Prehospital Evaluation of the FAST-ED as a Secondary Stroke Screen to Identify Large Vessel Occlusion Strokes.

Introduction: The Field Assessment Stroke Triage for Emergency Destination (FAST-ED) was developed to identify Large Vessel Occlusion Strokes (LVOS) presenting out of hospital, although there is limited prospective research validating its use in this setting. This study evaluated the test characteristics of the FAST-ED to identify LVOS when used as a secondary stroke screen in the prehospital environment. Secondary analysis compared the performance of the CPSS and the FAST-ED in identifying an LVOS. Methods: This prospective, observational study was conducted from April 2018 to December 2019 in a municipal EMS system with all ALS ambulance response. The FAST-ED was implemented as a secondary screening tool for emergent stroke patients who had at least one positive Cincinnati Prehospital Stroke Screen (CPSS) item. CPSS and FAST-ED scores were extracted from prehospital electronic care reports, while the presence of LVOS was extracted from hospital records. Results: A total 1,359 patients were enrolled; 55.3% female, 47.5% white, with a mean age of 69.4 (SD 15.8). In this cohort, 11.3% of patients experienced an LVOS. The mean FAST-ED for a patient experiencing an LVOS was 5.33 (95%CI 4.97-5.69) compared to 3.06 (95%CI 2.95-3.12) (p < 0.001). A score of greater or equal to 4 yielded the highest combination of sensitivity (77.78%) and specificity (65.34%) with positive likelihood ratio 2.24 (95% CI 2.00-2.52) and negative likelihood ratio 0.34 (95% CI 0.25-0.46). Area under the ROC curve was 0.77 (95%CI 0.73, 0.81). A CPSS with all three items positive demonstrated a sensitivity of 73.20% and 69.57% specificity, with an ROC area of 0.73 (95% CI 0.70-0.77). When comparing a FAST-ED ≥4 to a CPSS of all positive items, there was no significant difference in sensitivity (p > 0.05), and the FAST-ED had a significantly lower specificity than the CPSS (p < 0.005). Conclusion: As stroke care advances, EMS agencies must consider their destination triage needs. This study suggests agencies must consider the use of single versus secondary scales, and to determine the ideal sensitivity and specificity for their system.

Effect of Task Load Interventions on Fatigue in Emergency Medical Services Personnel and Other Shift Workers: A Systematic Review.

BACKGROUND: Modifying the task load of Emergency Medical Services (EMS) personnel may mitigate fatigue, sleep quality and fatigue related risks. A review of the literature addressing task load interventions may benefit EMS administrators as they craft policies related to mitigating fatigue. We conducted a systematic review of the peer-reviewed literature to address the following question: "In EMS personnel, do task load interventions mitigate fatigue, mitigate fatigue-related risks, and/or improve sleep?" (PROSPERO 2016:CRD42016040114). METHODS: We performed a systematic review of the literature that described use of randomized controlled trials, quasi-experimental studies, and observational study designs. We retained and reviewed research that involved EMS personnel or similar shift worker groups 18 years of age and older. Studies of 'healthy volunteers' and non-shift worker populations were excluded. Studies were included where the methodology of the study implied a theoretical framework of task load (or workload) affecting fatigue, and then fatigue related outcomes. Outcomes of interest included personnel safety, patient safety, personnel performance, acute fatigue, and cost to system. We used the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology to summarize findings and assess quality of evidence from very low to high quality. RESULTS: The search strategy yielded 3,394 unique records resulting in 58 records included as potentially eligible. An additional 69 studies were reviewed in full following searches of bibliographies. We detected wide variation in the description and measurement of task load in the retained and excluded research. Among 127 potentially relevant studies reviewed in full, five were judged eligible. None of the retained studies reported findings germane to personnel safety, patient safety, or cost to system. We judged most studies to have serious or very serious risk of bias. CONCLUSIONS: The effect of task load interventions on fatigue, fatigue-related risks, and/or sleep quality was not estimable and the overall quality of evidence was judged low or very low. There was considerable heterogeneity in how task load was defined and measured.

An assessment of pain management among patients presenting to emergency medical services after suffering a fall.

INTRODUCTION: Emergency Medical Services (EMS) professionals frequently care for patients experiencing acute pain. Analgesics are critical in patient comfort and satisfaction levels during the treatment of acute pain. The objective of this study was to assess the frequency of pain management in patients suffering a fall, the documented pain score, and the location of their injuries. It was hypothesized that the frequency of analgesia administration was low and would be associated with injury location. METHODS: This was a retrospective review of patients presenting with a complaint of an injury from a fall transported by a single municipal EMS system. Administration of analgesia was the primary outcome variable, with pain severity, injury location, age, gender, race, and distance of fall the independent variables of interest. Pain severity was assessed using a 0-10 scale. Injury location was defined as head/neck, extremities, back, and hip. Patients were deemed ineligible for analgesia, according to local protocol, if they reported chest or abdominal pain, or were hemodynamically unstable as determined by an assessment of pulse and blood pressure. RESULTS: There were 1,200 patients who were classified as having injuries suffered from a fall, with 76 (6.3%) ineligible for analgesia. Ninety-two (8.2%) patients received analgesia, and they had a mean recorded pain score of 9.1 (95% CI, 8.7-9.5), which was higher than those who did not receive analgesia (5.8; 95% CI, 5.5-6.2). Analgesia administration was associated with injury location; patients experiencing an extremity injury (OR = 13.23; 95% CI, 5.58-31.36; P < .001) or hip injury (OR = 11.65; 95% CI, 4.64-29.24; P < .001) had increased odds of analgesia administration compared to those with head/neck injury. The odds of analgesia administration were decreased for black patients (OR = 0.19; 95% CI, 0.08-0.44; P < .001) when compared to white patients. CONCLUSION: Analgesia administration was provided to 10% of eligible patients, and was associated with injury location. Of concern was the number of patients who suffered a fall and did not receive a documented pain score. The results from this study indicated a need for education relating to pain management in patients suffering a fall.

Introduction of performance coaching during cardiopulmonary resuscitation improves compression depth and time to defibrillation in out-of-hospital cardiac arrest.

INTRODUCTION: Quality cardiopulmonary resuscitation (CPR) and timely defibrillation are associated with increasing survival to hospital discharge from out-of-hospital cardiac arrest (OHCA). The objective of this study was to demonstrate that performance coaching during an OHCA would improve compression depth and time to defibrillation (TTD). METHODS: This study was conducted in a single emergency medical services (EMS) agency and utilized data collected from 815 patients treated between 1/1/2012 and 12/31/2013. The intervention used multiple Plan-Do-Study-Act (PDSA) cycles to train fire captains to translate performance data into active direction. Testing began in simulation with small-scale expansions prior to system-wide implementation. Performance metrics included average (reported as a percentage) and actual compression depth (reported in millimeters), and TTD (an average in seconds). Analysis was conducted using Xbar and S control charts with standard assessment of special cause for performance data. A statistical shift was seen in means and standard deviations for both depth metrics. RESULTS: Average depth of compressions improved from 69.8% (SD=28.0%) to 80.4 (SD=21.8%). Depth of compressions delivered increased from 43.6mm (SD=8.2mm) to 47.2mm (SD=8.1mm). Analysis of the S charts indicates a statistical shift in process variation for TTD. CONCLUSION: Early results indicate that utilization of a CPR coach during OHCA improves compression depth and TTD. Further data are needed to assess sustainability.