Location of Cardiac Arrests in the Public Access Defibrillation Trial

BACKGROUND

The Public Access Defibrillation (PAD) Trial found an overall doubling in the number of out-of-hospital cardiac arrest (CA) survivors when a lay responder team was equipped with an automated external defibrillator (AED), compared with cardiopulmonary resuscitation (CPR) alone.

OBJECTIVES

To describe the types of facilities that participated in the trial and to report the incidence of CA and survival in these different types of facilities.

METHODS

In this post-hoc analysis of PAD Trial data, the physical characteristics of the participating facilities and the numbers of presumed CAs, treatable CAs, and survivors are reported for each category of facilities.

RESULTS

There were 625 presumed CAs at 1,260 participating facilities. Just under half (n = 291) of the presumed CAs were classified as treatable CAs. Treatable CAs occurred at a rate of 2.9 per 1,000 person-years of exposure; rates were highest in fitness centers (5.1) and golf courses (4.8) and lowest in office complexes (0.7) and hotels (0.7). Survival from treatable CA was highest in recreational complexes (0.5), public transportation sites (0.4), and fitness centers (0.4) and lowest in office complexes (0.1) and residential facilities (0.0).

CONCLUSIONS

During the PAD Trial, the exposure-adjusted rate of treatable CA was highest in fitness centers and golf courses, but the incidence per facility was low to moderate. Survival from treatable cardiac arrest was highest in recreational complexes, public transportation facilities, and fitness centers.

Effect of a Graduated Licensing System on Motor Vehicle Crashes andAssociated Injuries Involving Drivers Less Than 18 Years-of-Age

OBJECTIVES

The rate of motor vehicle crashes in the United States is higher among adolescent drivers than among any other age group. This study was conducted to determine whether implementation of a graduated driver's licensing program is associated with a reduced the rate of motor vehicle crashes and injuries involving adolescent driver.

METHODS

Time periods before and after establishment of Delaware's GDL program were compared. The one year "before" period spanned January 1, 1998, through December 31, 1998, and the 3-year "after" period spanned January 1, 2000, to December 31, 2002. Following enactment of the GDL program on July 1, 1999, we delayed data collection during the "after" period for 6 months to allow for full implementation of the program. Information was obtained for all Delaware registered drivers between ages 16 and 17 years were involved in motor vehicle crashes involving property damage or injury from 1998 to 2002. The rate of crashes involving property damage, EMS transport, injury, hospitalization, and death were determined pre- and post-GDL,. Length of hospitalization and hospital charges were compared, and the presence and age of passengers, along with time of day were determined.

RESULTS

The total number of licensed 16- and 17-year-old drivers in Delaware was 14,320 during 1998 (the before period), 16,849 for 2000, 14,098 for 2001, and 14,276 for 2002, for a total of 45,223 licensed drivers studied during the after period. The proportion of hospitalizations, injuries, crashes involving property damage and total number of crashes involving registered 16- and 17-year-old drivers after GDL each decreased by at least 30%. In addition, this GDL program was associated with a reduction in nighttime crashes and in crashes involving cars with multiple passengers in comparison with the time period before GDL.

CONCLUSIONS

Two years after implementation, the hospitalization rate, injury rate, and crash rate decreased significantly with enactment of the GDL program in the State of Delaware. The Delaware's GDL program appears successful in decreasing motor vehicle crashes and resultant injuries in adolescent drivers.

Trauma Triage: Concepts in Prehospital Trauma Care

This report examines the efficacy of current trauma triage rules to determine the exigency of field care and transport of severely injured patients from a variety of medical populations.

Physician medical oversight in emergency medical services: where are we?

OBJECTIVE

The objective of this study was to quantify the amount of direct contact with medical direction that nationally registered emergency medical services (EMS) professionals receive. The secondary objective was to determine whether differences in medical director contact were associated with work-related characteristics.

METHODS

As part of biennial reregistration paperwork, nationally registered EMS professionals reregistering in 2004 were asked to complete a survey regarding medical direction. There were three survey questions asking participants to indicate, on a five-point scale, how often they interacted with their medical director in specific situations (whether the medical director participated in continuing education, met personally to discuss an EMS issue, and was seen at the scene of an EMS call). Individuals were categorized as having limited contact if they had not observed their medical director in any of the above situations for more than six months. All others where categorized as having recent contact. Demographic characteristics were collected and statistical analysis was performed using chi-square.

RESULTS

In 2004, 45,173 individuals reregistered, with 28,647 (63%) returning surveys. A complete case analysis was performed, leaving 22,026 (49%) individuals. There were 13,756 (62.5%) individuals who reported having recent medical director contact. A stepwise increase in the percentage of those reporting recent contact was present when comparing the providers' certification levels (emergency medical technician EMT-Basic 47.6%, EMT-Intermediate 62.3%, and EMT-Paramedic 78.5%, p < 0.001). The highest percentage of recent contact was reported by those who worked for a hospital-based service, whereas the lowest percentage was reported by volunteer services (hospital-based 78.8%, county/municipal 70.8%, private 67.6%, military 62.4%, government 61.1%, fire-based 57.0%, and volunteer 50.8% chi(2) = 712.4, p < 0.001). EMS professionals working in urban areas were more likely to report recent contact than those in rural areas (64.9% vs. 59.2%, p < 0.001).

CONCLUSION

It has been suggested that EMS professionals benefit from direct contact with a physician medical director. Nearly one-third of participants in this study reported having limited medical director contact. Certification level, service type, and community size were significantly associated with the amount of contact with medical direction.

Does the simple triage and rapid treatment method appropriately triage patients based on trauma injury severity score?

OBJECTIVES

To correlate the simple triage and rapid treatment (START) colors to trauma injury severity scores (ISS).

DESIGN

Six volunteer healthcare providers unfamiliar with START were trained to triage. Each chart was designated a START color by a volunteer healthcare provider and the "expert" trainer. The colors and corresponding ISS were recorded.

SETTING

Level I trauma center at a suburban tertiary care hospital.

PATIENTS, PARTICIPANTS

One hundred charts of patients at least 65 years old who appear in Christiana Hospital's Trauma Registry were randomly chosen for the study, and 98 charts with complete data were included.

MAIN OUTCOME MEASURE(S)

Cohen's Kappa score measures the level of agreement between the "volunteer" and "expert" reviewers. Pearson correlation determines the association between the START colors and mean ISS.

RESULTS

The Cohen's Kappa score between the volunteer and expert reviewers was 0.9915, indicating a highly significant agreement between the reviewers on the triage category of the patients. The mean ISS for each color was as follows: green = 11, yellow = 12, red = 20, black = 24. The mean ISS increases as the acuity of the triage category increases, with a Pearson correlation of 0.969.

CONCLUSIONS

The START method is a simple technique used to triage quickly a large number of patients. Healthcare providers can undergo just-in-time training to learn this technique and use it effectively. The START colors also imply a correlation with the trauma ISS, with higher ISS more likely to be triaged "red" or "black."

Essential features of designating out-of-hospital cardiac arrest as a reportable event: a scientific statement from the American Heart Association Emergency Cardiovascular Care Committee; Council on Cardiopulmonary, Perioperative, and Critical Care; Council on Cardiovascular Nursing; Council on Clinical Cardiology; and Quality of Care and Outcomes Research Interdisciplinary Working Group

The 2010 impact goal of the American Heart Association is to reduce death rates from heart disease and stroke by 25% and to lower the prevalence of the leading risk factors by the same proportion. Much of the burden of acute heart disease is initially experienced out of hospital and can be reduced by timely delivery of effective prehospital emergency care. Many patients with an acute myocardial infarction die from cardiac arrest before they reach the hospital. A small proportion of those with cardiac arrest who reach the hospital survive to discharge. Current health surveillance systems cannot determine the burden of acute cardiovascular illness in the prehospital setting nor make progress toward reducing that burden without improved surveillance mechanisms. Accordingly, the goals of this article provide a brief overview of strategies for managing out-of-hospital cardiac arrest. We review existing surveillance systems for monitoring progress in reducing the burden of out-of-hospital cardiac arrest in the United States and make recommendations for filling significant gaps in these systems, including the following: 1. Out-of-hospital cardiac arrests and their outcomes through hospital discharge should be classified as reportable events as part of a heart disease and stroke surveillance system. 2. Data collected on patients' encounters with emergency medical services systems should include descriptions of the performance of cardiopulmonary resuscitation by bystanders and defibrillation by lay responders. 3. National annual reports on key indicators of progress in managing acute cardiovascular events in the out-of-hospital setting should be developed and made publicly available. Potential barriers to action on cardiac arrest include concerns about privacy, methodological challenges, and costs associated with designating cardiac arrest as a reportable event.

Black cohosh-induced hepatitis

Herbal products are widely used by American consumers. Herbal remedies are not regulated by the Food and Drug Administration, but they are not immune from serious medication side-effects. We report the case of a 50-year-old woman who presented with fatigue and right upper quadrant pain. The patient had begun the popular postmenopausal herbal remedy black cohosh two weeks prior to presentation. Laboratory results revealed acute hepatitis. After other causes of liver failure were ruled out, the patient was diagnosed with black cohosh-induced hepatitis. She recovered uneventfully following withdrawal of the herb. There are five prior reports of hepatitis or hepatic failure likely caused by the herbal remedy black cohosh in the English literature. This case illustrates the importance of a broad differential diagnosis for abdominal pain and highlights the importance of a complete medication list, including herbs.

A randomized controlled trial of ultrasound-assisted lumbar puncture

OBJECTIVE

Evidence showing the systematic utility of ultrasound imaging during lumbar puncture (LP) in the emergency department is lacking. Our hypothesis was that ultrasound-assisted LP would increase the success rate and ease of performing LP with a greater benefit in obese patients.

METHODS

This was an Institutional Review Board-approved, randomized, prospective, double-blind study conducted at the emergency department of a teaching institution. Patients undergoing LP from January to December 2004 were eligible for enrollment. Patients were randomized to undergo LP using palpation landmarks (PLs) or ultrasound landmarks (ULs). Data collected included age, body mass index, number of attempts, ease of performance and patient comfort on a 10-cm Visual Analog Scale, procedure time, success, and traumatic LP. Statistical analysis of data included relative risk (RR), the Mann-Whitney U test, and the Student t test.

RESULTS

A total of 46 patients were enrolled, 22 randomized to PLs and 24 to ULs. There were no differences between the groups in mean age or body mass index. Six of 22 attempts failed with PLs versus 1 of 24 with ULs (RR, 1.32; 95% confidence interval, 1.01-1.72). In 12 obese patients, 4 of 7 PL attempts failed versus 0 of 5 UL attempts (RR, 2.33; 95% confidence interval, 0.99-5.49). The ease of the procedure was better with ULs versus PLs. There were no statistical differences in the number of attempts, traumatic LPs, patient comfort, or procedure length.

CONCLUSIONS

The use of ultrasound for LP significantly reduced the number of failures in all patients and improved the ease of the procedure in obese patients.

The Delaware Trauma System: Impact of Level III Trauma Centers

BACKGROUND

In 2000, Delaware instituted a trauma system that included establishing four Level III trauma centers in counties previously without trauma centers. The purpose of this study was to analyze whether implementation of this inclusive trauma system reduced the injury-related mortality rates in these counties.

METHODS

Using the state trauma registry, patients with trauma admitted to all acute care hospitals in Delaware from January 1, 1995 through December 31, 2004 were identified and categorized into two groups: preimplementation of an inclusive trauma system (1995-1999), and postimplementation (2000-2004). These groups were compared in aggregate and by individual counties for age, sex, mechanism of injury, Abbreviated Injury Score, injury-related mortality rate, mean Injury Severity Score (ISS), acute transfers out, and acute transfers in (Level I only). chi test and Mann-Whitney U test were used where indicated. Significance was determined to be p < or = 0.05.

RESULTS

After implementation, mortality rates significantly decreased (5.3%-2.8%) and rate of acute transfers out increased (14.7%-19.5%) in the counties served by the Level III centers. The ISS of patients in the Level I trauma center significantly increased (mean ISS = 10) when compared with the Level III trauma centers (mean ISS = 6), reflecting increased transfers of patients with severe injuries.

CONCLUSION

An inclusive state trauma system that included the establishment of Level III trauma centers in previously underserved counties led to a decrease in trauma-related mortality rates in these counties. In the county served by the Level I trauma center, mortality remained unchanged despite an increase in admissions and the injury severity of these admissions.

Blast-related injuries from terrorism: an international perspective

Terrorism using conventional weapons and explosive devices is a likely scenario and occurs almost daily somewhere in the world. Caring for those injured from explosive devices is a major concern for acute injury care providers. Learning from nations that have experienced conventional weapon attacks on their civilian population is critical to improving preparedness worldwide. In September 2005, a multidisciplinary meeting of blast-related injury experts was convened including representatives from eight countries with experience responding to terrorist bombings (Australia, Colombia, Iraq, Israel, United Kingdom, Spain, Saudi Arabia, and Turkey). This article describes these experiences and provides a summary of common findings that can be used by others in preparing for and responding to civilian casualties resulting from the detonation of explosive devices.

Specialty coverage at non-tertiary care centers

The fundamental tenet of a trauma system is to get the right patient to the right hospital at the right time. Although most injuries are minor or moderate and can be managed at local community hospitals, a significant minority of injured patients require extensive and expensive care to survive or minimize injury. Most prehospital trauma triage criteria address a combination of factors to consider, but this approach sometimes fails to identify patients with severe injuries and often burdens trauma centers with patients suffering minor injuries. It is critical to utilize a method to differentiate those injury victims who need the specialized expertise and resources available in trauma centers from those who can be adequately cared for locally. Although trauma centers assume the leadership role, in a truly inclusive system, all health care providers (prehospital, community hospitals, and trauma centers) have a defined role in providing care to patients with trauma. All these institutions should establish and maintain transfer agreements for the transfer of patients meeting system trauma triage criteria. Because prehospital triage criteria are not 100% sensitive, there should be a mechanism in place for the secondary triage of patients. Initial management of patients should continue while efforts are made to transfer the patient.

Differentiating large-scale surge versus daily surge

This breakout session at the Academic Emergency Medicine 2006 Consensus Conference examined how baseline overcrowding impedes the ability of emergency departments to respond to sudden, unexpected surges in demand for patient care. Differences between daily and catastrophic surge were discussed, and the need to invoke a hospital-wide response to surge was explored.

Exercise-induced hyponatremia: causes, risks, prevention, and management

Exercise-induced hyponatremia is most commonly associated with prolonged exertion during sustained, high-intensity endurance activities such as marathons or triathlons. In most cases, exercise-induced hyponatremia is attributable to excess free water intake, which fails to replete the sometimes massive sodium losses that result from sweating. The risk of hyponatremia can be lowered by strategies to ensure fluid balance during exercise by maintaining the proper volume and type of fluid intake. Treatment of exercise-induced hyponatremia is based on whether the patient is volume-depleted, euvolemic, or fluid-overloaded. Because therapy must be tailored to volume status, physicians must make this determination before initiating therapy. If hyponatremia is life-threatening, hypertonic saline may be warranted to increase sodium in the extracellular fluid compartment and restore the natural balance.

Automated external defibrillator program does not impair cardiopulmonary resuscitation initiation in the public access defibrillation trial

OBJECTIVES

To evaluate whether automated external defibrillator (AED) training and AED availability affected the response of volunteer rescuers and performance of cardiopulmonary resuscitation (CPR) in presumed out-of-hospital cardiac arrest (OOH-CA) during the multicenter Public Access Defibrillation Trial.

METHODS

The Public Access Defibrillation Trial recruited 1,260 facilities in 24 North American regional sites to participate in a trial addressing survival from OOH-CA when AED training and availability were added to a volunteer-based emergency response team. Volunteers at each facility were trained to perform either CPR alone (CPR) or CPR in conjunction with AED use (CPR+AED) according to randomized assignments. This study reports the frequency of response and initiation of CPR actions (chest compressions and/or ventilations) by volunteers in the CPR and CPR+AED study groups.

RESULTS

A total of 314 presumed OOH-CA episodes occurred in CPR facilities, and 308 occurred in CPR+AED facilities. The volunteers were matched well for age, gender, and other features. Overall, ventilations (23.1% vs. 13.1%), chest compressions (24.4% vs. 12.1%), and both actions (19.8% vs. 10.5%; all p < 0.05) were more commonly performed in OOH-CA cases in the CPR+AED group. However, when only OOH-CA cases with volunteers responding were analyzed, the rates of CPR actions were similar. In the subgroup of CPR+AED cases with a responding volunteer, the AED was turned on for only 47% of cases. Volunteers initiated a CPR action more commonly when the AED was turned on (60.7% vs. 39.3%; p = 0.003).

CONCLUSIONS

In the Public Access Defibrillation Trial, rates of CPR actions for presumed OOH-CA victims were low but similar for CPR and CPR+AED responding volunteer rescuers. Factors associated with volunteer response, CPR action initiation, and AED activation warrant further investigation.

Are US informed consent requirements driving resuscitation research overseas?

Following a 2-year federally imposed moratorium on acute resuscitation research due to concern regarding the inability of patients in cardiac arrest to provide prospective, informed consent to participate in such research, the United States federal government in 1996 released regulations with provisions for exemption of prospective informed consent in certain types of emergency research. While very few acute resuscitation research studies have been attempted in the United States since that time, such research has continued overseas. We discuss one large multi-center, out-of-hospital trial of a device intended to improve the hemodynamics of cardiopulmonary resuscitation. After pilot implementation overseas, this trial could not be conducted in the United States, largely due to the difficulties and costs involved in implementing the requirements of the 1996 regulations. A recent European Union directive on the conduct of clinical trials may halt European research on patients who are unable to provide prospective, informed consent. The directive contains no provisions for exceptions or waiver of informed consent, and may hinder acute resuscitation research in Europe to an even greater degree than the 1996 regulations have in the United States.

Dangerous climate change: the role for risk research

The notion of "dangerous climate change" constitutes an important development of the 1992 United Nations Framework Convention on Climate Change. It persists, however, as an ambiguous expression, sustained by multiple definitions of danger. It also implicitly contains the question of how to respond to the complex and multi-disciplinary risk issues that climate change poses. The invaluable role of the climate science community, which relies on risk assessments to characterize system uncertainties and to identify limits beyond which changes may become dangerous, is acknowledged. But this alone will not suffice to develop long-term policy. Decisions need to include other considerations, such as value judgments about potential risks, and societal and individual perceptions of "danger," which are often contested. This article explores links and cross-overs between the climate science and risk communication and perception approaches to defining danger. Drawing upon nine articles in this Special Issue of Risk Analysis, we examine a set of themes: limits of current scientific understanding; differentiated public perceptions of danger from climate change; social and cultural processes amplifying and attenuating perceptions of, and responses to, climate change; risk communication design; and new approaches to climate change decision making. The article reflects upon some of the difficulties inherent in responding to the issue in a coherent, interdisciplinary fashion, concluding nevertheless that action should be taken, while acknowledging the context-specificity of "danger." The need for new policy tools is emphasised, while research on nested solutions should be aimed at overcoming the disjunctures apparent in interpretations of climate change risks.

Facilitating EMS turnaround intervals at hospitals in the face of receiving facility overcrowding

The escalating national problem of oversaturated hospital beds and emergency departments (EDs) has resulted in serious operational impediments within patient-receiving facilities. It has also had a growing impact on the 9-1-1 emergency care system. Beyond the long-standing difficulties arising from ambulance diversion practices, many emergency medical services (EMS) crews are now finding themselves detained in EDs for protracted periods, unable to transfer care of their transported patients to ED staff members. Key factors have included a lack of beds or stretcher space, and, in some cases, EMS personnel are used transiently for ED patient care services. In other circumstances, ED staff members no longer prioritize rapid turnaround of EMS-transported patients because of the increasing volume and acuity of patients already in their care. The resulting detention of EMS crews confounds concurrent ambulance availability problems, creates concrete risks for delayed EMS responses to impending critical cases, and incurs regulatory jeopardy for hospitals. Communities should take appropriate steps to ensure that delivery intervals (time elapsing from entry into the hospital to physical transfer of patient care to ED staff) remain extremely brief (less than a few minutes) and that they rarely exceed 10 minutes. While recognizing that the root causes of these issues will require far-reaching national health care policy changes, EMS and local government officials should still maintain ongoing dialogues with hospital chief administrators to mitigate this mutual crisis of escalating service demands. Federal and state health officials should also play an active role in monitoring progress and compliance.