Hospital follow-up of patients categorized as not needing an ambulance using a set of emergency medical technician protocols

OBJECTIVE

Using hospital outcomes, this study evaluated emergency medical technicians' (EMTs') ability to safely apply protocols to assign transport options.

METHODS

Protocols were developed that categorized patients as: 1) needs ambulance; 2) may go to emergency department (ED) by alternative means; 3) contact primary care provider (PCP); or 4) treat and release. After education on application of the protocols, EMTs categorized patients at the scene prior to transport but did not change current practice. Hospital charts were reviewed to determine outcome of patients whom EMTs categorized as not needing an ambulance. Category 2 patients were assumed to need the ambulance if they were admitted to a monitored bed or intensive care unit. Category 3 and 4 patients were assumed to need the ED if they were admitted.

RESULTS

The EMTs categorized 1,300 study patients: 1,023 (79%) ambulance transport, 200 (15%) alternative means, 63 (5%) contact PCP, and 14 (1%) treat and release. Hospital data were obtained for 140 (51%) patients categorized as not needing ambulance transport. Thirteen of 140 (9%) patients who transporting EMTs determined did not need the ambulance were considered to be undertriaged: five in category 2, six in category 3, and one in category 4. Six of 13 (46%) undertriaged patients had dementia or a psychiatric disorder as one of their presenting complaints.

CONCLUSION

These protocols led to a 9% undertriage rate. Patients with psychiatric complaints and dementia were at high risk for undertriage.

Can basic life support personnel safely determine that advanced life support is not needed?

OBJECTIVE

To determine whether firefighter/emergency medical technicians-basic (FF/EMT-Bs) staffing basic life support (BLS) ambulances in a two-tiered emergency medical services (EMS) system can safely determine when advanced life support (ALS) is not needed.

METHODS

This was a prospective, observational study conducted in two academic emergency departments (EDs) receiving patients from a large urban fire-based EMS system. Runs were studied to which ALS and BLS ambulances were simultaneously dispatched, with the patient transported by the BLS unit. Prospectively established criteria for potential need for ALS were used to determine whether the FF/EMT-B's decision to cancel the ALS unit was safe, and simple outcomes (admission rate, length of stay, mortality) were examined. In the system studied, BLS crews may cancel responding ALS units at their discretion; there are no protocols or medical criteria for cancellation.

RESULTS

A convenience sample of 69 cases was collected. In 52 cases (75%), the BLS providers indicated that they cancelled the responding ALS unit because they did not feel ALS was needed. Of these, 40 (77%) met study criteria for ALS: 39 had potentially serious chief complaints, nine had abnormal vital signs, and ten had physical exam findings that warranted ALS. Forty-five (87%) received an intervention immediately upon ED arrival that could have been provided in the field by an ALS unit, and 16 (31%) were admitted, with a median length of stay of 3.3 days (range 1.1-73.4 days). One patient died.

CONCLUSION

Firefighter/EMT-Bs, working without protocols or medical criteria, cannot always safely determine which patients may require ALS intervention.

Feasibility of paramedic treatment and referral of minor illnesses and injuries

BACKGROUND

Approximately 40% of Hennepin County Medical Center's (HCMC's) ambulance runs are for minor medical conditions as defined by billing criteria ["ALS minor," i.e., no advanced life support (ALS) procedures done in the field]. Current metropolitan guidelines mandate that all such patients must be transported to a hospital unless they refuse this service. It has been proposed that some patients with minor medical conditions could be better served by treatment in the field by paramedics and referred to a clinic or hospital for early follow-up care. It is proposed that this approach would save costs and improve paramedic availability for patients with more serious conditions.

OBJECTIVE

To evaluate the feasibility and safety of implementing such a program by identifying high-volume, low-complexity groupings of cases. Such high-volume, low-complexity cases would serve as the topics for curriculum development for paramedic training in field treatment and referral.

METHODS

Data were obtained from ambulance run sheets and emergency department (ED) records for all patients transported by the HCMC ambulance service in 1996 who were covered by the Metropolitan Health Plan (MHP) and who were categorized for billing purposes as "ALS minor" transports. The data included demographic information, vital signs, presenting problem, diagnoses in the ED, and procedures, laboratory studies, or x-rays done in the ED. Patients were classified as "potentially treatable" in the field if they were treated and discharged from the ED without undergoing any procedures or diagnostic studies. Patients who required more extensive evaluation in the ED, or who were admitted, were classified as likely too "complex" to be treated at the scene and then referred for early follow-up. The data were analyzed to find the most common presenting problems and the numbers, characteristics, and dispositions of "potentially treatable" and "complex" patients in each group. This information was used to determine what, if any, types of patients could potentially be treated safely and effectively according to this scheme.

RESULTS

The study group comprised 1,103 patients, representing 127 different presenting medical problems. There were 523 (47%) "potentially treatable" patients and 580 (53%) "complex" patients. The 127 medical problems were grouped and the 15 most common presenting problem groups were identified. Within these groups there was no single medical problem with high volume. Each of these 15 most common problem groups contained a substantial proportion of "complex" patients, ranging from 24% to 100%.

CONCLUSIONS

None of the 15 most frequently encountered problem groups consisted of a high enough proportion of "potentially treatable" cases to serve as a high-volume, low-complexity category for paramedic treatment in the field with early follow-up. Without any identified high-volume, low-complexity categories, a treatment and referral program as proposed in this article would require a substantial investment in development of appropriate criteria and in training paramedics to apply the criteria for numerous clinical entities. This would limit any cost saving, and require great care to avoid compromising patient safety accompanied by substantial professional liability exposure.

Experience and mentoring requirements for competence in new/inexperienced paramedics

A paramedic may be unprepared to practice alone or with an inexperienced partner immediately following completion of training. Emergency medical services systems have not generally set standards to ensure that a newly-licensed paramedic is competent to practice alone. Many other trades and professions, including health care providers, require many hours of mentoring or apprenticeship prior to working in an unsupervised environment. This paper summarizes mentoring requirements for other clinical professions and reviews studies from the out-of-hospital and hospital literature that demonstrate a positive correlation between experience and outcome and/or competence. The author recommends specific benchmarking and supervision by a training officer or an experienced paramedic to ensure competence in new and inexperienced paramedics.

Intubation success rates by air ambulance personnel during 12-versus 24-hour shifts: does fatigue make a difference?

OBJECTIVES

To determine whether the skill performance and psychomotor agility, as measured by the endotracheal intubation success rate, of air ambulance medical personnel would be affected by the potential fatigue incurred when increasing the length of their shifts from 12 to 24 hours.

METHODS

This was a retrospective review of all flight and intubation records from a large air medical transport system from 1997, when 24-hour shifts were in place, and six months (March-August) of 1996, during which 12-hour shifts were scheduled. Records of all intubation efforts during both periods, including multiple attempts per patient, and outcomes of all attempts, were recorded. Results of successes and failures were tabulated for both ultimate intubation outcome per patient and all attempts per patient for each calendar day and for the 12 hours between 19:00 and 07:00 when fatigue might play a role. Results from the two study periods were compared using Fisher's exact test.

RESULTS

During the six months of 1996, 190 of 199 (95.5%) patients were ultimately successfully intubated. These patients required 237 attempts (80.1% successful). During 1997, 362 of 376 (96.3%) patients were successfully intubated, and required 438 attempts (82.6% successful). There was no statistically significant difference in the number of ultimately successful intubations (p = 0.66) or total intubation attempts (p = 0.37) between 1996 and 1997. Analysis of intubations between 19:00 and 07:00 revealed 81 of 84 (96.4%) patients successfully intubated in 1996, with 81 of 103 (78.6%) attempts successful. During 1997, 173 of 180 (96.1%) patients were ultimately successfully intubated, with 173 of 212 (81.6%) attempts successful. Again, there was no significant difference in the number of successful intubations (p = 0.99) or intubation attempts (p = 0.55) between 1996 and 1997.

CONCLUSION

Psychomotor agility of air ambulance medical personnel, as measured by the success rate of endotracheal intubation, was not affected by the potential additional fatigue incurred as a result of increasing shift length from 12 to 24 hours.

Characteristics of fatal ambulance crashes in the United States: an 11-year retrospective analysis

BACKGROUND

Ambulance crashes have become an increasing source of public concern. Emergency medical services directors have little data to develop ambulance operation and risk management policies.

OBJECTIVE

To describe fatal ambulance crash characteristics, identifying those that differentiate emergency and nonemergency use crashes.

METHODS

This was a retrospective analysis of all fatal ambulance crashes on U.S. public roadways reported to the Fatality Analysis Reporting System (FARS) database from 1987 to 1997. Main outcome measures were 42 variables describing crash demographics, crash configuration, vehicle description, crash severity, and ambulance operator and vehicle occupant attributes.

RESULTS

Three hundred thirty-nine ambulance crashes caused 405 fatalities and 838 injuries. These crashes occurred more often between noon and 6 PM (39%), on improved (99%), straight (86%), dry roads (69%) during clear weather (77%), while going straight (80%), through an intersection (53%), and striking (81%) another vehicle (80%) at an angle (56%). Most crashes (202/339) and fatalities (233/405) occurred during emergency use. These crashes occurred significantly more often at intersections (p < 0.001), at an angle (p < 0.001), with another vehicle (p < 0.001). Most crashes resulted in one fatality, not in the ambulance. Thirty pedestrians and one bicyclist comprised 9% of all fatalities. In the ambulance, most serious and fatal injuries occurred in the rear (OR 2.7 vs front) and to improperly restrained occupants (OR 2.5 vs restrained). Sixteen percent of ambulance operators were cited; 41% had poor driving records.

CONCLUSIONS

Most crashes and fatalities occurred during emergency use and at intersections. The greater burden of injury fell upon persons not in the ambulance. Rear compartment occupants were more likely to be injured than those in the front. Crash and injury reduction programs should address improved intersection control, screening to identify high-risk drivers, appropriate restraint use, and design modifications to the rear compartment of the ambulance.

A comparison of rural and urban Emergency Medical System (EMS) personnel: a Texas study

INTRODUCTION

In treating accident victims, actions by the Emergency Medical Personnel (EMP) at the scene may be the difference between life or death, full recovery or permanent disability. Development of selected profiles based on locale of services, tenure, and paramedic certification will provide valuable insight into the diversity within the Emergency Medical Services (EMS) profession. Not only will these profiles enable administrators to improve their recruitment, training, and retention of the emergency medical workforce, it potentially could enhance the quality of health care in the community.

POPULATION

Emergency medical personnel attending a statewide conference in Texas in late 1996 (n = 425).

HYPOTHESES

1) There is no difference between the profiles of urban and rural EMP; 2) There is no difference between the profiles of urban EMP with < 9 years of experience and those with > or = 9 years of experience; 3) There is no differences between the profiles of rural EMP with < 9 years of experience and those with > or = 9 years of experience. 4) There is no difference between the profiles of urban EMP with paramedic certification and those without certification; and 5) There is no difference between the profiles of rural EMP with paramedic certification and those without certification.

METHODS

EMP attending the conference completed 425 survey instruments measuring five demographic features, five work-related features, and two psychological features. Survey instruments were included in each registrant's conference package. Completed surveys were deposited anonymously in labeled receptacles throughout the statewide conference site. Data collection ceased at the end of the conference. Discriminant analysis identified distinct profiles for the urban and rural EMP.

RESULTS

The urban EMP, more than rural subjects, was younger (mean = 36 years), more likely to be compensated 100% for their services, had a higher level of education (mean = 13.8 years), and reported a lower level of burnout. Urban EMP with < 9 years of experience tended to be younger, male, married, and reported less burnout. Urban paramedics were more likely to be compensated 100% for their services, and had achieved a higher level of education. The rural EMP with < 9 years of experience were less likely to be paramedic, reported lower burnout scores, and was younger. The rural EMP without paramedic certification was more likely to be a volunteer, and have had fewer years of service.

CONCLUSIONS

In Texas, locale of service (urban or rural), length of tenure as an EMP (> or = 9 years), and paramedic certification appear to be significant factors that define the EMP population in Texas.

Responding to aquatic facilities

The primary and fundamental responsibility of a local EMS system is to provide prehospital care to the citizens of the community. Therefore, each community must have a system in place to ensure continual, efficient prehospital care. There are a variety of levels of EMS education, which include first responder, EMT-Basic, EMT-Intermediate and EMT-Paramedic, along with other components, including the emergency medical dispatcher, other healthcare providers and specialty care centers. In order for a community to provide and ensure continual, efficient prehospital care, the components must work together in a well-planned and coordinated effort. If lifeguard personnel are expected to respond to respiratory, cardiac and spinal-injury incidents within their aquatic facilities, they must be included within this comprehensive community EMS system. Therefore, fire, rescue and other prehospital EMS agencies must coordinate their efforts and training responsibilities with the local lifeguard services in their area.

Accuracy of Estimation of External Blood Loss by EMS Personnel

BACKGROUND

Emergency Medical Services (EMS) personnel provide care in the out-of-hospital setting. The EMS report, including blood volume estimates, influences hospital management. Our objective was to assess the accuracy of EMS blood volume estimates.

METHODS

In this prospective, observational study, EMS providers were asked to view four simulated blood loss scenarios in random order. Each scenario used a specific volume of spilled blood corresponding to the loss likely to cause the four classes of hemorrhagic shock. Estimates are reported using median and interquartile ranges.

RESULTS

Ninety-two EMS providers gave 368 estimates. Only 8% were within 20% of the actual volume. Furthermore, only 24% were within 50% of actual volume. There was no correlation between accuracy and any demographic variable, level of training, or years of EMS experience.

CONCLUSION

EMS personnel are unable to estimate "blood" volume accurately irrespective of level of training.

Effects of the video case study in preparing paramedic preceptors for the role of evaluator

INTRODUCTION

Accurate field evaluations are critical in determining paramedic students' competency to provide patient care. The [U.S.] National Paramedic Curriculum does not address the skills needed by evaluators, and requirements to be a preceptor/evaluator vary from state to state. Therefore, it is imperative that educational programs develop an evaluation process that reflects valid performance criteria and assure a high degree of rating consistency among the evaluators. This study sought to determine the effects of using a video case based teaching approach in preparing paramedic preceptors for the role of evaluator.

HYPOTHESIS

Paramedic preceptors receiving the case-based teaching approach to prepare them for the role of evaluator would demonstrate significantly higher scores on a video posttest than paramedic preceptors who were not prepared for the role of evaluator using the case-based approach.

METHODS

Thirty-four paramedic preceptors from a Midwestern fire-based EMS system were enrolled in this study. Two scripted video student/patient encounters were used to measure evaluation scores in a pretest-posttest comparison of control versus experimental group. The experimental group was given structured rating guidelines and practice applying those guidelines to a case study. Pretest and posttest scores were weighted and analyzed using ANOVA.

RESULTS

Analysis of the pretest-posttest differences revealed significantly higher scores for the experimental group in the categories containing complex behaviors: communication F (1,16) = 13.21,p <.01, assessment F (1,16) = 8.81,p <.01, and knowledge F (1,16) = 29.64, p <.001. There was no significant difference between groups in the categories containing simple, easily observed behaviors: reliability F (1,16) = .55, p >.05 and cooperativeness F (1,16) = 3.02,p >.05.

CONCLUSIONS

Using the case study method and written guidelines that provide concrete examples of complex behaviors appears to increase reliability of evaluations among preceptors.

Student field performances: how valid are your preceptors' evaluations?

Developing relevant performance standards and rating criteria and preparing preceptors for the role of evaluator are critical to establishing valid student field performance evaluations and providing assurance to educational institutions that graduating students truly are competent and ready to assume an entry-level position. Using scripted, pre-scored video case studies in conjunction with written guidelines for rating the performance standards and providing specific feedback to explain rationale can significantly improve interrater agreement between preceptors.

Cost-benefit of trained transport teams: estimates for head-injured children

INTRODUCTION

Care during transport influences the outcome of head-injured children. Secondary adverse events, e.g., hypotension and hypoxia, worsen morbidity and mortality. Trained transport teams lower the incidence of such secondary "insults."

OBJECTIVE

To estimate the cost-benefit of improved care from trained escorts.

METHODS

The setting was a provincial air ambulance service during transition to trained pediatric escort paramedics. A retrospective review of transport and hospital records for a 12-month period was conducted. All children with head injuries (n = 43) transported to tertiary care [11 by untrained escorts (UE), 32 by trained escorts (TE)] were enrolled. Severity of injury was classified by Glasgow Coma Score (GCS); incidence of adverse events was counted and cost of change of severity resulting from preventable insults was estimated using published care costs.

RESULTS

There were 13 preventable insults in six patients (55%) in the UE group and five preventable insults in four patients (12%) in the TE group (p<0.05). Among those in the UE group, two changed in severity from moderate to severe, one moderate worsened (decrease in GCS of 2 or more), and two severe worsened. In the TE group, there were no changes >1. Cost-benefit estimates based on change in severity were $136,000 (median) to $238,000 (mean).

CONCLUSION

Significant cost-benefit likely accrues from training escorts who transport children with significant head injuries to tertiary care.

Successful prehospital airway management by EMT-Ds using the combitube

OBJECTIVE

To evaluate the ability to train emergency medical technicians-defibrillation (EMT-Ds) to effectively use the Combitube for intubations in the prehospital environment.

METHODS

This was an 18-month prospective field study in which EMT-Ds were trained how and in what situations to use the Combitube. Data were then obtained for all patients in whom Combitube insertion was attempted. Indications for use of the Combitube included: unconsciousness without a purposeful response, absence of the gag reflex, apnea or respiratory rate less than 6 breaths/min, age more than 16 years, and height at least 5 feet tall. Contraindications were: obvious signs of death, intact gag reflex, inability to advance the device due to resistance, or known esophageal pathology. Data were entered prospectively from the San Diego County EMS QANet database for prehospital providers.

RESULTS

Twenty-two EMT-D provider agencies, involving approximately 500 EMT-Ds, were included as study participants. Combitube insertions were attempted in 195 prehospital patients in cardiorespiratory arrest, with appropriate indication for Combitube use. An overall successful intubation rate (defined as the ability to successfully ventilate) of 79% was observed. Identical success rates for medical and trauma patients were noted. The device was placed in the esophagus 91% of the time. Resistance during insertion was the major reason for unsuccessful Combitube intubations. An overall hospital admission rate of 19% was observed. No complications were reported.

CONCLUSION

EMT-Ds can be trained to use the Combitube as a means of establishing an airway in the prehospital setting. Future studies will need to further evaluate its effect on patient outcome.