On-line medical direction: a prospective study

Assessing Infrastructure to Care for Pediatric Patients in the Prehospital Setting

OBJECTIVES

Pediatric patients represent a small proportion of emergency medical services (EMS) calls, challenging providers in maintaining skills in treating children. Having structural capacity to appropriately diagnose and treat pediatric patients is critical. Our study measured the availability of off-line and on-line medical direction and recommended pediatric equipment at EMS agencies.

METHODS

A Web-based survey was sent to EMS agencies in 2010 and 2013, and results were analyzed to determine availability of medical direction and equipment.

RESULTS

Approximately 5000 agencies in 32 states responded, representing over 80% response. Availability of off-line medical direction increased between years (78% in 2010 to 85% in 2013), was lower for basic life support (BLS) (63% and 72%) than advanced life support (ALS) agencies (90% and 93%), and was generally higher in urban than rural or frontier locations. On-line medical direction was consistently available (90% both years) with slight increases for BLS agencies (87% to 90%) and slightly greater availability for urban and rural compared with frontier agencies. The majority of agencies carried most recommended equipment; however, less than one third of agencies reported carrying all equipment. Agencies with off-line medical direction, on-line medical direction, and with both off-line and on-line medical direction were respectively 1.69, 1.31, and 2.21 times more likely to report carrying all recommended equipment.

CONCLUSIONS

Basic structural capacity exists in EMS for treating children, with improvements seen over time. However, gaps remain, particularly for BLS and nonurban agencies. Continuous attention to infrastructure is necessary, and the recent development of national performance measures should further promote quality emergency care for all children.

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.

Videotelephony-assisted medical direction to improve emergency medical service

INTRODUCTION

In South Korea, on-line medical direction using voice calls has been implemented to improve the quality of the emergency medical system. However, in the same, short time span, video will be able to convey more information than by voice. The purpose of this study is to find out if videotelephony-assisted medical direction (VAMD) can change the intervention of the emergency medical technician compared to using conventional voice calls.

METHODS

We conducted a prospective study of 312 patients with online medical direction from November 2017 to November 2018. We assisted patients with direct medical direction using conventional voice calls from October to November 2017, and then VAMD was implemented from October to November 2018.

RESULTS

From the total number of conventional voice calls, 131 were used for this study, and of the total number of VAMD interventions, 181 were included. There were differences between conventional voice call and VAMD interventions in such types of medical direction as hospital selection (7.6% vs. 36.6%), ECG interpretation (0% vs. 3.4%), and advice on medical techniques (0% vs. 25.1%). The effectiveness of VAMD by survey is greater compared to conventional direct medical direction using voice calls (median value, 3.0 vs. 1.5).

CONCLUSIONS

The number of instances of medical direction for some interventions, such as interpretation of ECG and advice on medical techniques that did not perform well in conventional voice calls, increased in VAMD. VAMD may play an important role in the prehospital emergency care.

Clinical outcomes on real-time telemetry system in developing emergency medical service system

OBJECTIVE

With the development of information technology, real-time telemetry has been invented for checking patients' physiologic parameters during their transport, via an Emergency Medical Service (EMS) system. We developed a Real-Time Telemetry System (RTS), which sends physiologic parameters including electrocardiogram (ECG), vital signs, and pulse asymmetry in real-time from the ambulance to a hospital through the Emergency Medical Information Center, a kind of central control unit. Therefore, we asked whether the RTS monitoring affects the use of medical direction in EMS system.

METHODS

Of six ambulance stations covering EMS transport with RTS monitor, 941 patients who were classified as emergency patients by an Emergency Medical Technician were retrospectively enrolled in this study. We divided them into two groups: group 1 (the patients using RTS monitoring) and group 2 (control group).

RESULTS

The mean age was 53.5 ± 22.8 years, and 494 patients were men. RTS monitoring was used in 118 (20%) patients. Medical direction for treatments in group 1 was much more than that of group 2 (8.0% vs. 0.3%; p  <0.001). Ambulance diversion to proper hospitals in group 1 was much more than that of group 2 (14.4% vs. 0.1%; p  <0.001). The mean treatment time at the scene in group 1 also decreased more significantly than that of group 2 (4.4 ± 3.5  min vs. 6.3 ± 5.9 min; p  <0.001).

CONCLUSION

The results showed that intermediate medical direction in the cases using the RTS was conducted more than in the conventional method-ambulance to the hospital. These results suggest that the RTS monitoring enhances the quality in developing EMS system.

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.

[E-health in emergency medicine - the research project Med-on-@ix]

There is a need for new strategies to face current and future problems in German Emergency Medical Services (EMS). Lack of quality management and increasing costs in the presence of a deficit of EMS physicians are typical challenges, resulting in an increasing deficit in medical care. In addition, information and communication technology used in German EMS is out of date. The physician-powered EMS has to be modernized to increase quality and show measurable evidence of its effectiveness. Otherwise its future existence is at serious risk. Therefore, the project Med-on-@ix was created by the Department of Anaesthesiology at the University Hospital Aachen, Germany. The aim was to develop a new emergency telemedicine service system and to implement it clinically in order to advance medical care and effectiveness in the EMS by process optimization of each scene call. This system offers EMS physicians and paramedics an additional consultation by a specialised centre of competence, thus assuring medical therapy according to evidence-based guidelines. Several prospective studies are conducted to analyse this system in comparison to the conventional EMS.

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.

EMS ... agenda for the future

In 1996, the National Highway Traffic Safety Administration and the Health Resources and Services Administration, Maternal and Child Health Bureau published the EMS Agenda for the Future. To date, thousands of copies have been distributed to EMS-knowledgeable people, and those who aspire to be, throughout the United States. This article reviews the findings discussed within the EMS Agenda for the Future. This discussion also assesses the effects of these findings on EMS development.

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.

Emergency medical services for children: a general pediatrician's perspective

The EMSC movement is still in its infancy, and there is much that remains to be done. The primary care pediatrician plays a major role in the EMSC system and should continue to advocate for efficient, high-quality pediatric emergency care. In summary, there are several ways that the office-based pediatrician can and should become involved with EMSC: 1. Pediatricians should emphasize safe and injury prevention at each health maintenance visit throughout a child's life. 2. Pediatricians should encourage all parents to become certified in BLS/CPR. Ideally, training in CPR should be provided during prenatal and childbirth classes. 3. Pediatricians should advocate for injury prevention and safety campaigns in their communities. They can also become involved with efforts to develop legislation dealing with issues in injury prevention and safety. 4. Pediatricians should ensure that all children receive the appropriate immunizations. 5. Pediatricians need to maintain office emergency preparedness. All office personnel should maintain certification in BLS as a minimum and ideally, PALS. Equipment used for pediatric resuscitation should be available and functional. Monthly mock codes should be scheduled to ensure that all personnel clearly know their roles and responsibilities in the event of an emergency. 6. Pediatricians should maintain their skills in emergency pediatrics. In addition, they should maintain certification in PALS. Continuing medical education (CME) workshops and conferences in emergency pediatrics are available throughout the year. Also, pediatricians can maintain their airway management skills by practicing endotracheal intubation in the operating room setting. 7. Pediatricians must become familiar with the prehospital care providers, EDs, and transport services in their communities. Association with a pediatric intensive care unit at a tertiary care center would also be beneficial. 8. Pediatricians must be available for consultation to local EDs. They must realize that, in many instances, they may represent the physician who is most experienced with caring for the critically ill or injured child. 9. Pediatricians can serve as medical advisors to the EMS systems in their communities. 10. Pediatricians should stay well informed on issues pertaining to EMSC.

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.