Prehospital assessment and management of patients with ventricular-assist devices

Emergency Medical Services Protocols for Assessment and Treatment of Patients with Ventricular Assist Devices

BACKGROUND

Patients with ventricular assist devices (VADs) represent a growing population presenting to Emergency Medical Services (EMS), but little is known about their prehospital care. This study aimed to characterize current EMS protocols in the United States for patients with VADs.

METHODS

States with state-wide EMS protocols were included. Protocols were obtained from the state EMS website. If not available, the office of the state medical director was contacted. For each state, protocols were analyzed for patient and VAD assessment and treatment variables.

RESULTS

Of 32 states with state-wide EMS protocols, 21 had VAD-specific protocols. With 17 (81%) states noting a pulse may not be palpable, protocols recommended assessing alternate measures of perfusion and mean arterial pressure (MAP; 15 [71%]). Assessment of VAD was advised through listening for pump hum (20 [95%]) and alarms (20 [95%]) and checking the power supply (15 [71%]). For treatment, EMS prehospital consultation was required to begin chest compression in three (14%) states, and mechanical (device) chest compressions were not permitted in two (10%) states. Contact information for VAD coordinator was listed in a minority of five (24%) states. Transport of VAD equipment/backup bag was advised in 18 (86%) states.

DISCUSSION

This national analysis of EMS protocols found VAD-specific EMS protocols are not universally adopted in the United States and are variable when implemented, highlighting a need for VAD teams to partner with EMS agencies to inform standardized protocols that optimize these patients' care.

VAD 911: Process Improvement for First Responders Treating Ventricular Assist Device Patients

Ventricular assist devices (VAD) complications including stroke, device failure, gastrointestinal bleeding, and infection all can manifest in the outpatient environment. Often, first responders do not have the knowledge base to respond appropriately. This study conducted an assessment of first responders generalized knowledge and self-reported competency regarding VAD use, provided an education course, and tested for improvement immediately after and 1 month postintervention. Two hundred thirty-six first responders participated from communities with known VAD patients. Responses indicated poor knowledge, experience, and competency. Twenty-one percent had seen a manufacturer training video, 26% had attended prior training, and 38% knew who to contact with a VAD emergency. Generalized knowledge of VAD therapy was poor with majority not understanding use of anticoagulation, when to initiate chest compressions and assessment variations. Self-reported competency was low with 80% of participants reporting unsafe to marginal about VAD awareness. Comparison of 1 month postintervention to preintervention, generalized knowledge improved by a minimum of 38% for each question and competency increased by over 50%. From this study comes the recommendation that VAD centers must include the community first responders as part of their discharge planning for the VAD patient and improve community outreach to ensure appropriate patient outcomes.

An Urban 9-1-1 System's Experience with Left Ventricular Assist Device Patients

Background: Left ventricular assist devices (LVADs) are used with increasing frequency and left in place for longer periods of time. Prior publications have focused on the mechanics of troubleshooting the device itself. We aim to describe the epidemiology of LVAD patient presentations to emergency medical services (EMS), prehospital assessments and interventions, and hospital outcomes. Methods: This is a retrospective chart review of known LVAD patients that belong to a single academic center's heart failure program who activated the 9-1-1 system and were transported by an urban EMS system to one of the center's 2 emergency departments between January 2012 and December 2015. Identifying demographics were used to query the electronic medical record of the responding city fire agency and contracted transporting ambulance service. Two reviewers abstracted prehospital chief complaint, vital signs, assessments, and interventions. Emergency department and hospital outcomes were retrieved separately. Results: From January 2012 to December 2015, 15 LVAD patients were transported 16 times. The most common prehospital chief complaint was weakness (7/16), followed by chest pain (3/16). Of the 7 patients presenting with weakness, one was diagnosed with a stroke in the emergency department. Another patient was diagnosed with subarachnoid hemorrhage and expired during hospital admission. This was the only death in the cohort. The most common hospital diagnosis was GI bleed (3/16). The overall admission rate was 87.5% (14/16). Conclusions: EMS interactions with LVAD patients are infrequent but have high rates of admission and incidence of life-threatening diagnoses. The most common prehospital presenting symptoms were weakness and chest pain, and most prehospital interactions did not require LVAD-specific interventions. In addition to acquiring technical knowledge regarding LVADs, EMS providers should be aware of non-device-related complications including intracranial and GI bleeding and take this into account during their assessment.