, and that this study is used as a stepping-stone for additional research into meaningful quality improvement in emergency medical services in South Africa.
Background
Recently, the Norwegian Helicopter Emergency Medical Service (HEMS) has developed a procedure for a special type of static rope rescue operation, referred to as the offset technique. In this technique, the helicopter is offset from the accident site, and the HEMS technical crew member uses an offset throw line to gain access to the scene. Today, there is little practical experience of such operations, and a need has been identified for more knowledge on the potential hazards encountered during this type of operation. Such knowledge is of importance for further development of the procedure for the offset technique.
Objective
To identify potential hazards for helicopter rescue operations using the static rope offset technique and, thereby, to improve the procedure for such operations. This may lead to improved safety for patients and crew members during offset rescue operations.
Method
A Safe Job Analysis was used to identify the hazards of offset rescue operations. Such operations are divided into tasks and sub-tasks. For each sub-task, we identified potential hazards and suggested ways of preventing these.
Results
Through the Safe Job Analysis, we suggest some changes in the existing procedure for the offset technique, to make it more robust against potential hazards.
Conclusion
We have demonstrated the value of Safe Job Analysis for improving the static rope offset evacuation procedure. Our analysis has led to some changes in the procedure for offset rescue operations. This is the importance of having two throw lines and focusing on “why” in the procedure.
Background:
In 2019, the National EMS Quality Alliance (NEMSQA) established a suite of 11 evidence-based EMS quality measures, yet little is known regarding EMS performance on a national level. Our objective was to describe EMS performance at a response and agency level using the National EMS Information System (NEMSIS) dataset.
Methods:
The 2019 NEMSIS research dataset of all EMS 9-1-1 responses in the United States was utilized to calculate 10 of 11 NEMSQA quality measures. Measure criteria and pseudocode was implemented to calculate the proportion meeting measure criteria and 95% confidence intervals across all encounters and for each anonymized agency. We omitted Pediatrics-03b because the NEMSIS national dataset does not report patient weight. Agency level analysis was subsequently stratified by call volume and urbanicity.
Results:
Records from 9,679 agencies responding to 26,502,968 9-1-1 events were analyzed. Run-level average performance ranged from 12% for Safety-01 (encounter documented as initial response without the use of lights and siren to 82% for Pediatrics-02 (documented respiratory assessment in pediatric patients with respiratory distress) At the agency level, significant variation in measure performance existed by agency size and by urbanicity. At the individual agency performance analysis, Trauma-04 (trauma patients transported to trauma center) had the lowest agency-level performance with 47% of agencies reporting 0% of eligible runs with documented transport to a trauma center.
Conclusion:
There is a wide range of performance in key EMS quality measures across the United States that demonstrate a need to identify strategies to improve quality and equity of care in the prehospital environment, system performance and data collection.
Urban sprawl is the development of sparse suburban areas with low population density, limited land use diversity, and poor street connectivity. Numerous studies demonstrated that urban form settings influence indoor and outdoor environments and, consequently, public health in diverse ways. This review aims to assess the association between sprawl and each health outcome evaluated in the literature to better define urban sprawl and its effects on human health. Using the PRISMA statement, this narrative review evaluates the associations between urban sprawl and any health outcome analyzed by researchers seeking to assess a possible relationship. A total of 826 records were identified via PubMed/MEDLINE (227) and Scopus (599) and 36 studies were deemed suitable for inclusion: 21/36 studies (58%) focused on obesity as the primary health outcome, 4/36 (11%) on life expectancy and/or mortality, 7/36 (19%) on accidents or emergency medical service response, and 4/36 (11%) on the self-reported psychological distress and/or physical health conditions associated with urban sprawl. In most studies, there is a general lack of uniformity and urban sprawl is loosely defined, with urban sprawl definitions frequently corresponding to different combinations of items within sprawl indexes. Nonetheless, urban sprawl appeared to be a determinant of health in many of the examined outcomes; therefore, it is necessary to promote alternatives to sprawling patterns when developing urban settings.
Objective:
In the United States, police are often important co-responders to 911 calls with emergency medical services for medical emergencies. To date, there remains a lack of a comprehensive understanding of the mechanisms by which police response modifies time to in-hospital medical care for traumatically injured patients. Further, it remains unclear if differentials exist within or between communities. A scoping review was performed to identify studies evaluating prehospital transport of traumatically injured patients and the role or impact of police involvement.
Methods:
PubMed, SCOPUS, and Criminal Justice Abstracts databases were utilized to identify articles. English-language, US-based, peer-reviewed articles published on or prior to March 30, 2022 were eligible for inclusion.
Results:
Of 19,437 articles initially identified, 70 articles were selected for full review and 17 for final inclusion. Key findings included (1) current law enforcement practices involving scene clearance introduce the potential for delayed patient transport but to date there is little research quantifying delays; (2) police transport protocols may decrease transport times; and (3) there are no studies examining the potential impact of scene clearance practices at the patient or community level.
Conclusions:
Our results highlight that police are often the first on scene when responding to traumatic injuries and have an active role via scene clearance or, in some systems, patient transport. Despite the significant potential for impact on patient well-being, there remains a paucity of data examining and driving current practices.
Achieving and sustaining improvement in health care systems is challenging. This chapter introduces the aims and practice of quality improvement for medical directors and quality leaders to make meaningful improvement and change in their EMS systems, agencies, or regions. Based on the work of Edward Deming and other quality leaders who have transformed health care quality, this chapter outlines and applies the System of Profound Knowledge, the Model for Improvement, and the other key principles of the quality improvement approach. The chapter is divided into three sections. “Vision: Defining Quality” discusses how quality can transform the way business is done in EMS, recognizing that EMS is a practice of medicine and requires a reliable approach to health care quality. “Strategy: Using the Science of Quality and Performance to Create Improvement” applies the Model for Improvement to EMS and guides readers through the steps of quality improvement methodology. “Tactics: Reimagining the EMS Quality Improvement Program” reimagines standard tools of medical oversight in EMS in the context of the Model for Improvement.
Background:
After cardiac arrest, the possibility of death or irreversible complications will highly increase in the absence of cardiac resuscitation within 4 to 6 minutes. Accordingly, measuring the pre-hospital services time intervals is important for better management of emergency medical services delivery. The purpose of this study then was to investigate pre-hospital time intervals for patients with heart attack in Arak city, based on locations and time variables.
Methods:
This is a retrospective descriptive cross-sectional study, which was conducted at the Arak Emergency Medical Services (EMS) during 2017-2018. Data were analyzed by SPSS version 13.
Results:
The total number of heart attack patients registered in Arak emergency medical services was 2,659 of which 51% of patients were males. Six percent of patients were under 25 and about 49 percent were between 46 and 65 years old. The average of activation, response, on-scene, transportation, recovery and total time intervals were 3:30, 7:56, 15:15, 13:34, 11:07, 12:11, and 41:25, respectively. In the city area, the shortest and longest average response time intervals were in spring and winter, respectively. In out of the city area, the shortest average response time interval was in summer and the longest one in autumn. The shortest and the longest average response time intervals in the city area were in June and March, respectively, and in out of the city area, the shortest average response time interval was in June and the longest one in April.
Conclusions:
The shorter response and delivery time interval compared to the other studies may indicate improvement in the provision of EMS. Special attention should be paid to the facilities and equipment of vehicles during cold seasons to be in the shortest possible time. Also, training and informing the staff more about the code of cardiac patients along with general public education can help improve these intervals.
Introduction
Effective teamwork has been shown to optimize patient safety. However, research centered on the critical inputs, processes, and outcomes of team effectiveness in emergency medical services (EMS) has only recently begun to emerge. We conducted a theory-driven qualitative study of teamwork processes—the interdependent actions that convert inputs to outputs—by frontline EMS personnel in order to provide a model for use in EMS education and research.
Methods
We purposively sampled participants from an EMS agency in Houston, TX. Full-time employees with a valid emergency medical technician license were eligible. Using semi-structured format, we queried respondents on task/team functions and enablers/obstacles of teamwork in EMS. Phone interviews were recorded and transcribed. Using a thematic analytic approach, we combined codes into candidate themes through an iterative process. Analytic memos during coding and analysis identified potential themes, which were reviewed/refined and then compared against a model of teamwork processes in emergency medicine.
Results
We reached saturation once 32 respondents completed interviews. Among participants, 30 (94%) were male; the median experience was 15 years. The data demonstrated general support for the framework. Teamwork processes were clustered into four domains: planning; action; reflection; and interpersonal processes. Additionally, we identified six emergent concepts during open coding: leadership; crew familiarity; team cohesion; interpersonal trust; shared mental models; and procedural knowledge.
Conclusion
In this thematic analysis, we outlined a new framework of EMS teamwork processes to describe the procedures that EMS operators employ to convert individual inputs into team performance outputs. The revised framework may be useful in both EMS education and research to empirically evaluate the key planning, action, reflection, and interpersonal processes that are critical to teamwork effectiveness in EMS.
Introduction: Multiple national organizations have identified a need to incorporate more evidence-based medicine in emergency medical services (EMS) through the creation of evidence-based guidelines (EBGs). Tools like the Appraisal of Guidelines for Research and Evaluation (AGREE) II and criteria outlined by the National Academy of Medicine (NAM) have established concrete recommendations for the development of high-quality guidelines. While many guidelines have been created that address topics within EMS medicine, neither the quantity nor quality of prehospital EBGs have been previously reported.
Objectives: To perform a systematic review to identify existing EBGs related to prehospital care and evaluate the quality of these guidelines using the AGREE II tool and criteria for clinical guidelines described by the NAM.
Methods: We performed a systematic search of the literature in MEDLINE, EMBASE, PubMED, Trip, and guidelines.gov, through September 2018. Guideline topics were categorized based on the 2019 Core Content of EMS Medicine. Two independent reviewers screened titles for relevance and then abstracts for essential guideline features. Included guidelines were appraised with the AGREE II tool across 6 domains by 3 independent reviewers and scores averaged. Two additional reviewers determined if each guideline reported the key elements of clinical practice guidelines recommended by the NAM via consensus.
Results: We identified 71 guidelines, of which 89% addressed clinical aspects of EMS medicine. Only 9 guidelines scored >75% across AGREE II domains and most (63%) scored between 50-75%. Domain 4 (Clarity of Presentation) had the highest (79.7%) and domain 5 (Applicability) had the lowest average score across EMS guidelines. Only 38% of EMS guidelines included a reporting of all criteria identified by the NAM for clinical practice guidelines, with elements of a systematic review of the literature most commonly missing.
Conclusions: EBGs exist addressing a variety of topics in EMS medicine. This systematic review and appraisal of EMS guidelines identified a wide range in the quality of these guidelines and variable reporting of key elements of clinical guidelines. Future guideline developers should consider established methodological and reporting recommendations to improve the quality of EMS guidelines.
Background: Quality Indicator (QI) appraisal protocols are a novel methodology that combine multiple appraisal methods in order to comprehensively assess the “appropriateness” of QIs for a particular healthcare setting. However, they remain inadequately explored compared to the single appraisal method approach. The aim of this paper was to describe and test a QI appraisal protocol versus the single method approach, against a series of QIs potentially relevant to the South African Prehospital Emergency Care setting.
Methods: An appraisal protocol was developed consisting of two categorical-based appraisal methods, the Qualify tool and Rand/Appropriateness method, combined with the qualitative analysis of the discussion generated during the consensus application of each method, by a QI Appraisal Working Group. Inter-rater reliability of each individual method was assessed prior to group consensus rating. Variation in the number of non-valid QIs identified between each method and the proportion of non-valid QIs identified between each method and the protocol were compared and assessed.
Results: There was mixed inter-rater reliability of the individual methods prior to the group consensus. There was similarly poor to moderate correlation of the results obtained between the individual methods (Spearman’s rank correlation = 0.42, p<0.001). From a series of 104 QIs, 11 were identified that were shared between the appraisal methods. A further 19 QIs were identified and not shared by each method, highlighting the benefits of a multimethod approach. There was little evidence to support a difference in the proportion of non-valid QIs identified between individual methods (difference=-0.03); between the Quality tool and the protocol (difference=-0.05); or between the Rand method and the protocol (difference=-0.02). The outcomes were additionally evident in the group discussion analysis, which in and of itself added further input towards understanding and appraising the appropriateness of the QIs that would not have otherwise been captured or understood by the individual methods alone.
Conclusion: The utilisation of a multi-method appraisal protocol offers multiple benefits, when compared to the single appraisal approach, and can provide the confidence that the outcomes of the appraisal will ensure a strong foundation on which the measurement framework can be QI successfully implemented and employed.
Objectives:
To assess the mass casualty incident (MCI) preparedness of pre-hospital care providers in Saudi Arabia and to identify and highlight their strengths and weaknesses when responding to MCIs. Methods: This cross-sectional descriptive quantitative analysis was conducted between January 2017 and 2018 and included all Saudi Red Crescent Authority (SRCA) general administration branches in 13 regions in Saudi Arabia. The modified version of the emergency medical specialists (EMS) incident response and readiness assessment (EIRRA) tool was used in this study. Results: The Makkah region has the largest number of ambulances and medics vehicles, followed by Riyadh. Makkah and Al Madinah Al Munawarah obtained a median score of 4 and showed substantial preparedness for MCIs. However, Al Madinah Al Munawarah showed higher level of MCI preparedness than Makkah, and a significant difference was found (p=0.019). By contrast, Riyadh and the Eastern region showed limited MCI preparedness. In addition, a moderate positive correlation was observed between the overall median scores and the number of physicians (r=0.656 and p=0.015). Conclusion: The SRCA showed substantial preparedness in Makkah and Al Madinah Al Munawarah. The SRCA were highly prepared to face MCIs.
Background: Chest pain is a leading complaint in emergency settings. Timely emergency medical services (EMS) responses can reduce delays to treatment and improve clinical outcomes for acute myocardial infarction patients and other medical emergencies. We investigated national-level EMS response, scene, and transport times for acute chest pain patients in the United States.
Methods: A retrospective analysis was performed using 2015-2016 data from the National EMS Information System (NEMSIS). Eligible patients were identified as having a provider impression of chest pain or discomfort and not due to trauma or resulting in cardiac arrest during EMS care. Descriptive analyses of prehospital time intervals and patient-, response-, and system-level covariates were performed. Multivariable logistic regression was used to measure associations between meeting response and scene time benchmarks (8-min and 15-min, respectively) and covariates.
Results: Our study identified 1,672,893 eligible EMS encounters of chest pain. Patients had a mean age of 63.1 years (SD, 14.8). The population was evenly distributed by sex (51% male; 49% female). Most encounters occurred in home or residence (58%) and had lights and sirens response to scene (84%). Most encounters were in urban areas (78%). The median (interquartile range, IQR) response time was 7 (5-10) minutes. The median (IQR) scene time was 16 (12-20) minutes. The median (IQR) transport time was 13 (8-20) minutes. Generally, median response and transport times were longer in rural and frontier areas compared to urban and suburban areas. Only 65% and 49% met the 8-min response and 15-min scene time benchmarks. Responding with lights and sirens was associated with greater compliance with EMS response time benchmark. EMS care of older age groups and females was less likely to meet the scene time benchmark.
Conclusions: Substantial proportions of EMS encounters for chest pain did not meet response and scene time benchmarks. Regional and urban-rural differences were observed in adherence with the response time benchmark. Our findings also suggest age and gender disparities in on-scene delays by EMS. Our study contributes important evidence on timely EMS responses for cardiac chest pain and provides suggestions for EMS system benchmarking and quality improvement.
Background:
The burden of out-of-hospital cardiac arrest (OHCA) on different population segments in developing countries is not well studied. Previous studies from Lebanon report poor survival to hospital discharge (4.8%-5.5%). This study describes characteristics and outcomes of young OHCA victims in Beirut, Lebanon METHODS: This retrospective observational study included young patients (<35 years of age) with OHCA admitted to the emergency department (ED) of a tertiary care center in Lebanon over a 10-year period.
Results:
Fifty-four patients with OHCA were identified. Most were males (74.1%, n = 40) and the mean age was 17.9 ± 10.9 years. The most common arrest location was home (44.4%, n = 24). The majority were witnessed (78.8%, n = 41) with 15.4% (n = 8) witnessed by emergency medical services (EMS). Prehospital cardiopulmonary resuscitation was done for 22 patients (41.5%) mostly by EMS (n = 19, 86.4%), 9.1% (n = 2) by a bystander, and 4.5% (n = 1) by a family member. Prehospital automated external defibrillator use was documented in 13% (n = 7) of cases. Most patients (n = 48, 88.9%) were resuscitated in the ED where the most common rhythm was asystole (55.6%, n = 30). Half of the patients (50%, n = 27) survived to hospital admission. Overall survival to hospital discharge was 16.7% (n = 9). Good neurologic outcome (cerebral performance category 1 or 2) was documented in seven patients (9.3%).
Conclusion:
Survival rate of young OHCA victims in Lebanon (16.7%) is higher than previously reported rates of OHCA in the overall population. Targeted community activities and medical oversight of EMS activities are needed to link EMS activities to clinical outcomes.
Introduction
Despite United States national learning objectives referencing research fundamentals and the critical appraisal of medical literature, many paramedic programs are not meeting these objectives with substantive content.
Problem
The objective was to develop and implement a journal club educational module for paramedic training programs, which is all-inclusive and could be distributed to Emergency Medical Services (EMS) educators and EMS medical directors to use as a framework to adapt to their program.
Methods
Four two-hour long journal club sessions were designed. First, the educator provided students with four types of articles on a student-chosen topic and discussed differences in methodology and structures. Next, after a lecture about peer-review, students used search engines to verify references of a trade magazine article. Third, the educator gave a statistics lecture and critiqued the results section of several articles found by students on a topic. Finally, students found an article on a topic of personal interest and presented it to their classmates, as if telling their paramedic partner about it at work. Before and after the series, students from two cohorts (2017, 2018) completed a survey with questions about demographics and perceptions of research. Students from one cohort (2017) received a follow-up survey one year later.
Results
For the 2016 cohort, 13 students participated and provided qualitative feedback. For the 2017 and 2018 cohorts, 33 students participated. After the series, there was an increased self-reported ability to find, evaluate, and apply medical research articles, as well as overall positive trending opinions of participating in and the importance of prehospital research. This ability was demonstrated by every student during the final journal club session. McNemar’s and Related-Samples Cochran’s Q testing of questionnaire responses suggested a statistically significant improvement in student approval of exceptions from informed consent.
Conclusion
The framework for this paramedic journal club series could be adapted by EMS educators and medical directors to enable paramedics to search for, critically appraise, and discuss the findings of medical literature.
Background
It is now more important than ever to equip paramedic students, the likely future managers and leaders of ambulance services, with the knowledge and skills of improvement science. Effective teaching requires a range of teaching methods that will engage students actively in learning. Although the array and effectiveness of methods used for teaching improvement science to clinicians and healthcare students has been systematically reviewed, the evidence regarding the specific sub-group of paramedicine students has yet to be fully explored and synthesized in the literature. The aim of this scoping review is to systematically explore and critically appraise the current state of evidence regarding strategies to teach improvement science to paramedicine students.
Methods
A number of electronic databases (i.e., PubMed, CINAHL, Embase, Scopus, and ERIC) and gray literature (i.e., ProQuest Dissertations and Theses, Open Thesis, and Networked Digital Library of Theses and Dissertations) will be searched for published and unpublished evidence regarding teaching improvement science to paramedicine students. Included studies will undergo narrative synthesis to examine similarities and differences and to identify patterns, themes, and relationships (e.g., how and why certain teaching strategies or methods have worked in achieving desired learning outcomes (or not) and factors that might have influenced this).
Discussion
To the knowledge of the authors, this is the first review that will systematically explore and critically appraise the current state of research evidence regarding strategies to teach improvement science specifically to paramedicine students. It is anticipated that the findings of this review will help to inform academics, developers of paramedicine teaching curricula, and researchers who are planning projects in this area.
Systematic review registration
Scoping reviews are currently not eligible for registration on the international prospective register of systematic reviews (i.e., PROSPERO).
Electronic supplementary material
The online version of this article (10.1186/s13643-018-0910-7) contains supplementary material, which is available to authorized users.
Methods:
This project used a descriptive, qualitative design to examine facilitators and barriers to achieving 10-minute OSTs on trauma calls, from the perspective of paramedics. Paramedics from a regional Emergency Services organization were interviewed extensively over the course of one year, using qualitative interviewing techniques developed by experts in that field. All interviews were recorded, transcribed, and entered into NVivo for Mac (QSR International; Victoria, Australia) software that supports qualitative research, for ease of data analysis. Researcher triangulation was used to ensure credibility of the data.
Results:
Thirteen percent of the calls had OSTs that were less than 10 minutes. The following six categories were outlined by the paramedics as impacting the duration of OSTs: (1) scene characteristics; (2) the presence and effectiveness of allied services; (3) communication with dispatch; (4) the paramedics' ability to effectively manage the scene; (5) current policies; and (6) the quantity and design of equipment.
Conclusion:
These findings demonstrate the complexity of the prehospital environment and bring into question the feasibility of the 10-minute OST standard. LevitanM, LawMP, FerronR, Lutz-GraulK. Paramedics' perspectives on factors impacting on-scene times for trauma calls.
Objectives:
The federal Maternal, Infant, and Early Childhood Home Visiting (MIECHV) program requires grantees to demonstrate program improvement as a condition of funding. The MIECHV program monitors grantee progress in federally mandated conceptual areas (ie, benchmarks) that are further subcategorized into related sub-areas or constructs (eg, breastfeeding). Each construct has an associated performance measure that helps MIECHV collect data on program implementation and performance. In 2016, MIECHV modified the constructs and associated performance measures required of grantees. Our objective was to identify whether the constructs were supported by the home visiting literature.
Methods:
We conducted an evaluation of one of the MIECHV program's benchmarks (Benchmark 1: Maternal and Newborn Health) for alignment of the Benchmark 1 constructs (preterm birth, breastfeeding, depression screening, well-child visit, postpartum care, and tobacco cessation referrals) with home visiting evidence. In March 2016, we searched the Home Visiting Evidence of Effectiveness database for all publicly available articles on studies conducted in the United States to determine how well the study findings aligned with the MIECHV program constructs.
Results:
Of 59 articles reviewed, only 3 of the 6 MIECHV constructs-preterm birth, breastfeeding, and well-child visits-were supported by home visiting evidence.
Conclusions:
This evaluation highlights a limited evidence base for the MIECHV Benchmark 1 constructs and a need to clarify other criteria, beyond evidence, used to choose constructs and associated performance measures. One implication of not having evidence-based performance measures is a lack of confidence that the program will drive positive outcomes. If performance measures are not evidence based, it is difficult to attribute positive outcomes to the home visiting services.
Ultrasound (US) is an essential tool for evaluating trauma patients in the hospital setting. Many previous in-hospital studies have been extrapolated to out of hospital setting to improve diagnostic accuracy in prehospital and austere environments. This review article presents the role of prehospital US in blunt and penetrating trauma management with emphasis on its current clinical applications, challenges, and future implications of such use. © 2018 Journal of Emergencies, Trauma, and Shock | Published by Wolters Kluwer - Medknow.
Objective:
This study aims to understand the adoption of clinical quality measurement throughout the United States on an EMS agency level, the features of agencies that do participate in quality measurement, and the level of physician involvement. It also aims to barriers to implementing quality improvement initiatives in EMS.
Methods:
A 46-question survey was developed to gather agency level data on current quality improvement practices and measurement. The survey was distributed nationally via State EMS Offices to EMS agencies nation-wide using Surveymonkey©. A convenience sample of respondents was enrolled between August and November, 2015. Univariate, bivariate and multiple logistic regression analyses were conducted to describe demographics and relationships between outcomes of interest and their covariates using SAS 9.3©.
Results:
A total of 1,733 surveys were initiated and 1,060 surveys had complete or near-complete responses. This includes agencies from 45 states representing over 6.23 million 9-1-1 responses annually. Totals of 70.5% (747) agencies reported dedicated QI personnel, 62.5% (663) follow clinical metrics and 33.3% (353) participate in outside quality or research program. Medical director hours varied, notably, 61.5% (649) of EMS agencies had <5 hours of medical director time per month. Presence of medical director time was correlated with tracking of QI measures. Air medical [OR 9.64 (1.13, 82.16)] and hospital-based EMS agencies [OR 2.49 (1.36, 4.59)] were more likely to track quality measures compared to fire-based agencies. Agencies in rural only environments were less likely to follow clinical quality metrics. (OR 0.47 CI 0.31 -0.72 p < 0.0004). For those that track QI measures, the most common are; Response Time (Emergency) (68.3%), On-Scene Time (66.4%), prehospital stroke screen (64.6%), aspirin administration (64.5%), and 12 lead ECG in chest pain patients (63.0%).
Conclusions:
EMS agencies in the United States have significant practice variability with regard to quality improvement resources, medical direction and specific clinical quality measures. More research is needed to understand the impact of this variation on patient care outcomes.
Introduction
In a 2015 report, the Institute of Medicine (IOM; Washington, DC USA), now the National Academy of Medicine (NAM; Washington, DC USA), stated that the field of Emergency Medical Services (EMS) exhibits signs of fragmentation; an absence of system-wide coordination and planning; and a lack of federal, state, and local accountability. The NAM recommended clarifying what roles the federal government, state governments, and local communities play in the oversight and evaluation of EMS system performance, and how they may better work together to improve care.
Objective
This systematic literature review and environmental scan addresses NAM’s recommendations by answering two research questions: (1) what aspects of EMS systems are most measured in the peer-reviewed and grey literatures, and (2) what do these measures and studies suggest for high-quality EMS oversight?
Methods
To answer these questions, a systematic literature review was conducted in the PubMed (National Center for Biotechnology Information, National Institutes of Health; Bethesda, Maryland USA), Web of Science (Thomson Reuters; New York, New York USA), SCOPUS (Elsevier; Amsterdam, Netherlands), and EMBASE (Elsevier; Amsterdam, Netherlands) databases for peer-reviewed literature and for grey literature; targeted web searches of 10 EMS-related government agencies and professional organizations were performed. Inclusion criteria required peer-reviewed literature to be published between 1966-2016 and grey literature to be published between 1996-2016. A total of 1,476 peer-reviewed titles were reviewed, 76 were retrieved for full-text review, and 58 were retained and coded in the qualitative software Dedoose (Manhattan Beach, California USA) using a codebook of themes. Categorizations of measure type and level of application were assigned to the extracted data. Targeted websites were systematically reviewed and 115 relevant grey literature documents were retrieved.
Results
A total of 58 peer-reviewed articles met inclusion criteria; 46 included process, 36 outcomes, and 18 structural measures. Most studies applied quality measures at the personnel level (40), followed by the agency (28) and system of care (28), and few at the oversight level (5). Numerous grey literature articles provided principles for high-quality EMS oversight.
Conclusions
Limited quality measurement at the oversight level is an important gap in the peer-reviewed literature. The grey literature is ahead in this realm and can guide the policy and research agenda for EMS oversight quality measurement.
TaymourRK , AbirM , ChamberlinM , DunneRB , LowellM , WahlK , ScottJ . Policy, practice, and research agenda for Emergency Medical Services oversight: a systematic review and environmental scan .
Introduction
Historically, the quality and performance of prehospital emergency care (PEC) has been assessed largely based on surrogate, non-clinical endpoints such as response time intervals or other crude measures of care (eg, stakeholder satisfaction). However, advances in Emergency Medical Services (EMS) systems and services world-wide have seen their scope and reach continue to expand. This has dictated that novel measures of performance be implemented to compliment this growth. Significant progress has been made in this area, largely in the form of the development of evidence-informed quality indicators (QIs) of PEC.
Problem
Quality indicators represent an increasingly popular component of health care quality and performance measurement. However, little is known about the development of QIs in the PEC environment. The purpose of this study was to assess the development and characteristics of PEC-specific QIs in the literature.
Methods
A scoping review was conducted through a search of PubMed (National Center for Biotechnology Information, National Institutes of Health; Bethesda, Maryland USA); EMBase (Elsevier; Amsterdam, Netherlands); CINAHL (EBSCO Information Services; Ipswich, Massachusetts USA); Web of Science (Thomson Reuters; New York, New York USA); and the Cochrane Library (The Cochrane Collaboration; Oxford, United Kingdom). To increase the sensitivity of the literature, a search of the grey literature and review of select websites was additionally conducted. Articles were selected that proposed at least one PEC QI and whose aim was to discuss, analyze, or promote quality measurement in the PEC environment.
Results
The majority of research (n=25 articles) was published within the last decade (68.0%) and largely originated within the USA (68.0%). Delphi and observational methodologies were the most commonly employed for QI development (28.0%). A total of 331 QIs were identified via the article review, with an additional 15 QIs identified via the website review. Of all, 42.8% were categorized as primarily Clinical, with Out-of-Hospital Cardiac Arrest contributing the highest number within this domain (30.4%). Of the QIs categorized as Non-Clinical (57.2%), Time-Based Intervals contributed the greatest number (28.8%). Population on Whom the Data Collection was Constructed made up the most commonly reported QI component (79.8%), followed by a Descriptive Statement (63.6%). Least reported were Timing of Data Collection (12.1%) and Timing of Reporting (12.1%). Pilot testing of the QIs was reported on 34.7% of QIs identified in the review.
Conclusion
Overall, there is considerable interest in the understanding and development of PEC quality measurement. However, closer attention to the details and reporting of QIs is required for research of this type to be more easily extrapolated and generalized.
HowardI , CameronP , WallisL , CastrenM , LindstromV . Quality indicators for evaluating prehospital emergency care: a scoping review .
Background:
Current ambulance quality and performance measures, such as response times, do not reflect the wider scope of care that services now provide. Using a three-stage consensus process, we aimed to identify new ways of measuring ambulance service quality and performance that represent service provider and public perspectives.
Design:
A multistakeholder consensus event, modified Delphi study, and patient and public consensus workshop.
Setting and participants:
Representatives from ambulance services, patient and public involvement (PPI) groups, emergency care clinical academics, commissioners and policymakers.
Results:
Nine measures/principles were highly prioritized by >75% of consensus event participants, including measures relating to pain, patient experience, accuracy of dispatch decisions and patient safety. Twenty experts participated in two Delphi rounds to further refine and prioritize measures; 20 measures in three domains scored ≥8/9, indicating good consensus, including proportion of calls correctly prioritized, time to definitive care and measures related to pain. Eighteen patient/public representatives attended a consensus workshop, and six measures were identified as important. These include time to definitive care, response time, reduction in pain scores, calls correctly prioritized to appropriate levels of response and survival to hospital discharge for treatable emergency conditions.
Conclusions:
Using consensus methods, we identified a shortlist of ambulance outcome and performance measures that are important to ambulance clinicians and service providers, service users, commissioners, and clinical academics, reflecting current pre-hospital ambulance care and services. The measures can potentially be used to assess pre-hospital quality or performance over time, with most calculated using routinely available data.
Out-of-hospital cardiac arrest (OHCA) can be used to evaluate the overall performance of the emergency medical services’ (EMS) system. This study assessed the impact of EMS on OHCA survival rates in a setting where the prehospital system is underdeveloped.
A retrospective chart review was carried out over a 5-year period of all adult OHCA patients admitted to the emergency department (ED) of a tertiary care center in Lebanon.
A total of 271 patients with OHCA (179 [66.1%] men, mean age of 69.9 [standard deviation = 15.0 years] were enrolled. The most common OHCA location was residence/home (58.7%). The majority of arrests were witnessed (51.7%) with 6.1% witnessed by EMS; 211 patients (75.6%) were transported to the ED by EMS. Prehospital cardiopulmonary resuscitation (CPR) was done by EMS for 43.2% of the patients, whereas only 4.4% received CPR from a family member/bystander. Prehospital automated external defibrillator use was documented in 1.5% of cases in the prehospital setting. Only 2 patients had return of spontaneous circulation prior to ED arrival. Most patients (96.7%) were resuscitated in the ED. Patients presented to the ED mostly in asystole (79.3%). Forty-three patients (15.9%) survived to hospital admission and 13 (4.8%) were discharged alive with over half of them (53.8%) had a good neurological outcome upon discharge (cerebral performance category 1 or 2).
Survival of EMS-treated OHCA victims in Lebanon is not as expected. Medical oversight of EMS activities is needed to link EMS activities to clinical outcomes and improve survival from cardiac arrest in Lebanon.
Background:
Dispatch centres (DCs) are considered an essential but expensive component of many highly developed healthcare systems. The number of DCs in a country, region, or state is usually based on local history and often related to highly decentralised healthcare systems. Today, current technology (Global Positioning System or Internet access) abolishes the need for closeness between DCs and the population. Switzerland went from 22 DCs in 2006 to 17 today. This study describes from a quality and patient safety point of view the merger of two DCs.
Methods:
The study analysed the performance (over and under-triage) of two medical DCs for 12 months prior to merging and for 12 months again after the merger in 2015. Performance was measured comparing the priority level chosen by dispatcher and the severity of cases assessed by paramedics on site using the National Advisory Committee for Aeronautics (NACA) score. We ruled that NACA score > 3 (injuries/diseases which can possibly lead to deterioration of vital signs) to 7 (lethal injuries/diseases) should require a priority dispatch with lights and siren (L&S). While NACA score < 4 should require a priority dispatch without L&S. Over-triage was defined as the proportion of L&S dispatches with a NACA score < 4, and under-triage as the proportion of dispatches without L&S with a NACA > 3.
Results:
Prior to merging, Dispatch A had a sensitivity/specificity regarding the use of lights and sirens and severity of cases of 86%/48% with over- and under-triage rates of 78% and 5%, respectively. Dispatch B had sensitivity and specificity of 92%/20% and over- and under-triage rates of 84% and 7%, respectively. After they merged, global sensitivity/specificity reached 87%/67%, and over- and under-triage rates were 71% and 3%, respectively CONCLUSIONS: A part the potential cost advantage achieved by the merger of two DCs, it can improve the quality of services to the population, reducing over- and under-triage and the use of lights and sirens and therefore, the risk of accidents. This is especially the case when a DC with poor triage performance merges with a high-performing DC.
Aim of database
The aim of the Danish quality database for prehospital emergency medical services (QEMS) is to assess, monitor, and improve the quality of prehospital emergency medical service care in the entire prehospital patient pathway. The aim of this review is to describe the design and the implementation of QEMS.
Study population
The study population consists of all “112 patient contacts” defined as emergency patients, where the entrance to health care is a 112 call forwarded to one of the five regional emergency medical coordination centers in Denmark since January 1, 2014. Estimated annual number of included “112 patients” is 300,000–350,000.
Main variables
We defined nine quality indicators and the following variables: time stamps for emergency calls received at one of the five regional emergency medical coordination centers, dispatch of prehospital unit(s), arrival of first prehospital unit, arrival of first supplemental prehospital unit, and mission completion. Finally, professional level and type of the prehospital resource dispatched to an incident and end-of-mission status (mission completed by phone, on scene, or admission to hospital) are registered.
Descriptive data
Descriptive data included age, region, and Danish Index for Emergency Care including urgency level.
Conclusion
QEMS is a new database under establishment and is expected to provide the basis for quality improvement in the prehospital setting and in the entire patient care pathway, for example, by providing prehospital data for research and other quality databases.
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.
Background:
Early activation and use of Emergency Medical Services (EMS) are associated with improved patient outcomes in EMS priority conditions in developed EMS systems. This study describes patterns of EMS use and identifies predictors of EMS utilization in EMS priority conditions in Lebanon METHODS: This was a cross-sectional study of a random sample of adult patients presenting to the emergency department (ED) of a tertiary care center in Beirut with the following EMS priority conditions: chest pain, major trauma, respiratory distress, cardiac arrest, respiratory arrest, and airway obstruction. Patient/proxy survey (20 questions) and chart review were completed. The responses to survey questions were "disagree," "neutral," or "agree" and were scored as one, two, or three with three corresponding to higher likelihood of EMS use. A total scale score ranging from 20 to 60 was created and transformed from 0% to 100%. Data were analyzed based on mode of presentation (EMS vs other).
Results:
Among the 481 patients enrolled, only 112 (23.3%) used EMS. Mean age for study population was 63.7 years (SD=18.8 years) with 56.5% males. Mean clinical severity score (Emergency Severity Index [ESI]) was 2.5 (SD=0.7) and mean pain score was 3.1 (SD=3.5) at ED presentation. Over one-half (58.8%) needed admission to hospital with 21.8% to an intensive care unit care level and with a mortality rate of 7.3%. Significant associations were found between EMS use and the following variables: severity of illness, degree of pain, familiarity with EMS activation, previous EMS use, perceived EMS benefit, availability of EMS services, trust in EMS response times and treatment, advice from family, and unavailability of immediate private mode of transport (P≤.05). Functional screening, or requiring full assistance (OR=4.77; 95% CI, 1.85-12.29); acute symptoms onset ≤ one hour (OR=2.14; 95% CI, 1.08-4.26); and higher scale scores (OR=2.99; 95% CI, 2.20-4.07) were significant predictors of EMS use. Patients with lower clinical severity (OR=0.53; 95% CI, 0.35-0.81) and those with chest pain (OR=0.05; 95% CI, 0.02-0.12) or respiratory distress (OR=0.15; 95% CI, 0.07-0.31) using cardiac arrest as a reference were less likely to use EMS.
Conclusion:
Emergency Medical Services use in EMS priority conditions in Lebanon is low. Several predictors of EMS use were identified. Emergency Medical Services initiatives addressing underutilization should result from this proposed assessment of the perspective of the EMS system's end user. El Sayed M , Tamim H , Al-Hajj Chehadeh A , Kazzi AA . Emergency Medical Services utilization in EMS priority conditions in Beirut, Lebanon. Prehosp Disaster Med. 2016;31(6):1-7.
Background:
The development of measures to monitor and evaluate the performance and quality of emergency medical services (EMS) systems has been a focus of attention for many years. The Medicare Rural Hospital Flexibility Program (Flex Program), established by Congress in 1997, provides grants to states to implement initiatives to strengthen rural healthcare delivery systems, including better integration of EMS into those systems of care.
Objective:
Building on national efforts to develop EMS performance measures, we sought to identify measures relevant to the rural communities and hospitals supported by the Flex Program. The measures are intended for use in monitoring rural EMS performance at the community level as well as for use by State Flex Programs and the Federal Office of Rural Health Policy (FORHP) to demonstrate the impact of the Flex Program.
Methods:
To evaluate the performance of EMS in rural communities, we conducted a literature search, reviewed research on performance measures conducted by key EMS organizations, and recruited a panel of EMS experts to identify and rate rurally-relevant EMS performance measures as well as emergent protocols for episodes of trauma, ST Elevation Myocardial Infarction (STEMI), and stroke. The rated measures were assessed for inclusion in the final measure set.
Results:
The Expert Panel identified 17 program performance measures to support EMS services in rural communities. These measures monitor the capacity of local agencies to collect and report quality and financial data, use the data to improve agency performance, and train rural EMS employees in emergent protocols for all age groups.
Conclusion:
The system of care approach on which this rural EMS measures set is based can support the FORHP's goal of better focusing State Flex Program activity to improve program impact on the performance of rural EMS services in the areas of financial viability, quality improvement, and local/regional health system performance.
Background
In Baden-Württemberg, a statewide, comparative, external quality assurance program for rescue services has been established. Based on quality indicators, the entire prehospital rescue chain is evaluated and illustrated as comprehensively as possible.
Objective
Representing quality by using indicators can especially be used to illustrate important aspects of the organizational procedures and the quality of care in emergency services. In addition, objective comparisons are possible. Identically defined and calculated quality indicators also allow comparison of emergency service quality beyond the borders of the federal state.
Materials and methods
The quality indicators for emergency services in Baden-Württemberg and the methodology for their development are described.
Results and conclusions
By using quality indicators, quality can be made measurable and comparable in the emergency services. The calculations provide an indication of the structure, procedure, and outcome quality and can be used for the targeted introduction of improvement measures. For a balanced representation, the whole rescue chain should be taken into consideration. In order to reliably assess the overall quality of results in emergency care, combining the results of preclinical and inhospital quality assurance would be desirable.
Objective:
While emergency medical service (EMS) response times (ERT) remain a leading measure of system performance in many developed countries, relatively few studies have explored the factors associated with meeting benchmark performance for potentially time critical incidents. The purpose of this study was to identify system-level and patient-level factors associated with ERT, which are readily available at the time of ambulance dispatch.
Methods:
Between July 2009 and June 2014, we included data from 1,000,458 EMS responses to time critical "lights and sirens" incidents in Melbourne, Australia. The primary outcome measure was ERT, defined as the time from emergency call to the arrival of the first EMS team on scene. Quantile regression models were used to identify system-level and patient-level factors associated with 10-percentile intervals of ERT.
Results:
The median ERT was 10.6 minutes (IQR: 8.1-14.0), increasing from 9.6 minutes (IQR: 7.6-12.5) in 2009/10 to 11.0 minutes (IQR: 8.4-14.7) in 2013/14 (p < 0.001). System-level factors independently associated with the 90th percentile ERT were distance to scene, activation time, turnout time, case upgrade, hour of day, day of week, workload in the previous hour, ambulance skill set, priority zero case (e.g., suspected cardiac or respiratory arrest), and average hospital delay time in the previous hour. Patient-level factors such as age, gender, chief medical complaint, and severity of complaint were also significantly associated with ERT.
Conclusions:
System-level and patient-level factors available at the time of ambulance dispatch are useful predictors of ERT performance, which could be used to improve the timeliness of EMS response.
Emergency medical services system financing and productivity analysis may initially seem matters of concern exclusive to system administrators. There are increasing accountabilities of health care expenditures and expectations of cost efficiencies while realizing improved clinical outcomes. Today's EMS medical director must develop a distinct, ongoing acumen in these disciplines as part of an effective foundation for clinical leadership in EMS systems. This finance chapter introduces and reviews the fundamentals of EMS system financing, productivity analysis, and applying those fundamentals to real-world decision making.
Medical oversight is defined as the physician supervision of a service, group, or system providing emergency medical services (EMS). Medical oversight has historically been used interchangeably with the term medical direction to describe a role that is complex and multifaceted and includes elements that affect patient care both directly (direct medical oversight) and indirectly (indirect medical oversight). Directly, a physician may provide orders to an EMS provider over the radio, by phone, or on scene. Indirectly, a medical director may affect patient care through the development and promulgation of protocols, the education and credentialing of EMS providers, supervision and quality improvement activities, and advocating for patients, EMS providers, and the EMS system. EMS physicians also provide direct patient care in the field. An EMS medical director is ideally engaged in all aspect of an EMS service or system, including emergency medical dispatch. This chapter includes four sections: an introduction to the medical oversight of EMS, followed by sections on indirect medical oversight, direct medical oversight, and the provision of direct patient care in the field.
Objectives: To systematically review the literature on quality indicators (QIs) for evaluating trauma care, identify QIs, map their definitions, and examine the evidence base in support of the QIs. Data Sources: We searched MEDLINE, EMBASE, CINAHL, Cochrane Database of Systematic Reviews, Cochrane Database of Abstracts of Reviews of Effects, and Cochrane Central Register of Controlled Trials from the earliest available date through January 14, 2009. To increase the sensitivity of the search, we also searched the grey literature and select journals by hand, reviewed reference lists to identify additional studies, and contacted experts in the field. Study Selection and Data Extraction: We selected all articles that identified or proposed 1 or more QIs to evaluate the quality of care delivered to patients with major traumatic injuries. Minimum inclusion criteria were a description of 1 or more QIs designed to evaluate patients with major traumatic injuries (defined as multisystem injuries resulting in hospitalization or death) and focused on prehospital care, hospital care, posthospital care, or secondary injury prevention. Data Synthesis: The literature search identified 6869 citations. Review of abstracts led to the retrieval of 538 fulltext articles for assessment, of which 192 articles were selected for review. Of these, 128 (66.7%) articles were original research, predominantly trauma database case series (57 [29.7%]) and cohort studies (55 [28.6%]), whereas 37 (19.3%) were narrative reviews and 8 (4.2%) were guidelines. A total of 1572 QIs in trauma care were identified and classified into 8 categories: non-American College of Surgeons Committee on Trauma (ACS-COT) audit filters (42.0%), ACS-COT audit filters (19.1%), patient safety indicators (13.2%), trauma center/system criteria (10.2%), indicators measuring or benchmarking outcomes of care (7.4%), peer review (5.5%), general audit measures (1.8%), and guideline availability or adherence (0.8%). Measures of prehospital and hospital processes (60.4%) and outcomes (22.8%) were the most common QIs identified. Posthospital and secondary injury prevention QIs accounted for less than 5% of QIs. Conclusions: Many QIs for evaluating the quality of trauma care have been proposed, but the evidence to support these indicators is not strong. Practical recommendations to select QIs to measure the quality of trauma care will require systematic reviews of identified candidate indicators and empirical studies to fill the knowledge gaps for postacute QIs.
Background:
Development of new evidence to support pre-hospital emergency care benefits both patients and practitioners. Clinical research must be conducted within a formal governance framework but it is challenging for paramedics to access traditional good clinical practice (GCP) training due to high service demands and some content is of little relevance to the pre-hospital setting.
Objective:
To establish the content and format of easily accessible research governance awareness training for use by paramedics and other members of the ambulance service as and when appropriate.
Methods:
A systematic literature review identified descriptions of pre-hospital research training. An online survey sought views about the formal research training undertaken by NHS paramedics and an expert consensus process confirmed the content of training materials.
Results:
Research governance training was rarely acknowledged in pre-hospital clinical trial literature and was recalled by only one in eight respondents who had assisted with clinical research. A pre-hospital orientated slide set and matching assessment questions were reviewed in two cycles by an expert panel to achieve a consensus on the content and format.
Conclusions:
Through a structured process of literature review, stakeholder engagement and expert consensus we have developed training and assessment materials which can be used flexibly to prepare paramedics and the wider ambulance workforce for safe hosting of low-risk research activities.
IN AN earlier article1 we explored ethical decision making in the prehospital emergency setting with particular attention to emergency cardiac care (ECC). We argued in support of recent efforts to develop portable do-not-resuscitate (DNR) policies that allow patients' wishes to be honored outside the hospital setting, such as during interinstitutional transfer, in long-term care facilities, in the home, or elsewhere. We also proposed allowing emergency personnel to cease futile resuscitation in the field. We argued that unlike DNR orders, a judgment that resuscitation is futile should rest with qualified medical personnel and should reflect a professional consensus supported by sound empirical data.
In this article, we examine the most recent American Heart Association (AHA) Guidelines for cardiopulmonary resuscitation (CPR) and ECC.2 While we commend the new guidelines for acknowledging medical futility, we identify shortcomings in the definition of medical futility and suggest further revisions.
In this discussion, two principal types of ambulance deployment systems were compared and contrasted: 1) the multipurpose, sole-provider all-advanced life support (all-ALS) ambulance system in which all ambulance-related services (emergent and nonemergent) for a city or region are provided by one fleet of ambulances, each of which is staffed by ALS providers (paramedics); and 2) the tiered ambulance system (tiered) in which some 911 ambulances are staffed by paramedics and others are staffed by basic emergency medical technicians (EMT-Bs) who provide basic life support (BLS) care. When managed with advanced system status management (SSM) techniques, the multipurpose, sole-provider all-ALS ambulance system can significantly reduce response intervals while simultaneously providing both fiscal and operational efficiencies. It can also be used to readily integrate and expand the scope of services for the ambulance provider service, such as interfacility transfers, thus increasing revenues. On the other hand, in large urban centers, the tiered ambulance system can be used to reduce response intervals to critical calls, primarily through the use of sophisticated dispatch triage protocols. This approach requires fewer paramedics in the system and appears, in some systems, to also provide medical care advantages in terms of skills utilization for individual ALS providers as well as a more concentrated focus for medical supervision. Therefore, both of these deployment systems can offer certain advantages depending on local emergency medical services (EMS) system needs as well as the local philosophy of health care delivery. Applicability must therefore be considered in terms of local service demands and other factors that affect the EMS system, including catchment population, statutory and jurisdictional issues, available funding, accessibility of receiving facilities, and medical quality concerns.
Nebulised salbutamol can now be administered by ambulance personnel to patients with severe acute asthma en route to hospital. This treatment, however, is not yet available in all ambulances. The safety and effectiveness of allowing ambulance crews to initiate treatment with nebulised salbutamol has been assessed in patients with acute severe asthma.
After a basic training course in the assessment of asthma and the use of a nebuliser, ambulance crews initiated treatment with nebulised salbutamol in asthmatic patients under the age of 40 years. Airflow obstruction was measured before and after treatment with a peak flow meter. A subjective assessment of any change in the patient's condition was also made.
Nebuliser treatment was associated with a significant increase in peak flow in almost 80% of patients who had recordable values before and after treatment. The mean percentage increase in peak flow was 56.5%. Subjective assessments correlated well with peak flow measurements. No unwanted side effects were recorded.
Nebulised salbutamol is an effective and safe treatment for acute asthma when administered by ambulance personnel after a short training course.
Use of automated external defibrillators (AEDs) by first arriving emergency medical technicians (EMTs) is advocated to improve the outcome for out-of-hospital ventricular fibrillation (VF). However, adding AEDs to the emergency medical system in Seattle, Wash, did not improve survival. Studies in animals have shown improved outcomes when cardiopulmonary resuscitation (CPR) was administered prior to an initial shock for VF of several minutes' duration.
To evaluate the effects of providing 90 seconds of CPR to persons with out-of-hospital VF prior to delivery of a shock by first-arriving EMTs.
Observational, prospectively defined, population-based study with 42 months of preintervention analysis (July 1, 1990-December 31, 1993) and 36 months of post-intervention analysis (January 1, 1994-December 31, 1996).
Seattle fire department-based, 2-tiered emergency medical system.
A total of 639 patients treated for out-of-hospital VF before the intervention and 478 after the intervention.
Modification of the protocol for use of AEDs, emphasizing approximately 90 seconds of CPR prior to delivery of a shock.
Survival and neurologic status at hospital discharge determined by retrospective chart review as a function of early (<4 minutes) and later (> or =4 minutes) response intervals.
Survival improved from 24% (155/639) to 30% (142/478) (P=.04). That benefit was predominantly in patients for whom the initial response interval was 4 minutes or longer (survival, 17% [56/321] before vs 27% [60/220] after; P = .01). In a multivariate logistic model, adjusting for differences in patient and resuscitation factors between the periods, the protocol intervention was estimated to improve survival significantly (odds ratio, 1.42; 95% confidence interval, 1.07-1.90; P = .02). Overall, the proportion of victims who survived with favorable neurologic recovery increased from 17% (106/634) to 23% (109/474) (P = .01). Among survivors, the proportion having favorable neurologic function at hospital discharge increased from 71% (106/150) to 79% (109/138) (P<.11).
The routine provision of approximately 90 seconds of CPR prior to use of AED was associated with increased survival when response intervals were 4 minutes or longer.
Study objective:
More than 1,000 patients experience sudden cardiac arrest each day. Treatment for this includes cardiopulmonary resuscitation (CPR_ and emergency medical services (EMS) that provide CPR-basic life support (BLS), BLS with defibrillation (BLS-D), or advanced life support (ALS). Our previous systematic review of treatments for sudden cardiac arrest was limited by suboptimal data. Since then, debate has increased about whether bystander CPR is effective or whether attention should focus instead on rapid defibrillation. Therefore a cumulative meta-analysis was conducted to determine the relative effectiveness of differences in the defibrillation response time interval, proportion of bystander CPR, and type of EMS system on survival after out-of-hospital cardiac arrest.
Methods:
A comprehensive literature search was performed by using a priori exclusion criteria. We considered EMS systems that provided BLS-D, ALS, BLS plus ALS, or BLS-D plus ALS care. A generalized linear model was used with dispersion estimation for random effects.
Results:
Thirty-seven eligible articles described 39 EMS systems and included 33, 124 patients. Median survival for all rhythm groups to hospital discharge was 6.4% (interquartile range, 3.7 to 10.3). Odds of survival were 1.06 (95% confidence interval [Cl], 1.03 to 1.09; P<.01) per 5% increase in bystander CPR. Survival was constant if the defibrillation response time interval was less than 6 minutes, decreased as the interval increased from 6 to 11 minutes, and leveled of after 11 minutes (P<.01). Compared with BLS-D, odds of survival were as follows: ALS, 1.71 (95% Cl, 1.09 to 2.70; P=.01); BLS plus ALS, 1.47 (95% Cl, 0.89 to 2.42; P=.07); and BLS with defibrillation plus ALS, 2.31 (95% Cl, 1.47 to 3.62; P<.01.) Conclusion: We confirm that greater survival after sudden cardiac arrest is associated with provision of bystander CPR, early defibrillation, or ALS. More research is required to evaluate the relative benefit of early defibrillation versus early ALS.
Objective. Although the concept of emergency medical services (EMS) has existed for 30 years, there is little scientific evidence validating its impact on morbidity and mortality. A significant barrier to conducting meaningful assessments relates to the lack of reliable and uniform EMS data. The objective of this study was to determine the extent to which states incorporate the Uniform Prehospital EMS Data Elements into statewide EMS data collection systems. Methods. Study investigators requested and compared data elements from all states with a statewide prehospital data collection system. Results. During the study period, 43 states with statewide EMS data collection systems captured, on average, 79% of the Uniform Prehospital EMS Data Set. Variables considered essential to EMS evaluation were more likely collected (84%) than variables considered desirable (72%). Only eight (10%) of the 81 uniform data elements are collected by all 43 participating states. Conclusions. Findings suggest that related EMS d...
Among patients who underwent randomization at referral hospitals, the primary end point was reached in 8.5 percent of the patients in the angioplasty group, as compared with 14.2 percent of those in the fibrinolysis group (P=0.002). The results were similar among patients who were enrolled at invasive-treatment centers: 6.7 percent of the patients in the angioplasty group reached the primary end point, as compared with 12.3 percent in the fibrinolysis group (P=0.05). Among all patients, the better outcome after angioplasty was driven primarily by a reduction in the rate of reinfarction (1.6 percent in the angioplasty group vs. 6.3 percent in the fibrinolysis group, P<0.001); no significant differences were observed in the rate of death (6.6 percent vs. 7.8 percent, P=0.35) or the rate of stroke (1.1 percent vs. 2.0 percent, P=0.15). Ninety-six percent of patients were transferred from referral hospitals to an invasive-treatment center within two hours. conclusions A strategy for reperfusion involving the transfer of patients to an invasive-treatment center for primary angioplasty is superior to on-site fibrinolysis, provided that the transfer takes two hours or less.
In this issue of THE JOURNAL, McGrath and colleagues1
and Magid and colleagues2 examine 2 of the
most contentious issues in the provision of cardiac care: the relationship
between experience and outcome for percutaneous interventions, and the superiority
of percutaneous revascularization (eg, primary angioplasty or other procedures)
relative to thrombolytic therapy for acute myocardial infarction (AMI). These
2 issues lead to the question of whether primary angioplasty can be effectively
performed in low-volume hospitals and by low-volume physicians. Supporters
of both primary angioplasty and volume standards will no doubt refer to these
works in their future deliberations.
With the strong encouragement of leading health care agencies, business principles are being implemented throughout health care, including emergency medical services (EMS). The reason is simple—quality of care can be enhanced by incorporating the management concepts of continuous quality improvement (CQI). The CQI process couples carefully identified, measurable performance indicators with information systems to monitor, analyze, and trend data. Benchmarking outcomes with other EMS systems allows the identification of “best practices” and the evolution of standards. Emergency medical services professionals must actively participate with the broader health care community in creating performance measurements to ensure that high-quality care is delivered consistently.
Background: The purpose of the study was to compare the outcome of severely injured patients who were transported directly to a Level I, tertiary trauma center with those who were transferred after being first transported to less specialized hospitals. Methods: The data were based on all patients treated at three tertiary trauma centers in Quebec between April 1, 1993, and December 31, 1995. There were 1,608 patients (37%) transferred and 2,756 patients (63%) transported directly. Results: The mean age of the patients was approximately 45 years, and more than 60% were males. The predominant mechanisms of injury were falls and motor vehicle crashes. The transfer and direct transport groups were similar with respect to age, gender, and mechanism of injury. Body regions injured were also similar with the exception of head or neck injuries (transfer, 56%; direct, 28%; p < 0.0001). The mean Injury Severity Score was 14, the mean Pre-Hospital Index score was 5.5, and the mean Revised Trauma Score was 7.5. The two groups were similar with respect to these injury severity measures. The primary outcome of interest was mortality described as overall death rate, death rate in the emergency room, and death rate after admission. Other outcomes studied were hospital length of stay and duration of treatment in an intensive care unit. When compared with the direct transport group, transferred patients were at increased risk for overall mortality (transfer, 8.9%; direct, 4.8%; odds ratio, 1.96; 95% confidence interval (CI) = 1.53-2.50), emergency room mortality (transfer, 3.4%; direct, 1.2%; odds ratio, 2.96; 95% CI = 1.90-4.6), and mortality after admission (transfer, 5.5%; direct, 3.6%; odds ratio, 1.57; 95% CI = 1.17-2.11). All of these differences were statistically significant (p < 0.003). Stratified and multiple logistic regression analysis did not alter these results and failed to identify a patient subgroup for which transfer was associated with a reduced risk of mortality. After adjusting for patient age, Injury Severity Score, and presence of injuries to the head or neck and extremities, transferred patients stayed significantly longer in the hospital and the intensive care unit as indicated by the mean length of stay (transfer, 16.0 days; direct, 13.2 days; p = 0.02) and the mean intensive care unit stay(transfer, 2.0 days; direct, 0.95 days; p = 0.001). Conclusion: The results of this study have shown that transportation of severely injured patients from the scene directly to Level I trauma centers is associated with a reduction in mortality and morbidity. Further studies are required for the evaluation of transport protocols for rural trauma. Economic and cost-effectiveness considerations of patient triage are also essential.
Context Despite calls for wider national implementation of an integrated approach
to trauma care, the effectiveness of this approach at a regional or state
level remains unproven.Objective To determine whether implementation of an organized system of trauma
care reduces mortality due to motor vehicle crashes.Design Cross-sectional time-series analysis of crash mortality data collected
for 1979 through 1995 from the Fatality Analysis Reporting System.Setting All 50 US states and the District of Columbia.Subjects All front-seat passenger vehicle occupants aged 15 to 74 years.Main Outcome Measures Rates of death due to motor vehicle crashes compared before and after
implementation of an organized trauma care system. Estimates are based on
within-state comparisons adjusted for national trends in crash mortality.Results Ten years following initial trauma system implementation, mortality
due to traffic crashes began to decline; about 15 years following trauma system
implementation, mortality was reduced by 8% (95% confidence interval [CI],
3%-12%) after adjusting for secular trends in crash mortality, age, and the
introduction of traffic safety laws. Implementation of primary enforcement
of restraint laws and laws deterring drunk driving resulted in reductions
in crash mortality of 13% (95% CI, 11%-16%) and 5% (95% CI, 3%-7%), respectively,
while relaxation of state speed limits increased mortality by 7% (95% CI,
3%-10%).Conclusions Our data indicate that implementation of an organized system of trauma
care reduces crash mortality. The effect does not appear for 10 years, a finding
consistent with the maturation and development of trauma triage protocols,
interhospital transfer agreements, organization of trauma centers, and ongoing
quality assurance.
We developed a score predictive of survival following out-of-hospital cardiac arrest from an analysis of factors associated with 611 cases. The score is calculated from four pieces of information readily obtainable by emergency personnel directly at the scene. The four items are as follows: A, arrest witnessed; C, cardiac rhythm; L, lay bystander cardiopulmonary resuscitation (CPR); S, speed (response time of paramedic unit). Among 22 patients with favorable findings on all four predictive variables (witnessed arrest, ventricular fibrillation, bystander CPR, paramedic response time less than four minutes), 15 (70%) were discharged alive. The ACLS score for this group of patients was 70%. Among 97 patients with the most unfavorable findings (whose ACLS score was O), one (1%) was discharged. We believe the score can provide emergency personnel with a realistic appraisal of the likelihood of successful resuscitation.
(JAMA 1981;246:50-52)
Since the early 1970s, various publications and legislation have contributed to the development of emergency medical services (EMS) information systems and databases. Yet, even today, EMS systems vary in their ability to collect patient and systems data and to put these data to use. In addition, no means currently exists to easily link disparate EMS databases to allow analysis at local, state, and national levels. For this reason, the National Association of State EMS Directors is working with its federal partners at the National Highway Traffic Safety Administration (NHTSA) and the Trauma and EMS program of the Health Resources and Services Administration's (HRSA's) Maternal and Child Health Bureau to develop a national EMS database. Such a database would be useful in developing nationwide EMS training curricula, evaluating patient and EMS system outcomes, facilitating research efforts, determining national fee schedules and reimbursement rates, and providing valuable information on other issues related to EMS care.
The complete and irreversible cessation of life is often difficult to determine with complete confidence in the dynamic environment of out-of-hospital emergency care. As a result, resuscitation efforts often are initiated and maintained by emergency medical services (EMS) providers in many hopeless situations. Medical guidelines are reviewed here to aid EMS organizations with respect to decisions about: 1) initiating or waiving resuscitation efforts; 2) the appropriate duration of resuscitation efforts; and 3) recommended procedures for on-scene or prehospital pronouncement of death (termination of resuscitation). In cases of nontraumatic cardiac arrest, few unassailable criteria, other than certain physical signs of irreversible tissue deterioration, exist for determining medical futility at the initial encounter with the patient. Thus, the general medical recommendation is to attempt to resuscitate all patients, adult or child, in the absence of rigor mortis or dependent lividity. Conversely, well-founded guidelines now are available for decisions regarding termination of resuscitation in such patients once they have received a trial of advanced cardiac life support. In practice, however, the final decision to proceed with on-scene pronouncement of death for these patients may be determined more by family and provider comfort levels and the specific on-scene environment. For patients with posttraumatic circulatory arrest, the type of injury (blunt or penetrating), the presence of vital signs, and the electrocardiographic findings are used to determine the futility of initiating or continuing resuscitation efforts. In general, patients who are asystolic on-scene are candidates for on-scene pronouncement, regardless of mechanism. With a few exceptions, blunt trauma patients with a clearly associated mechanism of lethal injury are generally candidates for immediate cessation of efforts once they lose their pulses and respirations. Regardless of the medical futility criteria, specialized training of EMS providers and targeted related testing of operational issues need to precede field implementation of on-scene pronouncement policies. Such policies also must be modified and adapted for local issues and resources. In addition, although the current determinations of medical futility, as delineated here, are important to establish for societal needs, the individual patient's right to live must be kept in mind always as new medical advances are developed.
Emergency medical services (EMS) administrators seek methods to enhance system performance. One component scrutinized is the response time (RT) interval between call receipt and arrival on scene. While reducing RTs may improve survival, this remains speculative and unreported.
Objective: To determine the effect of current RTs on survival in an urban EMS system.
Methods: The study was conducted in a metropolitan county (population 620,000). The EMS system is a single‐tier, paramedic service and provides all service requests. The 90% fractile RT specifications required for county compliance include 10:59 minutes for emergency life‐threatening calls (priority I) and 12:59 minutes for emergency non‐life‐threatening calls (priority II). All emergency responses resulting in a priority I or priority II transport to a Level 1 trauma center emergency department over a six‐month period were evaluated to determine the relation between specified and arbitrarily assigned RTs and survival.
Results: Five thousand, four hundred twenty‐four transports were reviewed. Of these, 71 patients did not survive (1.31%; 95% CI = 1.04% to 1.67%). No significant difference in median RTs between survivors (6.4 min) and nonsurvivors (6.8 min) was noted (p = 0.10). Further, there was no significant difference between observed and expected deaths (p = 0.14). However, mortality risk was 1.58% for patients whose RT exceeded 5 minutes, and 0.51% for those whose RT was under 5 minutes (p = 0.002). The mortality risk curve was generally flat over RT intervals exceeding 5 minutes.
Conclusions: In this observational study, emergency calls where RTs were less than 5 minutes were associated with improved survival when compared with calls where RTs exceeded 5 minutes. While variables other than time may be associated with this improved survival, there is little evidence in these data to suggest that changing this system's response time specifications to times less than current, but greater than 5 minutes, would have any beneficial effect on survival.
Background:
Each year, approximately 40,000 patients with acute asthma are transported by the Fire Department of New York City (NYC) Emergency Medical Services (EMS). Out-of-hospital administration of bronchodilator therapy has, however, been restricted by scope of practice to advanced life support (ALS) providers. Since the rapid availability of ALS units cannot always be assured, some individuals with acute asthma may receive only basic life support (BLS) measures in the field.
Objectives:
To demonstrate that basic emergency medical technicians (EMT-Bs) are able to effectively administer nebulized albuterol to asthma patients in the out-of-hospital environment.
Methods:
This was a prospective, observational cohort study of 9-1-1 asthma calls received by the NYC EMS system for patients between the ages of 1 and 65 years. Baseline peak expiratory flow rate (PEFR) and other clinical measures were obtained prior to and following BLS administration of one or two treatments with nebulized albuterol.
Results:
Data were available for 3,351 patients over a one-year study period. One out-of-hospital albuterol treatment was given in 60%, while 40% of the patients received two. The PEFRs increased from 40.4% predicted (SD +/-21.0) to 54.8% predicted (SD +/-26.1), for a posttreatment improvement of 14.4% points (95% CI = 13.8 to 15.1). Other clinical outcome measures, including dyspnea index, respiratory rate, and use of accessory muscles, also showed improvement.
Conclusions:
This study demonstrates that EMT-Bs can effectively administer albuterol to acute asthma patients in the out-of-hospital environment.
Objectives:
Prehospital 12-lead electrocardiogram (PHECG) interpretation and advance emergency department (ED) notification may improve time-to-treatment intervals for a variety of treatment strategies to improve outcome in acute myocardial infarction. Despite consensus guidelines recommending this intervention, few emergency medical services (EMS) employ this. The authors systematically reviewed the literature to report whether mortality or treatment time intervals improved when compared with standard care.
Methods:
The authors used the Cochrane strategy to search MEDLINE, EMBASE, Current Contents, Dissertation Abstracts, Cochrane Library, and Index of Scientific and Technical Proceedings. Bibliographies and grant-agency Websites were reviewed, and primary investigators and industry were contacted for published and unpublished studies. Inclusion criteria included PHECG and advance ED notification versus standard EMS care; controlled trials; English only; and evaluation of treatment time intervals, all-cause mortality, or both. Study selection was hierarchical, blinded, and independent. Agreement at each level of review was evaluated by using a kappa statistic. Study quality was measured with a validated scale and was interpreted by two independent reviewers.
Results:
A total of 1,283 citations were identified, and five studies met the inclusion criteria. The weighted kappa for selection was 0.61 (standard error [SE], 0.045) for titles, 0.63 (SE, 0.051) for abstracts, and 0.79 (SE, 0.146) for full articles. Mean study quality measures by two independent reviewers were 6.0/15 and 5.5/15 (correlation coefficient, 0.85; p = 0.06). PHECG and advance ED notification increased the weighted mean on-scene time by 1.2 minutes (95% confidence interval [95% CI] = -0.84 to 3.2). The weighted mean door-to-needle interval was shortened by 36.1 minutes (95% CI = 9.3 to 63.0: range of means, 22-48 minutes vs. 50-97 minutes). One study reported all-cause mortality, with a statistically nonsignificant reduction from 15.6% to 8.4%.
Conclusions:
For patients with AMI, the literature would suggest that PHECG and advanced ED notification reduces in hospital time to fibrinolysis. One controlled trial found no difference in mortality with this out-of-hospital intervention.
The goal of management of patients with respiratory failure is to restore them to a state of quiet breathing, without complication. This goal is often achieved by pharmacotherapy alone. Inhaled albuterol sulfate, oxygen, and systemic corticosteroids are mainstays of acute care drug management, whereas other data support the use of inhaled steroids, ipratropium bromide, magnesium sulfate, theophylline, and heliox. Assisted ventilation by face mask or endotracheal tube may be required in refractory patients. In intubated patients, a ventilatory strategy that prolongs exhalation time and accepts hypercapnia minimizes lung hyperinflation and generally results in a good outcome. Acute asthma often represents failure of outpatient management; key aspects of the outpatient program should be addressed in the acute care setting to help prevent recurrent attacks.
Emergency center thoracotomy was performed at our facility on 389 patients from 1984 through 1989. There were no patients excluded from the study, and survival for all patients was 8.3% with survival rates of 15.2% and 7.3% for stab and gunshot wounds, respectively. Emergency center thoracotomy was performed on 42 patients suffering from isolated extrathoracic injuries with 7% survival. There were no survivors of blunt trauma in this study. Fifty-three percent of the patients arrived with cardiopulmonary resuscitation (CPR) in progress. The average time of prehospital CPR for survivors was 5.1 minutes compared with 9.1 minutes for nonsurvivors. Of the survivors, prehospital endotracheal intubation prolonged successful toleration of CPR to 9.4 minutes compared with 4.2 minutes for nonintubated surviving patients (p less than 0.001). Emergency center thoracotomy is useful in the resuscitation of victims dying of penetrating truncal trauma. Prehospital endotracheal intubation significantly lengthened the time of successful CPR.
Survival from out-of-hospital cardiac arrest in cities with populations of more than 1 million has not been studied adequately. This study was undertaken to determine the overall survival rate for Chicago and the effect of previously reported variables on survival, and to compare the observed survival rates with those previously reported.
Consecutive prehospital arrest patients were studied prospectively during 1987.
The study area was the city of Chicago, which has more than 3 million inhabitants in 228 square miles. The emergency medical services system, with 55 around-the-clock ambulances and 550 paramedics, is single-tiered and responds to more than 200,000 emergencies per year.
We studied 3,221 victims of out-of-hospital cardiac arrest on whom paramedics attempted resuscitation.
Ninety-one percent of patients were pronounced dead in emergency departments, 7% died in hospitals, and 2% survived to hospital discharge. Survival was significantly greater with bystander-witnessed arrest, bystander-initiated CPR, paramedic-witnessed arrest, initial rhythm of ventricular fibrillation, and shorter treatment intervals.
The overall survival rates were significantly lower than those reported in most previous studies, all based on smaller communities; they were consistent with the rates reported in the one comparable study of a large city. The single factor that most likely contributed to the poor overall survival was the relatively long interval between collapse and defibrillation. Logistical, demographic, and other special characteristics of large cities may have affected the rates. To improve treatment of cardiac arrest in large cities and maximize the use of community resources, we recommend further study of comparable metropolitan areas using standardized terms and methodology. Detailed analysis of each component of the emergency medical services systems will aid in making improvements to maximize survival of out-of-hospital cardiac arrest.
Unlabelled:
The purpose of this study was to investigate the distribution of various mechanisms of injury and the relative severity of such injury cases throughout the different geographic zones of a large urban area using a computerized emergency medical services (EMS) dispatch/patient record database. The study city (population, 2 million residents) was divided into 156 geographic grids (each 4.5 by 3 miles) and the incidence and relative severity of various injury mechanisms were determined for each zone.
Results:
In one year (1988), there were more than 115,000 separate EMS incidents involving more than 150,000 patients, 26,000 of whom were transported for injuries incurred in 10,064 motor vehicle accidents, 4,587 falls, 4,015 lacerations/stabwounds, 1,796 beatings, 1,270 gunshots, and 952 auto-pedestrian accidents. Analysis of the 156 zones showed a disproportionate number of EMS responses in the city center with two centralmost grids accounting for about 25% of all responses. Call volume then progressively diminished toward the periphery of the city. However, with some very minor exceptions, the relative incidence and severity of the various injury mechanisms remained proportionally uniform within each zone, regardless of geographic location. Therefore, contrary to popular notoriety, the incidence and associated severity of any given injury type generally was not necessarily predicted by any particular neighborhood predilection for it, but rather by the overall demand for EMS in that zone of the city.
Survival rates for out-of-hospital cardiac arrest vary widely among locations. We surveyed the definitions used in published studies of out-of-hospital cardiac arrest. Data from 74 studies involving 36 communities showed survival rates ranging from 2% to 44%. There were five different case definitions and 11 different definitions of survivors. The absence of uniform definitions prevents meaningful intersystem comparisons, prohibits explorations of hypotheses about effective interventions, and interferes with the efforts of quality assurance. The most satisfactory numerator for a survival rate appears to be survival to hospital discharge; the most appropriate denominator appears to be witnessed adult cardiac arrest of presumed heart disease etiology, with ventricular fibrillation as the initial identified rhythm. Proposed definitions for the data emergency medical services systems should report as they examine their cardiac arrest survival rates are presented.
Published reports of out-of-hospital cardiac arrest give widely varying results. The variation in survival rates within each type of system is due, in part, to variation in definitions. To determine other reasons for differences in survival rates, we reviewed published studies conducted from 1967 to 1988 on 39 emergency medical services programs from 29 different locations. These programs could be grouped into five types of prehospital systems based on the personnel who deliver CPR, defibrillation, medications, and endotracheal intubation; the five systems were three types of single-response systems (basic emergency medical technician [EMT], EMT-defibrillation [EMT-D], and paramedic) and two double-response systems (EMT/paramedic and EMT-D/paramedic). Reported discharge rates ranged from 2% to 25% for all cardiac rhythms and from 3% to 33% for ventricular fibrillation. The lowest survival rates occurred in single-response systems and the highest rates in double-response systems, although there was considerable variation within each type of system. Hypothetical survival curves suggest that the ability to resuscitate is a function of time, type, and sequence of therapy. Survival appears to be highest in double-response systems because CPR is started early. We speculate that early CPR permits definitive procedures, including defibrillation, medications, and intubation, to be more effective.
We developed a score predictive of survival following out-of-hospital cardiac arrest from an analysis of factors associated with 611 cases. The score is calculated from four pieces of information readily obtainable by emergency personnel directly at the scene. The four items are as follow: A, arrest witnessed; C, cardiac rhythm; L, lay bystander cardiopulmonary resuscitation (CPR); S, speed (response time of paramedic unit). Among 22 patients with favorable findings on all four predictive variables (witnessed arrest, ventricular fibrillation, bystander CPR, paramedic response time less than four minutes), 15 (70%) were discharged alive. The ACLS score for this group of patients was 70%. Among 97 patients with the most unfavorable findings (whose ACLS score was 0), one (1%) was discharged. We believe the score can provide emergency personnel with a realistic appraisal of the likelihood of successful resuscitation.
To document the incidence, source, and reasons for all complaints received by a large municipal emergency medical services (EMS) program.
A retrospective review of all complaints received during three consecutive years (1990-1992) in a centralized EMS system serving a large municipality (population 2 million). All cases were categorized by year, source, and nature of the complaint.
In the three study years, EMS responded to 416,892 incidents with nearly a half-million patient contacts. Concurrently, 371 complaints were received (incidence of 1.12 per thousand); 132 in 1990, 129 in 1991, and 110 in 1992. Most complaints involved either: 1) allegations of "rude or unprofessional conduct" (34%), 2) "didn't take patient to the hospital" (19%), or 3) "problems with medical treatment" (13%). Only 1.6% (n = 6) were response-time complaints. Other complaints included "lost/damaged property," "taken to the wrong hospital," "inappropriate billing," and "poor driving habits." The most common sources were patient's families (39%) and the patients themselves (30%). Only 7.8% were from health care providers.
Reviews of complaints provide information regarding EMS system performance and reveal targets for quality improvement. For the EMS system examined, this study suggests a future training focus on interpersonal skills and heightened sensitivities, not only toward patients, but also toward bystanders and family members.
Previous studies have found that hospitals at which more procedures, such as coronary-artery bypass grafting (CABG) and other vascular surgery, are performed have lower rates of mortality related to these procedures than hospitals where fewer such procedures are performed.
We examined the relation between the number of percutaneous transluminal coronary angioplasty (PTCA) procedures performed at hospitals (volume) and short-term mortality in a population of 217,836 Medicare beneficiaries 65 years of age or older who underwent angioplasty in the United States from 1987 through 1990.
The unadjusted in-hospital mortality among patients who underwent PTCA increased from 2.5 percent among the 10 percent of patients treated in hospitals with the highest volume of such procedures to 3.9 percent among the 10 percent of patients treated in hospitals with the lowest volume. The rate of bypass surgery after PTCA also increased, from 2.8 percent among patients in the highest-volume hospitals to 5.3 percent among those in the lowest-volume hospitals. Higher rates of mortality and CABG persisted in all the groups of patients treated in hospitals that performed fewer than 100 angioplasty procedures per year in Medicare beneficiaries; this volume in Medicare beneficiaries can be extrapolated to an overall annual volume of 200 to 400 angioplasty procedures. In a logistic-regression model, the volume of PTCA procedures at a hospital was found to be a highly significant predictor of in-hospital mortality (P < 0.001). These results suggest that if the hospitals with the lowest volume had achieved the experience and technical results of the highest-volume hospitals, 381 fewer patients would have undergone CABG and there would have been 300 fewer in-hospital deaths in the population we studied.
Hospitals that perform more PTCA procedures have lower short-term mortality rates after the procedure. These data provide evidence in support of the regionalization of angioplasty services.
To determine survival from out-of-hospital cardiac arrest in New York City and to compare this with other urban, suburban, and rural areas.
Observational cohort study.
New York City.
Consecutive out-of-hospital cardiac arrests occurring between October 1, 1990, and April 1, 1991.
Trained paramedics performed immediate postarrest interviews with care providers, using a standardized questionnaire.
Entry criteria, elapsed time intervals, and nodal events conformed to Utstein recommendations. The single target end point was death or discharge home.
Of 3243 consecutive cardiac arrests on which resuscitation was attempted, 2329 (72%) met entry criteria as primary cardiac events. Overall survival was 1.4% (99% confidence interval [CI], 0.9% to 2.3%). No patients were lost to follow-up. Survival from witnessed ventricular fibrillation was 5.3% (99% CI, 2.9% to 8.8%). Using survival from witnessed ventricular fibrillation for intersystem comparison, our survival rate was similar to that of Chicago, Ill (4.0%; 99% CI, 1.9% to 7.5%; P = .41), the only other large city on which data were available. However, it was significantly lower than that reported from midsized urban/suburban areas (33.0%; 99% CI, 30.4% to 35.6%; P < .0001) and suburban/rural areas (12.6%; 99% CI, 8.9% to 16.3%; P < .0001). Survival rate among arrests occurring after arrival of emergency medical services personnel (8.5%; 99% CI, 4.7% to 14.0%) was comparable with Chicago (6.6%; 99% CI, 3.3% to 11.5%; P = .41) but markedly lower than King County, Washington (36%; 99% CI, 28.6% to 43.8%; P < .0001).
Survival from out-of-hospital cardiac arrest in New York City was poor. This was partly attributable to lengthy elapsed time intervals at every step in the chain of survival. However, examination of survival among arrests occurring after emergency medical services arrival suggests that other features may predispose residents of large cities to higher cardiac arrest mortality than individuals living in more suburban or rural settings. Since half the US population resides in large metropolitan areas, this represents a public health problem of considerable magnitude.
There is no better place to test life-saving resuscitation interventions than in the prehospital setting. Patients rarely survive cardiac arrest if resuscitation techniques have failed before leaving the scene. Also, paramedics are usually very experienced in key initial resuscitative techniques, and they routinely operate under strict paramilitary protocol, resulting in better study compliance. In addition, the large study populations that are derived from emergency medical services (EMS) systems lead to faster study completion and statistically stronger data. Most important, by reinforcing standardized care, rigidly scrutinized trials improve patient care, regardless of the effect of the study intervention. The success of productive EMS research centers requires routine communication between hospital and EMS administrators and their medical directors, designation of mutually acceptable data collectors who guarantee confidentiality, reciprocal exchange of study data provided as educational seminars to the hospitals, commitments to support the budget requests of an EMS program and appropriate system modifications, inclusion of EMS personnel in study design from the very beginning, prospective education of the medical community and media before protocol implementation, an authoritative grassroots medical director, and a paramedic supervisor system.
With the expectation that physicians who perform larger numbers of coronary angioplasty procedures will have better outcomes, the American College of Cardiology/ American Heart Association guidelines recommend minimum physician volumes of 75 procedures per year. However, there is little empirical data to support this recommendation.
We examined in-hospital bypass surgery and death after angioplasty according to 1992 physician and hospital Medicare procedure volume. In 1992, 6115 physicians performed angioplasty on 97,478 Medicare patients at 984 hospitals. The median numbers of procedures performed per physician and per hospital were 13 (interquartile range, 5 to 25) and 98 (interquartile range, 40 to 181), respectively. With the assumption that Medicare patients composed one half to one third of all patients undergoing angioplasty, these median values are consistent with an overall physician volume of 26 to 39 cases per year and an overall hospital volume of 196 to 294 cases per year. After adjusting for age, sex, race, acute myocardial infarction, and comorbidity, low-volume physicians were associated with higher rates of bypass surgery (P < .001) and low-volume hospitals were associated with higher rates of bypass surgery and death (P < .001). Improving outcomes were seen up to threshold values of 75 Medicare cases per physician and 200 Medicare cases per hospital.
More than 50% of physicians and 25% of hospitals performing coronary angioplasty in 1992 were unlikely to have met the minimum volume guidelines first published in 1988, and these patients had worse outcomes. While more recent data are required to determine whether the same relationships persist after the introduction of newer technologies, this study suggests that adherence to minimum volume standards by physicians and hospitals will lead to better outcomes for elderly patients undergoing coronary angioplasty.
The purpose of the study was to compare the outcome of severely injured patients who were transported directly to a Level I, tertiary trauma center with those who were transferred after being first transported to less specialized hospitals.
The data were based on all patients treated at three tertiary trauma centers in Quebec between April 1, 1993, and December 31, 1995. There were 1,608 patients (37%) transferred and 2,756 patients (63%) transported directly.
The mean age of the patients was approximately 45 years, and more than 60% were males. The predominant mechanisms of injury were falls and motor vehicle crashes. The transfer and direct transport groups were similar with respect to age, gender, and mechanism of injury. Body regions injured were also similar with the exception of head or neck injuries (transfer, 56%; direct, 28%; p < 0.0001). The mean Injury Severity Score was 14, the mean Pre-Hospital Index score was 5.5, and the mean Revised Trauma Score was 7.5. The two groups were similar with respect to these injury severity measures. The primary outcome of interest was mortality described as overall death rate, death rate in the emergency room, and death rate after admission. Other outcomes studied were hospital length of stay and duration of treatment in an intensive care unit. When compared with the direct transport group, transferred patients were at increased risk for overall mortality (transfer, 8.9%; direct, 4.8%; odds ratio, 1.96; 95% confidence interval (CI) = 1.53-2.50), emergency room mortality (transfer, 3.4%; direct, 1.2%; odds ratio, 2.96; 95% CI = 1.90-4.6), and mortality after admission (transfer, 5.5%; direct, 3.6%; odds ratio, 1.57; 95% CI = 1.17-2.11). All of these differences were statistically significant (p < 0.003). Stratified and multiple logistic regression analysis did not alter these results and failed to identify a patient subgroup for which transfer was associated with a reduced risk of mortality. After adjusting for patient age, Injury Severity Score, and presence of injuries to the head or neck and extremities, transferred patients stayed significantly longer in the hospital and the intensive care unit as indicated by the mean length of stay (transfer, 16.0 days; direct, 13.2 days; p = 0.02) and the mean intensive care unit stay (transfer, 2.0 days; direct, 0.95 days; p = 0.001).
The results of this study have shown that transportation of severely injured patients from the scene directly to Level I trauma centers is associated with a reduction in mortality and morbidity. Further studies are required for the evaluation of transport protocols for rural trauma. Economic and cost-effectiveness considerations of patient triage are also essential.
The concept of uniform reporting of data in resuscitation has demonstrated its potential value in pre-hospital and in-hospital
cardiac arrest in adults, infants and children, in laboratory research, in disaster research and, hopefully, also in trauma
care and research.
More than 1,000 patients experience sudden cardiac arrest each day. Treatment for this includes cardiopulmonary resuscitation (CPR) and emergency medical services (EMS) that provide CPR-basic life support (BLS), BLS with defibrillation (BLS-D), or advanced life support (ALS). Our previous systematic review of treatments for sudden cardiac arrest was limited by suboptimal data. Since then, debate has increased about whether bystander CPR is effective or whether attention should focus instead on rapid defibrillation. Therefore a cumulative meta-analysis was conducted to determine the relative effectiveness of differences in the defibrillation response time interval, proportion of bystander CPR, and type of EMS system on survival after out-of-hospital cardiac arrest.
A comprehensive literature search was performed by using a priori exclusion criteria. We considered EMS systems that provided BLS-D, ALS, BLS plus ALS, or BLS-D plus ALS care. A generalized linear model was used with dispersion estimation for random effects.
Thirty-seven eligible articles described 39 EMS systems and included 33,124 patients. Median survival for all rhythm groups to hospital discharge was 6.4% (interquartile range, 3.7 to 10.3). Odds of survival were 1.06 (95% confidence interval [CI], 1.03 to 1.09; P <.01) per 5% increase in bystander CPR. Survival was constant if the defibrillation response time interval was less than 6 minutes, decreased as the interval increased from 6 to 11 minutes, and leveled off after 11 minutes (P <.01). Compared with BLS-D, odds of survival were as follows: ALS, 1. 71 (95% CI, 1.09 to 2.70; P =.01); BLS plus ALS, 1.47 (95% CI, 0.89 to 2.42; P =.07); and BLS with defibrillation plus ALS, 2.31 (95% CI, 1.47 to 3.62; P <.01.)
We confirm that greater survival after sudden cardiac arrest is associated with provision of bystander CPR, early defibrillation, or ALS. More research is required to evaluate the relative benefit of early defibrillation versus early ALS.