Comparison of interventions in prehospital care by standing orders versus interventions ordered by direct [on-line] medical command

Retrospective Analysis of Emergency Medical Services (EMS) Physician Medical Control Calls

INTRODUCTION

Although emergency medical services (EMS) standing-order protocols provide more efficient and accurate on-scene management by paramedics, online medical direction (OLMD) has not been eliminated from practice. In this modern era of OLMD, no studies exist to describe the prevalence of reasons for contacting OLMD.

OBJECTIVES

The primary goal of this study was to describe the quantity of and reasons for calls for medical direction. We also sought to determine time diverted from emergency physicians due to OLMD. Finally, we hoped to identify any areas for potential improvement or additional training opportunities for EMS providers.

METHODS

This was a descriptive study with retrospective data analysis of recorded OLMD calls from January 1, 2016, to December 31, 2016. Data were extracted by research personnel listening to audio recordings and were entered into a database for descriptive analysis. We abstracted the date and length of call, patient demographic information (age and gender), category of call (trauma, medical, cardiac, or obstetrics), reason for call, and origin of call (prehospital, interhospital, nursing home, or discharge).

RESULTS

The total number of recordings analyzed was 519. Calls were divided into four categories pertaining to their nature: 353 (68.5%) medical; 70 (13.6%) trauma; 83 (16.1%) cardiac; and 9 (8%) were obstetrics related. Repeat calls regarding the same patient encounter comprised 48 (9.4%) of the calls. Patient refusal of transport was the most common reason for a call medical direction (32.3% of calls). The total time for medical direction calls for the year was 26.6 hours. The maximum number of calls in a single day was seven, with a mean of 2.04 calls per day (standard deviation [SD] ± 1.18). The mean call length was 3.06 minutes (SD ± 2.51).

CONCLUSION

Our analysis shows that the use of OLMD frequently involves complex decision-making such as determination of the medical decision-making capacity of patients to refuse treatment and transport, and evaluation of the appropriate level of care for interfacility transfers. Further investigation into the effect of EMS physician-driven medical direction on both the quality and time required for OLMD could allow for better identification of areas of potential improvement and training.

Barriers to Real-Time Medical Direction via Cellular Communication for Prehospital Emergency Care Providers in Gujarat, India

BACKGROUND

Many low- and middle-income countries depend on emergency medical technicians (EMTs), nurses, midwives, and layperson community health workers with limited training to provide a majority of emergency medical, trauma, and obstetric care in the prehospital setting. To improve timely patient care and expand provider scope of practice, nations leverage cellular phones and call centers for real-time online medical direction. However, there exist several barriers to adequate communication that impact the provision of emergency care. We sought to identify obstacles in the cellular communication process among GVK Emergency Management and Research Institute (GVK EMRI) EMTs in Gujarat, India.

METHODS

A convenience sample of practicing EMTs in Gujarat, India were surveyed regarding the barriers to call initiation and completion.

RESULTS

108 EMTs completed the survey. Overall, ninety-seven (89.8%) EMTs responded that the most common reason they did not initiate a call with the call center physician was insufficient time. Forty-six (42%) EMTs reported that they were unable to call the physician one or more times during a typical workweek (approximately 5-6 twelve-hour shifts/week) due to their hands being occupied performing direct patient care. Fifty-eight (54%) EMTs reported that they were unable to reach the call center physician, despite attempts, at least once a week.

CONCLUSION

This study identified multiple barriers to communication, including insufficient time to call for advice and inability to reach call center physicians. Identification of simple interventions and best practices may improve communication and ensure timely and appropriate prehospital care.

Evolution of the Literature Identifying Physicians' Roles in Leadership, Clinical Development, and Practice of the Subspecialty of Emergency Medical Services

Purpose: The 2007 Institute of Medicine report entitled Emergency Medical Services at the Crossroads identified a need for the establishment of physician subspecialty certification in emergency medical services (EMS). The purpose of this study was to identify and explore the evolution of publications that define the role of the physician in EMS systems in the United States.

Methods: Three comprehensive searches were undertaken to identify articles that define the physician's role in the leadership, clinical development, and practice of EMS. Independent reviewers then evaluated these articles to further determine whether the articles identified the physician's role in EMS. Then, identified articles were classified by the type of publication in order to evaluate the transition from a non-peer reviewed to peer-reviewed literature base and an analysis was performed on the differences in the growth between these two groups. In addition, for the peer-reviewed articles, an analysis was performed to identify the proportion of articles that were quantitative versus qualitative in nature.

Results: The comprehensive review identified 1,504 articles. Ninety articles were excluded due to lack of relevance to the US. The remaining 1,414 articles were reviewed, and 194 papers that address the physician's role within EMS systems were identified; 72 additional articles were identified by hand search of references for a total of 266 articles. The percentage of peer-reviewed articles has increased steadily over the past three decades. In addition, the percentage of quantitative articles increased from the first decade to the second and third decades.

Conclusions: This comprehensive review demonstrates that over the past 30 years an evidence base addressing the role of the physician in EMS has developed. This evidence base has steadily evolved to include a greater proportion of peer-reviewed, quantitative literature.

Physician medical direction and clinical performance at an established emergency medical services system

OBJECTIVE

Few developed emergency medical services (EMS) systems operate without dedicated medical direction. We describe the experience of Hamad Medical Corporation (HMC) EMS, which in 2007 first engaged an EMS medical director to develop and implement medical direction and quality assurance programs. We report subsequent changes to system performance over time.

METHODS

Over one year, changes to the service's clinical infrastructure were made: Policies were revised, paramedic scopes of practice were adjusted, evidence-based clinical protocols were developed, and skills maintenance and education programs were implemented. Credentialing, physician chart auditing, clinical remediation, and online medical command/hospital notification systems were introduced.

RESULTS

Following these interventions, we report associated improvements to key indicators: Chart reviews revealed significant improvements in clinical quality. A comparison of pre- and post-intervention audited charts reveals a decrease in cases requiring remediation (11% to 5%, odds ratio [OR] 0.43 [95% confidence interval (CI) 0.20-0.85], p = 0.01). The proportion of charts rated as clinically acceptable rose from 48% to 84% (OR 6 [95% CI 3.9-9.1], p < 0.001). The proportion of misplaced endotracheal tubes fell (3.8% baseline to 0.6%, OR 0.16 [95% CI 0.004-1.06], (exact) p = 0.05), corresponding to improved adherence to an airway placement policy mandating use of airway confirmation devices and securing devices (0.7% compliance to 98%, OR 714 [95% CI 64-29,334], (exact) p < 0.001). Intravenous catheter insertion in unstable cases increased from 67% of cases to 92% (OR 1.31 [95% CI 1.09-1.71], p = 0.004). EMS administration of aspirin to patients with suspected ischemic chest pain improved from 2% to 77% (OR 178 [95% CI 35-1,604], p < 0.001).

CONCLUSIONS

We suggest that implementation of a physician medical direction is associated with improved clinical indicators and overall quality of care at an established EMS system.

Implementation of standing field treatment protocols in an urban EMS system

The objective was to describe our experience with implementation of standing field treatment protocols (SFTP) in a large, urban EMS system. A prospective, consecutive observational study examining the first 21 days of implementation of SFTPs in the City of Los Angeles, California. SFTPs were developed for 7 medical chief complaints and all major trauma patients. There were 13,586 EMS incidents, of which 4,037 (30%) received ALS treatment. SFTPs were used on 2,177 of these incidents, representing 54% of all ALS runs and 16% of all EMS incidents. The most frequently used SFTPs were for altered level of consciousness (29%), and chest pain (25%). The most common errors found were failure to document reassessment of the patient after each medication administration (45% fallout rate), and failure to document and attach a copy of the ECG to the EMS report (40%). The mean fallout rate for failure to establish or attempt IV access, administer oxygen, or provide cardiac monitoring was 7%. Out of 1,450 incidents with outcome data provided by the receiving hospitals, only 3 cases (2%) involved incorrect treatment, with an additional 2 involving the unnecessary use of lidocaine. None of these instances resulted in adverse effects or complications. SFTPs were integrated into a large EMS system with few procedural errors or adverse outcomes.

On-line medical control versus protocol-based prehospital care

STUDY OBJECTIVE

To compare on-scene time, appropriateness of therapy, and accuracy of paramedic clinical assessments when prehospital care was provided with the use of on-line medical control (OLMC) by EMS-certified nurses from a single base station or by paramedics using chief complaint-based protocols.

METHODS

We assembled a prospective before-and-after series to compare OLMC (phase 1) and protocol (phase 2) care rendered by all paramedics in a single urban municipality using a single base station. The subjects were consecutively enrolled patients who met protocol inclusion criteria and presented with altered level of consciousness, nontraumatic chest pain, or shortness of breath. For both phases, EMS and corresponding ED records were compiled; all references identifying phase were removed. After establishing interrater reliability, we randomly assigned charts to one of two reviewers for scoring. Complaint-specific scoring elements included on-scene time, assessments performed, presence or absence of indications for common treatments, treatments given, paramedic diagnosis, and emergency physician diagnosis. The percentages of inappropriate treatment decisions and paramedic diagnostic accuracy (versus that of the receiving emergency physician) were calculated.

RESULTS

Phase 1 comprised 287 patients, phase 2 294. Interrater reliability between the two scorers was high. Of 2,190 elements scored jointly, the raters agreed in 97%, with kappa-values ranging from .6 to 1.0. On-scene time was 1 minute shorter during phase 2 (95% confidence interval [CI] for difference in median time, 0 to 2 minutes; P < .03). From phase 1 to phase 2 (relative risk [RR], 1.5; 95% CI, 1.0 to 2.1), inappropriate treatment decisions decreased from 7.4% to 5.1%. The percentage of cases in which paramedics and physicians were in complete diagnostic agreement was high (77% to 78%) and did not change across phases.

CONCLUSION

The use of protocols resulted in small improvements in both on-scene time and the appropriateness of therapeutic decisions, without a change in agreement between paramedic and physician. Protocol care for these three chief complaints is clinically safe and, by reducing training and staffing considerations, may offer a cost-effective alternative to OLMC.

Effects of on-line medical control in the prehospital treatment of atraumatic illness

OBJECTIVE

On-line medical control (OLMC) is costly and time-consuming, yet little is known about the direct effect of OLMC on the quality of care provided. The objective of this study was to analyze the effect of OLMC on adherence to protocol and quality of care provided.

METHODS

Retrospective review of trip sheets completed by out-of-hospital personnel in an urban/suburban/rural emergency medical services system with a volume of 144,000 calls/year; approximately 15,000/year are ALS calls. Two levels of provider--paramedics and critical care technicians (CCTs)--work under single standard protocols and a single medical director. Prehospital trip sheets of 774 sequential patients with atraumatic illnesses for whom an ALS crew was dispatched were reviewed for adherence to standard protocol and for appropriateness of deviations from protocol, with and without the use of OLMC.

RESULTS

Adherence to protocols occurred in 78.3% of all patient encounters. OLMC was utilized in 61.5% of patient encounters. The CCTs were more likely to utilize OLMC than were the paramedics, 72% vs 56% (p < 0.001). There was a trend towards paramedics' adhering to protocol more frequently than did the CCTs, 80% vs 74%, which did not reach statistical significance (p = 0.057). Adherence to protocol was significantly less likely to occur with OLMC than without OLMC, regardless of the training of the provider, 72.8% vs 86.5% (95% CI 8.1-19.3%, p < 0.001). Adherence to protocol was significantly less likely to occur as the acuity of the patient's condition increased (p < 0.001). Nonadherence was more likely to be judged appropriate rather than inappropriate (p < 0.05) as the acuity level increased. When there was nonadherence to protocol, the use of OLMC did not improve the care provided.

CONCLUSIONS

OLMC does not improve adherence to protocol or the quality of care provided in the treatment of atraumatic illness.

On-line medical direction: a prospective study

OBJECTIVES

To determine the frequency with which physician, on-line medical direction (OLMD) [direct medical control] of prehospital care results in orders, to describe the nature of these orders, and to measure OLMD time intervals.

METHODS

Blinded, prospective study.

SETTING

A university hospital base-station resource center.

PARTICIPANTS

Ten emergency physicians, 50 advanced life support providers.

INTERVENTIONS

Prehospital treatment was directed by both standing orders and OLMD physician orders. Independent observers recorded event times and the characteristics of OLMD.

RESULTS

Physician orders were given in 47 (19%) of the 245 study cases, and covered a variety of interventions, including many already authorized by standing orders. Mean OLMD radio time was four minutes (245 +/- 216 seconds [sec]), and time from beginning of OLMD to hospital arrival averaged 12 minutes (718 +/- 439 sec). Mean transport time in this system was 13 minutes.

CONCLUSION

Despite detailed standing orders, OLMD results in orders for clinical interventions in 19% of cases. On-line medical direction requires about four minutes of physician time per call. This constituted about one-third of the potential field treatment time interval in this system. Thus, OLMD appears to play an important role in providing quality prehospital care.