Achieving Equity in EMS Care and Patient Outcomes through Quality Management Systems: A Position Statement

Improving health and safety in our communities requires deliberate focus and commitment to equity. Inequities are differences in access, treatment, and outcomes between individuals and across populations that are systemic, avoidable, and unjust. Within health care in general, and Emergency Medical Services (EMS) in particular, there are demonstrated inequities in the quality of care provided to patients based on a number of characteristics linked to discrimination, exclusion, or bias. Given the critical role that EMS plays within the health care system, it is imperative that EMS systems reduce inequities by delivering evidence-based, high-quality care for the communities and patients we serve.To achieve equity in EMS care delivery and patient outcomes, the National Association of EMS Physicians recommends that EMS systems and agencies:make health equity a strategic priority and commit to improving equity at all levels.assess and monitor clinical and safety quality measures through the lens of inequities as an integrated part of the quality management process.ensure that data elements are structured to enable equity analysis at every level and routinely evaluate data for limitations hindering equity analysis and improvement.involve patients and community stakeholders in determining data ownership and stewardship to ensure its ongoing evolution and fitness for use for measuring care inequities.address biases as they translate into the quality of care and standards of respect for patients.pursue equity through a framework rooted in the principles of improvement science.

Thoracic ultrasound may improve paramedic diagnostic and management accuracy in undifferentiated respiratory distress

Objectives

Patients with chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF) exacerbations present with similar history and physical examination findings. This complicates both the diagnostic process and the creation of appropriate treatment plans for patients presenting in respiratory distress, particularly in the prehospital setting. Thoracic point-of-care-ultrasound (POCUS) may increase diagnostic accuracy; however, its potential to improve patient management by emergency medical services clinicians is unknown. We aimed to determine whether a brief thoracic POCUS educational intervention would improve prehospital diagnostic accuracy and treatment plans for patients with COPD and CHF exacerbations.

Methods

In this prospective pre-/post-study, paramedics completed a thoracic POCUS training program. The pre-test presented history and physical examination data for 10 patients and asked paramedics to diagnose each patient with COPD or CHF exacerbation and to select the appropriate treatment(s). The post-test asked paramedics to interpret ultrasound images in addition to selecting diagnosis and treatment(s). Pre-post differences in average cumulative diagnostic and management accuracy were analyzed using paired two-tailed t-tests.

Results

Thirty-three paramedics participated in the study. At baseline, paramedics selected the accurate patient diagnosis and treatment(s) 73% and 60% of the time, respectively. On the post-test, diagnostic accuracy improved by 17% (95% confidence interval [CI]: 11-24, p < 0.001) and appropriate treatment selection improved by 23% (95% CI: 16-28, p < 0.001). Paramedics correctly interpreted ultrasound images 90% of the time.

Conclusion

Effective training of paramedics to recognize the clinical scenario of undifferentiated respiratory distress and their associated thoracic ultrasound images may lead to improved treatment plans.

Improving Emergency Medicine Clinician Awareness of Prehospital-Administered Medications

Background/problem: Information transfer between emergency medical services (EMS) and emergency medicine (EM) is at high risk for omissions and errors. EM awareness of prehospital medication administration affects patient management and medication error. In April 2020, we surveyed emergency physicians and emergency department nurse practitioners (NPs) and physician assistants (PAs) regarding the EMS handoff process. Emergency physicians and NPs/PAs endorsed knowing what medications were given, or having received direct verbal handoff from EMS "Often" or "Always" only 20% of the time (n = 71), identifying a need to improve the written handoff process. To assess rates of medication error due to lack of awareness of prehospital administered medications, we measured glucocorticoid redosing in the emergency department (ED) following prehospital dexamethasone administration. In 2020, glucocorticoids were redosed 30% of the time, and our aim was to reduce glucocorticoid redosing to 10% by June 2022. Intervention: We developed and implemented a system innovation where prehospital-administered medications documented in a nursing flowsheet during verbal handoff are pulled directly into the triage note where they are more likely to be reviewed by receiving EM clinicians. Results: Shewhart p-charts were used to evaluate for statistical process change in the process measure of triage note documentation of prehospital medication administration and the outcome measure of glucocorticoid redosing. While the frequency of prehospital dexamethasone administration in the triage note increased, no statistical process change outcome measure of glucocorticoid redosing was observed. However, on repeat survey of EM clinicians in July 2022, 50% now indicated they were aware of prehospital medication administration "Often" or "Always" (n = 61, p = 0.003), 87% maintained they use the triage note as the main source of information regarding prehospital medication administration, and 81% "Always" review the triage note. Conclusions: Innovations that improve accessibility of written documentation of prehospital medication administration were associated with improved subjective assessment of EM clinician awareness of prehospital medications, but not the outcome measure of medication error. Effective error reduction likely requires better system integration between prehospital and EM records.

Prehospital Airway Management Training and Education: An NAEMSP Position Statement and Resource Document

AbstractAirway management competency extends beyond technical skills to encompass a comprehensive approach to optimize patient outcomes. Initial and continuing education for airway management must therefore extend beyond a narrow focus on psychomotor skills and task completion to include appreciation of underlying pathophysiology, clinical judgment, and higher-order decision making. NAEMSP recommends:Active engagement in deliberate practice should be the guiding approach for developing and maintaining competence in airway management.EMS learners and clinicians must be educated in an escalating approach to airway management, where basic airway maneuvers form the central focus.Educational activities should extend beyond fundamental knowledge to focus on the development of clinical judgment.Optimization of patient outcomes should be valued over performance of individual airway management skills.Credentialing and continuing education activities in airway management are essential to advance clinicians beyond entry-level competency.Initial and continuing education programs should be responsive to advances in the evidence base and maintain adaptability to re-assess content and expected outcomes on a continual basis.

EMS Curriculum Should Educate Beyond a Technical Scope of Practice: Position Statement and Resource Document

Position Statement and Resource document approved by the NAEMSP Board of Directors on April 27, 2021.

Evidence-based crisis standards of care for out-of-hospital cardiac arrests in a pandemic

BACKGROUND & PURPOSE

Pandemics such as COVID-19 can lead to severe shortages in healthcare resources, requiring the development of evidence-based Crisis Standard of Care (CSC) protocols. A protocol that limits the resuscitation of out-of-hospital cardiac arrests (OHCA) to events that are more likely to result in a positive outcome can lower hospital burdens and reduce emergency medical services resources and infection risk, although it would come at the cost of lives lost that could otherwise be saved. Our primary objective was to evaluate candidate OHCA CSC protocols involving known predictors of survival and identify the protocol that results in the smallest resource burden, as measured by the number of hospitalizations required per favorable OHCA outcome achieved. Our secondary objective was to describe the effects of the CSC protocols in terms of health outcomes and other measures of resource burden.

METHODS

We conducted a retrospective cohort study of adult patients in the Cardiac Arrest Registry to Enhance Survival (CARES) database. Non-traumatic OHCA events from 2018 were included (n = 79,533). Candidate CSC protocols involving combinations of known predictors of good survival for OHCA were applied to the existing dataset to measure the resulting numbers of resuscitation attempts, transportations to hospital, hospital admissions, and favorable neurological outcomes. These outcomes were also assessed under Standard Care, defined as no CSC protocol applied to the data.

RESULTS

The CSC protocol with the smallest number of hospitalizations per survivor with a favorable neurological outcome was that an OHCA resuscitation should only be attempted if the arrest was witnessed by emergency medical services or the first monitored rhythm was shockable (number of hospitalizations: 2.26 [95% CI: 2.21-2.31] vs. 3.46 [95% CI: 3.39-3.53] under Standard Care). This rule resulted in significant reductions in resource utilization (46.1% of hospitalizations and 29.2% of resuscitation attempts compared to Standard Care) while still preserving 70.5% of the favorable neurological outcomes under Standard Care. For every favorable neurological outcome lost under this CSC protocol, 6.3 hospital beds were made free that could be used to treat other patients.

CONCLUSION

In a pandemic scenario, pre-hospital CSC protocols that might not otherwise be considered have the potential to greatly improve overall survival, and this study provides an evidence-based approach towards selecting such a protocol. As this study was performed using data generated before the COVID-19 pandemic, future studies incorporating pandemic-era data will further help develop evidence-based CSC protocols.

Diagnosis and Treatment of Central Nervous System Infections in the Emergency Department

Central nervous system (CNS) infections, including meningitis, encephalitis, and brain abscess, are rare but time-sensitive emergency department (ED) diagnoses. Patients with CNS infection can present to the ED with nonspecific signs and symptoms, including headache, fever, altered mental status, and behavioral changes. Neuroimaging and CSF fluid analysis can appear benign early in the course of disease. Delaying therapy negatively impacts outcomes, particularly with bacterial meningitis and herpes simplex virus encephalitis. Therefore, diagnosis of CNS infection requires vigilance and a high index of suspicion based on the history and physical examination, which must be confirmed with appropriate imaging and laboratory evaluation.

PRP-17 and the pre-mRNA splicing pathway are preferentially required for the proliferation versus meiotic development decision and germline sex determination in Caenorhabditis elegans

In C. elegans, the decision between germline stem cell proliferation and entry into meiosis is controlled by GLP-1 Notch signaling, which promotes proliferation through repression of the redundant GLD-1 and GLD-2 pathways that direct meiotic entry. We identify prp-17 as another gene functioning downstream of GLP-1 signaling that promotes meiotic entry, largely by acting on the GLD-1 pathway, and that also functions in female germline sex determination. PRP-17 is orthologous to the yeast and human pre-mRNA splicing factor PRP17/CDC40 and can rescue the temperature-sensitive lethality of yeast PRP17. This link to splicing led to an RNAi screen of predicted C. elegans splicing factors in sensitized genetic backgrounds. We found that many genes throughout the splicing cascade function in the proliferation/meiotic entry decision and germline sex determination indicating that splicing per se, rather than a novel function of a subset of splicing factors, is necessary for these processes.

A role for dynein in the inhibition of germ cell proliferative fate

During normal development as well as in diseased states such as cancer, extracellular "niches" often provide cues to proximal cells and activate intracellular pathways. Activation of such signaling pathways in turn instructs cellular proliferation and differentiation. In the Caenorhabditis elegans gonad, GLP-1/Notch signaling instructs germ line stem cells to self-renew through mitotic cell division. As germ cells progressively move out of the niche, they differentiate by entering meiosis and eventually form gametes. In this model system, we uncovered an unexpected role for the dynein motor complex in promoting normal differentiation of proliferating germ cells. We demonstrate that dynein light chain 1 (DLC-1) and its partner, dynein heavy chain 1, inhibit the proliferative cell fate, in part through regulation of METT-10, a conserved putative methyltransferase. We show that DLC-1 physically interacts with METT-10 and promotes both its overall levels and nuclear accumulation. Our results add a new dimension to the processes controlled by the dynein motor complex, demonstrating that dynein can act as an antiproliferative factor.

Nipped-A, the Tra1/TRRAP subunit of the Drosophila SAGA and Tip60 complexes, has multiple roles in Notch signaling during wing development

The Notch receptor controls development by activating transcription of specific target genes in response to extracellular signals. The factors that control assembly of the Notch activator complex on target genes and its ability to activate transcription are not fully known. Here we show, through genetic and molecular analysis, that the Drosophila Nipped-A protein is required for activity of Notch and its coactivator protein, mastermind, during wing development. Nipped-A and mastermind also colocalize extensively on salivary gland polytene chromosomes, and reducing Nipped-A activity decreases mastermind binding. Nipped-A is the fly homologue of the yeast Tra1 and human TRRAP proteins and is a key component of both the SAGA and Tip60 (NuA4) chromatin-modifying complexes. We find that, like Nipped-A, the Ada2b component of SAGA and the domino subunit of Tip60 are also required for mastermind function during wing development. Based on these results, we propose that Nipped-A, through the action of the SAGA and Tip60 complexes, facilitates assembly of the Notch activator complex and target gene transcription.