Use of personal protective equipment during infectious disease outbreak and nonoutbreak conditions: a survey of emergency medical technicians.

OBJECTIVE: We sought to assess the knowledge of, use of and barriers to the use of personal protective equipment for airway management among emergency medical technicians (EMTs) during and since the 2003 Canadian outbreak of Severe Acute Respiratory Syndrome (SARS). METHODS: Using a cross-sectional survey, EMTs in Toronto, Ont., were surveyed 1 year after the SARS outbreak during mandatory training on the use of personal protective equipment in airway management during the outbreak and just before taking the survey. Practices that were addressed reflected government directives on the use of this equipment. Main outcome measures included the frequency of personal protective equipment use and, as applicable, why particular items were not always used. RESULTS: The response rate was 67.3% (n = 230). During the SARS outbreak, an N95-type particulate respirator was reported to be always used by 91.5% of respondents. Conversely, 72.9% of the respondents reported that they never used the open face hood. Equipment availability and vision impairment were often cited as impediments to personal protective equipment use. In nonoutbreak conditions, only the antimicrobial airway filter was most often reported to be always used (52.0%), while other items were used at an intermediate frequency. The most common reason for not always donning equipment was that paramedics deemed it unnecessary for the situation. CONCLUSION: Personal protective equipment is not consistently employed as per medical directives. Reasons given for nonuse included nonavailability, judgment of nonnecessity or technical difficulties. There are important public health implications of noncompliance.

Inter-rater reliability and comfort in the application of a basic life support termination of resuscitation clinical prediction rule for out of hospital cardiac arrest.

STUDY OBJECTIVE: This study evaluates inter-rater reliability and comfort of BLS providers with the application of an out-of-hospital Basic Life Support Termination of Resuscitation (BLS TOR) clinical prediction rule. This rule suggests that continued BLS cardiac resuscitation is futile and can be terminated in the field if the following three conditions are met: (1) no return of spontaneous circulation; (2) no shock given prior to transport; (3) cardiac arrest not witnessed by EMS personnel. METHODS: Providers hypothetically applied the rule and rated their comfort level on a five-point Likert-type scale, from "very comfortable" to "very uncomfortable" during the prospective validation of a BLS TOR clinical prediction rule in out-of-hospital cardiac arrest conducted in 12 rural and urban communities [Morrison LJ, Visentin LM, Kiss A, et al. Validation of a rule for termination of resuscitation in out-of-hospital cardiac arrest. New Engl J Med 2006;355(5):478-87]. A Kappa score measured agreement between providers and compared to the correct interpretation of the rule. RESULTS: We compared mean comfort levels of providers who interpreted the rule correctly versus incorrectly. Of 1240 enrolled cases, 1184 (95.5%) had paramedic attendant forms and 1211 (97.7%) had driver forms and 1175 (94.7%) had both. Kappa for interpretation agreement between driver and attendant was 0.90 (95% CI, 0.87-0.92); between attendant and correct interpretation of the BLS TOR clinical prediction rule, 0.88 (95% CI, 0.85-0.91); between driver and correct interpretation of the BLS TOR clinical prediction rule, 0.88 (95% CI, 0.85-0.91). For instances in which both providers applied the rule correctly (607/635 [95.6%]), the providers were significantly more comfortable (chi(2)(4)=30.5, p<0.0001) than those instances in which they did not (28/635 [4.4%]. CONCLUSIONS: The vast majority of providers were able to apply the BLS TOR clinical prediction rule correctly and were comfortable doing so. This suggests that both reliability and comfort will remain high during routine application of the rule when paramedics are well trained as users of the rule.

Validation of a rule for termination of resuscitation in out-of-hospital cardiac arrest.

BACKGROUND: We prospectively evaluated a clinical prediction rule to be used by emergency medical technicians (EMTs) trained in the use of an automated external defibrillator for the termination of basic life support resuscitative efforts during out-of-hospital cardiac arrest. The rule recommends termination when there is no return of spontaneous circulation, no shocks are administered, and the arrest is not witnessed by emergency medical-services personnel. Otherwise, the rule recommends transportation to the hospital, in accordance with routine practice. METHODS: The study included 24 emergency medical systems in Ontario, Canada. All patients 18 years of age or older who had an arrest of presumed cardiac cause and who were treated by EMTs trained in the use of an automated external defibrillator were included. The patients were treated according to standard guidelines. Characteristics of diagnostic tests for the prediction rule were calculated. These characteristics include sensitivity, specificity, and positive and negative predictive values. RESULTS: Follow-up data were obtained for all 1240 patients. Of 776 patients with cardiac arrest for whom the rule recommended termination, 4 survived (0.5 percent). The rule had a specificity of 90.2 percent for recommending transport of survivors to the emergency department and had a positive predictive value for death of 99.5 percent when termination was recommended. Implementation of this rule would result in a decrease in the rate of transportation from 100 percent of patients to 37.4 percent. The addition of other criteria (a response interval greater than eight minutes or a cardiac arrest not witnessed by a bystander) would further improve both the specificity and positive predictive value of the rule but would result in the transportation of a larger proportion of patients. CONCLUSIONS: The use of a clinical prediction rule for the termination of resuscitation may help clinicians decide whether to terminate basic life support resuscitative efforts in patients having an out-of-hospital cardiac arrest.

Print format and sender recognition were related to survey completion rate.

OBJECTIVE: To assess whether print format (single-sided vs. double) and sender recognition (known vs. unknown) affect response and completion rates among physician survey respondents. STUDY DESIGN AND SETTING: Postal survey of 399 members of the Canadian Association of Emergency Physicians; 2 x 2 factorial design. RESULTS: Response rate was 69.4%. Single-sided printing yielded 7.4% (odds ratio OR = 1.41; 95% confidence interval CI = 0.90-2.20; P = 0.13), and a known sender yielded a 6.3% greater response rate (OR = 0.73; 95% CI = 0.47-1.14; P = 0.16). Overall item completion was 98.2%; items missed per respondent ranged from 1 to 14 out of 50. Print format and sender recognition interacted in predicting completion rate (OR = 13.33; 95% CI = 3.10-57.4; P = 0.001); completion was higher for double-sided printing with an unknown sender, and for single-sided printing with a known sender. Completion was also lower when response came after later mailouts (chi2(2) = 10.13; P = 0.006). CONCLUSIONS: Print format and sender recognition both yielded 6%-7% (nonsignificant) response rate differences. Survey completion rate varied even when overall item completion was high. Completion rate was useful for identifying subgroups likely to provide incomplete data (i.e., late responders), and may provide important information for subsequent surveys. Combining factors that on their own improve survey response may have unexpected consequences.

Clinical decision rules "in the real world": how a widely disseminated rule is used in everyday practice.

BACKGROUND: Widespread, appropriate use of clinical decision rules would result in many benefits for health care. While it is known that clinicians report using these rules, little is known about how the rules are actually used in everyday practice. OBJECTIVES: To conduct a survey of emergency physicians to examine whether they use the Ottawa Ankle Rules (OAR) consistently, exclusively, and accurately. METHODS: A postal survey was administered to 399 emergency physicians randomly selected from the membership list of the Canadian Association of Emergency Physicians using Dillman's tailored design method for postal surveys. Results were analyzed via frequency distributions and linear regression. RESULTS: Response rate was 69.7% (262 of 376 eligible respondents), of whom 99.2% were familiar with the OAR. Most physicians (89.6%) reported using the OAR always or most of the time in appropriate circumstances, while only 42.2% reported basing their decisions to order radiography primarily on the rule. Physicians reported considering non-rule factors that are not related to the presence of a fracture (e.g., swelling: 54%), and factors that add no more predictive value over and above the rule (e.g., age >55 years: 55.2%). While 82.4% reported not having reviewed the rule for months or years, only 30.9% of the respondents were able to correctly remember the components of the rule. Errors in remembering rule components were more common among part-time (beta = 0.18, p = 0.009) and older (beta = 0.18, p = 0.04) physicians, and those who do not apply the rule consistently (beta = 0.14, p = 0.04). CONCLUSIONS: Most physicians report using and applying the OAR consistently, but most report that the rule is not the primary determinant of their decisions. Most apply this rule without referring to memory aids, yet their memory for this simple rule is imperfect. Future work should study how different memory aid strategies might improve the accuracy of rule application and reduce the use of nonpredictive cues.

A serine/threonine-rich motif is one of three nuclear localization signals that determine unidirectional transport of the mineralocorticoid receptor to the nucleus.

The mineralocorticoid receptor (MR) is a tightly regulated nuclear hormone receptor that selectively transmits corticosteroid signals. Steroid treatment transforms MR from a transcriptionally inert state, in which it is distributed equally between the nucleus and cytoplasm, to an active completely nuclear transcription factor. We report here that MR is an atypical nuclear hormone receptor that moves unidirectionally from the cytoplasm to the nucleus. We show that nuclear import of MR is controlled through three nuclear localization signals (NLSs) of distinct types. Nuclear localization of naive MR was mediated primarily through a novel serine/threonine-rich NLS (NL0) in the receptor N terminus. Specific amino acid substitutions that mimicked phosphorylation selectively enhanced or repressed NL0 activity, highlighting the potential for active regulation of this new type of NLS. The second NLS (NL2) within the ligand-binding domain also lacks a recognizable basic motif. Nuclear transfer through this signal was strictly dependent on steroid agonist, but was independent of the interaction of MR with coactivator proteins. The third MR NLS (NL1) is a bipartite basic motif localized to the C terminus of the MR DNA-binding domain with properties distinct from those of NL1 of the closely related glucocorticoid receptor. NL1 acted in concert with NL0 and NL2 to stimulate nuclear uptake of the agonist-treated receptor, but also directed the complete nuclear localization of MR in response to treatment with steroid antagonist. These results present MR as a nuclear hormone receptor whose unidirectional transfer to the nucleus may be regulated through multiple pathways.