Predictors of Prolonged Length of Stay and Adverse Events among Older Adults with Behavioral Health-Related Emergency Department Visits: A Systematic Medical Record Review.

BACKGROUND: Behavioral health (BH)-related visits to the emergency department (ED) by older adults are increasing. This population has unique challenges to providing quality, timely care. OBJECTIVE: To characterize older adults with BH-related ED visits and determine risk factors associated with prolonged length of stay (LOS) and adverse events (AEs). METHODS: We performed a retrospective electronic health record review of all patients ≥65 years who presented to our ED from September 2011 to August 2012 for BH-related complaints. Sociodemographic, clinical, and utilization data were tested for association with LOS and AE. RESULTS: The 213 elder BH patients represented 4% of the 5267 total elder visits during the study period. Median age was 75 (interquartile range [IQR] 70-82); largely white (84.5%), female (58.7%), and non-Hispanic (69.5%). There was a median of two comorbidities (IQR 1-3), and 46.9% were cognitively impaired. Most (71.5%) were being evaluated on an involuntary basis. Median LOS was 16.2 h (IQR 9.7-29.7). Increased LOS was associated with involuntary status (12.4 h, 95% confidence interval [95% CI] 6.4-18.4); use of restraints (11.9 h, 95% CI 5.7-18.2); and failed discharge (28.8 h, 95% CI 21.2-36.6). For every 10 additional hours in the ED, the risk for an AEs (p = .002) or potential AEs (p = .01) increased 20%. CONCLUSION: Elderly ED patients with BH complaints had high rates of cognitive impairment and multiple comorbidities. LOS was prolonged, and there were multiple contributing factors including involuntary status, chemical or physical restraint, and failed discharge. Patients with longer LOS were at increased risk of an AE or potentially AEs.

Statewide regionalization of postarrest care for out-of-hospital cardiac arrest: association with survival and neurologic outcome.

STUDY OBJECTIVE: For out-of-hospital cardiac arrest, authoritative, evidence-based recommendations have been made for regionalization of postarrest care. However, system-wide implementation of these guidelines has not been evaluated. Our hypothesis is that statewide regionalization of postarrest interventions, combined with emergency medical services (EMS) triage bypass, is associated with improved survival and neurologic outcome. METHODS: This was a prospective before-after observational study comparing patients admitted to cardiac receiving centers before implementation of the interventions ("before") versus those admitted after ("after"). In December 2007, the Arizona Department of Health Services began officially recognizing cardiac receiving centers according to commitment to provide specified postarrest care. Subsequently, the State EMS Council approved protocols allowing preferential EMS transport to these centers. Participants were adults (≥ 18 years) experiencing out-of-hospital cardiac arrest of presumed cardiac cause who were transported to a cardiac receiving center. Interventions included (1) implementation of postarrest care at cardiac receiving centers focusing on provision of therapeutic hypothermia and coronary angiography or percutaneous coronary interventions (catheterization/PCI); and (2) implementation of EMS bypass triage protocols. Main outcomes included discharged alive from the hospital and cerebral performance category score at discharge. RESULTS: During the study (December 1, 2007, to December 31, 2010), 31 hospitals were recognized as cardiac receiving centers statewide. Four hundred forty patients were transported to cardiac receiving centers before and 1,737 after. Provision of therapeutic hypothermia among patients with return of spontaneous circulation increased from 0% (before: 0/145; 95% confidence interval [CI] 0% to 2.5%) to 44.0% (after: 300/682; 95% CI 40.2, 47.8). The post return of spontaneous circulation catheterization PCI rate increased from 11.7% (17/145; 95% CI 7.0, 18.1) before to 30.7% (210/684; 95% CI 27.3, 34.3) after. All-rhythm survival increased from 8.9% (39/440) to 14.4% (250/1,734; adjusted odds ratio [aOR] = 2.22; 95% CI 1.47 to 3.34). Survival with favorable neurologic outcome (cerebral performance category score = 1 or 2) increased from 5.9% (26/439) to 8.9% (153/1,727; aOR = 2.26 [95% CI 1.37, 3.73]). For witnessed shockable rhythms, survival increased from 21.4% (21/98) to 39.2% (115/293; aOR = 2.96 [95% CI 1.63, 5.38]) and cerebral performance category score = 1 or 2 increased from 19.4% (19/98) to 29.8% (87/292; aOR = 2.12 [95% CI 1.14, 3.93]). CONCLUSION: Implementation of a statewide system of cardiac receiving centers and EMS bypass was independently associated with increased overall survival and favorable neurologic outcome. In addition, these outcomes improved among patients with witnessed shockable rhythms.

Can anticoagulated patients be discharged home safely from the emergency department after minor head injury?

BACKGROUND: Anticoagulated patients have increased risk for bleeding, and serious outcomes could occur after head injury. Controversy exists regarding the utility of head computed tomography (CT) in allowing safe discharge dispositions for anticoagulated patients suffering minor head injury. CLINICAL QUESTION: What is the risk of delayed intracranial hemorrhage in anticoagulated patients with minor head injury and a normal initial head CT scan? EVIDENCE REVIEW: Four observational studies were reviewed that investigated the outcomes of anticoagulated patients who presented after minor head injury. RESULTS: Overall incidence of death or neurosurgical intervention ranged from 0 to 1.1% among the patients investigated. The studies did not clarify which patients were at highest risk. CONCLUSION: The literature does not support mandatory admission for all anticoagulated patients after minor head injury, but further studies are needed to identify the higher-risk patients for delayed bleeding to determine appropriate management.

A prospective, multicenter study of pharmacist activities resulting in medication error interception in the emergency department.

STUDY OBJECTIVE: The primary objective of this study is to determine the activities of pharmacists that lead to medication error interception in the emergency department (ED). METHODS: This was a prospective, multicenter cohort study conducted in 4 geographically diverse academic and community EDs in the United States. Each site had clinical pharmacy services. Pharmacists at each site recorded their medication error interceptions for 250 hours of cumulative time when present in the ED (1,000 hours total for all 4 sites). Items recorded included the activities of the pharmacist that led to medication error interception, type of orders, phase of medication use process, and type of error. Independent evaluators reviewed all medication errors. Descriptive analyses were performed for all variables. RESULTS: A total of 16,446 patients presented to the EDs during the study, resulting in 364 confirmed medication error interceptions by pharmacists. The pharmacists' activities that led to medication error interception were as follows: involvement in consultative activities (n=187; 51.4%), review of medication orders (n=127; 34.9%), and other (n=50; 13.7%). The types of orders resulting in medication error interceptions were written or computerized orders (n=198; 54.4%), verbal orders (n=119; 32.7%), and other (n=47; 12.9%). Most medication error interceptions occurred during the prescribing phase of the medication use process (n=300; 82.4%) and the most common type of error was wrong dose (n=161; 44.2%). CONCLUSION: Pharmacists' review of written or computerized medication orders accounts for only a third of medication error interceptions. Most medication error interceptions occur during consultative activities.

"Paramedics are bringing in a hypotensive gastrointestinal bleeder": an unexpected diagnosis.

BACKGROUND: Acute esophageal rupture is a rare emergency that must be diagnosed quickly and treated aggressively to avoid significant morbidity and mortality. The typical presentation of this disease includes chest pain, and the diagnosis is challenging when cardinal features such as this are absent. OBJECTIVES: This case report discusses an atypical presentation of esophageal rupture in a patient with a predisposing condition and highlights the diagnostic and cognitive difficulties involved in making the appropriate diagnosis. CASE REPORT: We report a case of a 51-year-old woman who presented to the Emergency Department with hypotension and an emergency medical services report of hematemesis. The patient had a documented history of upper gastrointestinal bleeding and Zollinger-Ellison syndrome during her past hospitalizations; however, the patient was not anemic and had a negative stool guiac despite symptoms for 3 days. A subsequent chest radiograph led to the diagnosis of esophageal rupture with a bilateral pneumothorax requiring thoracostomies. She reported no chest pain. CONCLUSIONS: The esophageal rupture and subsequent hypotension was likely secondary to the combination of her Zollinger-Ellison syndrome and recent vomiting episodes. It is important to avoid premature diagnostic closure and think about unusual presentations of emergent conditions such as esophageal rupture.

Rescuer fatigue in the elderly: standard vs. hands-only CPR.

BACKGROUND: Hands-only cardiopulmonary resuscitation (HO-CPR) is recommended as an alternative to standard CPR (STD-CPR). Studies have shown a degradation of adequate compressions with HO-CPR after 2 min when performed by young, healthy medical students. Elderly rescuers' ability to maintain an adequate compression rate and depth until emergency medical services (EMS) arrives is unknown. OBJECTIVES: The specific aim of this study was to compare elderly rescuers' ability to maintain adequate compression rate and depth during HO-CPR and STD-CPR in a manikin model. METHODS: In this prospective, randomized crossover study, 17 elderly volunteers performed both HO-CPR and STD-CPR, separated by at least 2 days, on a manikin model for 9 min each. The primary endpoint was the number of adequate chest compressions (> 38 mm) delivered per minute. Secondary endpoints were total compressions, compression rate, and the number of breaks taken for rest. RESULTS: There was no difference in the number of adequate compressions between groups in the first minute; however, the STD-CPR group delivered significantly more adequate chest compressions in minutes 2-9 (p<0.05). The total number of compressions delivered was significantly greater in the HO-CPR than STD-CPR group when considering the entire resuscitation period. A significantly greater number of rescuers took breaks for rest during HO-CPR than STD-CPR. CONCLUSIONS: Although HO-CPR resulted in a greater number of overall compressions than STD-CPR, STD-CPR resulted in a greater number of adequate compressions in all but the first minute of resuscitation.

Proposed guidance on cost-avoidance studies in pharmacy practice.

PURPOSE: Cost-avoidance studies of pharmacist interventions are common and often the first type of study conducted by investigators to quantify the economic impact of clinical pharmacy services. The purpose of this primer is to provide guidance for conducting cost-avoidance studies pertaining to clinical pharmacy practice. SUMMARY: Cost-avoidance studies represent a paradigm conceptually different from traditional pharmacoeconomic analysis. A cost-avoidance study reports on cost savings from a given intervention, where the savings is estimated based on a counterfactual scenario. Investigators need to determine what specifically would have happened to the patient if the intervention did not occur. This assessment can be fundamentally flawed, depending on underlying assumptions regarding the pharmacists' action and the patient trajectory. It requires careful identification of the potential consequence of nonaction, as well as probability and cost assessment. Given the uncertainty of assumptions, sensitivity analyses should be performed. A step-by-step methodology, formula for calculations, and best practice guidance is provided. CONCLUSIONS: Cost-avoidance studies focused on pharmacist interventions should be considered low-level evidence. These studies are acceptable to provide pilot data for the planning of future clinical trials. The guidance provided in this article should be followed to improve the quality and validity of such investigations.

Methods used to attribute costs avoided from pharmacist interventions in acute care: A scoping review.

PURPOSE: Cost-avoidance studies are common in pharmacy practice literature. This scoping review summarizes, critiques, and identifies current limitations of the methods that have been used to determine cost avoidance associated with pharmacists' interventions in acute care settings. METHODS: An Embase and MEDLINE search was conducted to identify studies that estimated cost avoidance from pharmacist interventions in acute care settings. We included studies with human participants and articles published in English from July 2010 to January 2021, with the intent of summarizing the evidence most relevant to contemporary practice. RESULTS: The database search retrieved 129 articles, of which 39 were included. Among these publications, less than half (18 of 39) mentioned whether the researchers assigned a probability for the occurrence of a harmful consequence in the absence of an intervention; thus, a 100% probability of a harmful consequence was assumed. Eleven of the 39 articles identified the specific harm that would occur in the absence of intervention. No clear methods of estimating cost avoidance could be identified for 7 studies. Among all 39 included articles, only 1 attributed both a probability to the potential harm and identified the cost specific to that harm. CONCLUSION: Cost-avoidance studies of pharmacists' interventions in acute care settings over the last decade have common flaws and provide estimates that are likely to be inflated. There is a need for guidance on consistent methodology for such investigations for reporting of results and to confirm the validity of their economic implications.

A prospective observational study of medication errors in a tertiary care emergency department.

STUDY OBJECTIVE: We determine the rate and severity of medication errors, as well as factors associated with error occurrence in the emergency department (ED). METHODS: This was a prospective observational study conducted between May 1, 2008, and February 1, 2009. The pharmacist observer was present in the ED for 28 shifts (12 hours each). Information was collected on the medication use process by observing the activities of nurses caring for the patients. Errors were categorized by severity. Logistic regression was used to analyze factors associated with a risk of medication error. RESULTS: The observer identified 178 medication errors in 192 patients during the data collection period. At least 1 error occurred in 59.4% of patients, and 37% of patients overall had an error that reached them. No errors in the study resulted in permanent harm to the patient or contributed to initial or prolonged hospitalization; however, interventions were performed to prevent patient harm that likely influenced the severity of error. Errors categorized according to stage were prescribing (53.9%), transcribing (10.7%), dispensing (0.6%), and administering (34.8%). Variables predictive of medication errors were boarded patient status (odds ratio [OR] 2.15; 95% confidence interval [CI] 1.03 to 4.5), number of medication orders (OR 1.25; 95% CI 1.12 to 1.39), number of medications administered (OR 1.22; 95% CI 1.07 to 1.38), and nursing employment status (less error if full time) (OR 0.37; 95% CI 0.16 to 0.86). CONCLUSION: Medication errors in the ED are common, and most errors occur in the prescribing and administering phases. Boarded patient status, increasing number of medications orders, increasing number of medications administered, and part-time nursing status are associated with an increased risk of medication error.

Summary of NIH Medical-Surgical Emergency Research Roundtable held on April 30 to May 1, 2009.

STUDY OBJECTIVE: In 2003, the Institute of Medicine Committee on the Future of Emergency Care in the United States Health System convened and identified a crisis in emergency care in the United States, including a need to enhance the research base for emergency care. As a result, the National Institutes of Health (NIH) formed an NIH Task Force on Research in Emergency Medicine to enhance NIH support for emergency care research. Members of the NIH Task Force and academic leaders in emergency care participated in 3 roundtable discussions to prioritize current opportunities for enhancing and conducting emergency care research. The objectives of these discussions were to identify key research questions essential to advancing the scientific underpinnings of emergency care and to discuss the barriers and best means to advance research by exploring the role of research networks and collaboration between the NIH and the emergency care community. METHODS: The Medical-Surgical Research Roundtable was convened on April 30 to May 1, 2009. Before the roundtable, the emergency care domains to be discussed were selected and experts in each of the fields were invited to participate in the roundtable. Domain experts were asked to identify research priorities and challenges and separate them into mechanistic, translational, and clinical categories. After the conference, the lists were circulated among the participants and revised to reach a consensus. RESULTS: Emergency care research is characterized by focus on the timing, sequence, and time sensitivity of disease processes and treatment effects. Rapidly identifying the phenotype and genotype of patients manifesting a specific disease process and the mechanistic reasons for heterogeneity in outcome are important challenges in emergency care research. Other research priorities include the need to elucidate the timing, sequence, and duration of causal molecular and cellular events involved in time-critical illnesses and injuries, and the development of treatments capable of halting or reversing them; the need for novel animal models; and the need to understand why there are regional differences in outcome for the same disease processes. Important barriers to emergency care research include a limited number of trained investigators and experienced mentors, limited research infrastructure and support, and regulatory hurdles. The science of emergency care may be advanced by facilitating the following: (1) training emergency care investigators with research training programs; (2) developing emergency care clinical research networks; (3) integrating emergency care research into Clinical and Translational Science Awards; (4) developing emergency care-specific initiatives within the existing structure of NIH institutes and centers; (5) involving emergency specialists in grant review and research advisory processes; (6) supporting learn-phase or small, clinical trials; and (7) performing research to address ethical and regulatory issues. CONCLUSION: Enhancing the research base supporting the care of medical and surgical emergencies will require progress in specific mechanistic, translational, and clinical domains; effective collaboration of academic investigators across traditional clinical and scientific boundaries; federal support of research in high-priority areas; and overcoming limitations in available infrastructure, research training, and access to patient populations.

Continued breathing followed by gasping or apnea in a swine model of ventricular fibrillation cardiac arrest.

BACKGROUND: Continued breathing following ventricular fibrillation has here-to-fore not been described. METHODS: We analyzed the spontaneous ventilatory activity during the first several minutes of ventricular fibrillation (VF) in our isoflurane anesthesized swine model of out-of-hospital cardiac arrest. The frequency and type of ventilatory activity was monitored by pneumotachometer and main stream infrared capnometer and analyzed in 61 swine during the first 3 to 6 minutes of untreated VF. RESULTS: During the first minute of VF, the air flow pattern in all 61 swine was similar to those recorded during regular spontaneous breathing during anesthesia and was clearly different from the patterns of gasping. The average rate of continued breathing during the first minute of untreated VF was 10 breaths per minute. During the second minute of untreated VF, spontaneous breathing activity either stopped or became typical of gasping. During minutes 2 to 5 of untreated VF, most animals exhibited very slow spontaneous ventilatory activity with a pattern typical of gasping; and the pattern of gasping was crescendo-decrescendo, as has been previously reported. In the absence of therapy, all ventilatory activity stopped 6 minutes after VF cardiac arrest. CONCLUSION: In our swine model of VF cardiac arrest, we documented that normal breathing continued for the first minute following cardiac arrest.

Chest compression-only CPR by lay rescuers and survival from out-of-hospital cardiac arrest.

CONTEXT: Chest compression-only bystander cardiopulmonary resuscitation (CPR) may be as effective as conventional CPR with rescue breathing for out-of-hospital cardiac arrest. OBJECTIVE: To investigate the survival of patients with out-of-hospital cardiac arrest using compression-only CPR (COCPR) compared with conventional CPR. DESIGN, SETTING, AND PATIENTS: A 5-year prospective observational cohort study of survival in patients at least 18 years old with out-of-hospital cardiac arrest between January 1, 2005, and December 31, 2009, in Arizona. The relationship between layperson bystander CPR and survival to hospital discharge was evaluated using multivariable logistic regression. MAIN OUTCOME MEASURE: Survival to hospital discharge. RESULTS: Among 5272 adults with out-of-hospital cardiac arrest of cardiac etiology not observed by responding emergency medical personnel, 779 were excluded because bystander CPR was provided by a health care professional or the arrest occurred in a medical facility. A total of 4415 met all inclusion criteria for analysis, including 2900 who received no bystander CPR, 666 who received conventional CPR, and 849 who received COCPR. Rates of survival to hospital discharge were 5.2% (95% confidence interval [CI], 4.4%-6.0%) for the no bystander CPR group, 7.8% (95% CI, 5.8%-9.8%) for conventional CPR, and 13.3% (95% CI, 11.0%-15.6%) for COCPR. The adjusted odds ratio (AOR) for survival for conventional CPR vs no CPR was 0.99 (95% CI, 0.69-1.43), for COCPR vs no CPR, 1.59 (95% CI, 1.18-2.13), and for COCPR vs conventional CPR, 1.60 (95% CI, 1.08-2.35). From 2005 to 2009, lay rescuer CPR increased from 28.2% (95% CI, 24.6%-31.8%) to 39.9% (95% CI, 36.8%-42.9%; P < .001); the proportion of CPR that was COCPR increased from 19.6% (95% CI, 13.6%-25.7%) to 75.9% (95% CI, 71.7%-80.1%; P < .001). Overall survival increased from 3.7% (95% CI, 2.2%-5.2%) to 9.8% (95% CI, 8.0%-11.6%; P < .001). CONCLUSION: Among patients with out-of-hospital cardiac arrest, layperson compression-only CPR was associated with increased survival compared with conventional CPR and no bystander CPR in this setting with public endorsement of chest compression-only CPR.

Gasping during cardiac arrest in humans is frequent and associated with improved survival.

BACKGROUND: The incidence and significance of gasping after cardiac arrest in humans are controversial. METHODS AND RESULTS: Two approaches were used. The first was a retrospective analysis of consecutive confirmed out-of-hospital cardiac arrests from the Phoenix Fire Department Regional Dispatch Center text files to determine the presence of gasping soon after collapse. The second was a retrospective analysis of 1218 patients with out-of-hospital cardiac arrests in Arizona documented by emergency medical system (EMS) first-care reports to determine the incidence of gasping after arrest in relation to the various EMS arrival times. The primary outcome measure was survival to hospital discharge. An analysis of the Phoenix Fire Department Regional Dispatch Center records of witnessed and unwitnessed out-of-hospital cardiac arrests with attempted resuscitation found that 44 of 113 (39%) of all arrested patients had gasping. An analysis of 1218 EMS-attended, witnessed, out-of-hospital cardiac arrests demonstrated that the presence or absence of gasping correlated with EMS arrival time. Gasping was present in 39 of 119 patients (33%) who arrested after EMS arrival, in 73 of 363 (20%) when EMS arrival was <7 minutes, in 50 of 360 (14%) when EMS arrival time was 7 to 9 minutes, and in 25 of 338 (7%) when EMS arrival time was >9 minutes. Survival to hospital discharge occurred in 54 of 191 patients (28%) who gasped and in 80 of 1027 (8%) who did not (adjusted odds ratio, 3.4; 95% confidence interval, 2.2 to 5.2). Among the 481 patients who received bystander cardiopulmonary resuscitation, survival to hospital discharge occurred among 30 of 77 patients who gasped (39%) versus only 38 of 404 among those who did not gasp (9%) (adjusted odds ratio, 5.1; 95% confidence interval, 2.7 to 9.4). CONCLUSIONS: Gasping or abnormal breathing is common after cardiac arrest but decreases rapidly with time. Gasping is associated with increased survival. These results suggest that the recognition and importance of gasping should be taught to bystanders and emergency medical dispatchers so as not to dissuade them from initiating prompt resuscitation efforts when appropriate.

Passive oxygen insufflation is superior to bag-valve-mask ventilation for witnessed ventricular fibrillation out-of-hospital cardiac arrest.

STUDY OBJECTIVE: Assisted ventilation may adversely affect out-of-hospital cardiac arrest outcomes. Passive ventilation offers an alternate method of oxygen delivery for these patients. We compare the adjusted neurologically intact survival of out-of-hospital cardiac arrest patients receiving initial passive ventilation with those receiving initial bag-valve-mask ventilation. METHODS: The authors performed a retrospective analysis of statewide out-of-hospital cardiac arrests between January 1, 2005, and September 28, 2008. The analysis included consecutive adult out-of-hospital cardiac arrest patients receiving resuscitation with minimally interrupted cardiopulmonary resuscitation (CPR) consisting of uninterrupted preshock and postshock chest compressions, initial noninvasive airway maneuvers, and early epinephrine. Paramedics selected the method of initial noninvasive ventilation, consisting of either passive ventilation (oropharyngeal airway insertion and high-flow oxygen by nonrebreather facemask, without assisted ventilation) or bag-valve-mask ventilation (by paramedics at 8 breaths/min). The authors determined adjusted neurologically intact survival from hospital and public records and by telephone interview and mail questionnaire. The authors compared adjusted neurologically intact survival between ventilation techniques by using generalized estimating equations. RESULTS: Among the 1,019 adult out-of-hospital cardiac arrest patients in the analysis, 459 received passive ventilation and 560 received bag-valve-mask ventilation. Adjusted neurologically intact survival after witnessed ventricular fibrillation/ventricular tachycardia out-of-hospital cardiac arrest was higher for passive ventilation (39/102; 38.2%) than bag-valve-mask ventilation (31/120; 25.8%) (adjusted odds ratio [OR] 2.5; 95% confidence interval [CI] 1.3 to 4.6). Survival between passive ventilation and bag-valve-mask ventilation was similar after unwitnessed ventricular fibrillation/ventricular tachycardia (7.3% versus 13.8%; adjusted OR 0.5; 95% CI 0.2 to 1.6) and nonshockable rhythms (1.3% versus 3.7%; adjusted OR 0.3; 95% CI 0.1 to 1.0). CONCLUSION: Among adult, witnessed, ventricular fibrillation/ventricular tachycardia, out-of-hospital cardiac arrest resuscitated with minimally interrupted cardiac resuscitation, adjusted neurologically intact survival to hospital discharge was higher for individuals receiving initial passive ventilation than those receiving initial bag-valve-mask ventilation.

Improved neurological outcome with continuous chest compressions compared with 30:2 compressions-to-ventilations cardiopulmonary resuscitation in a realistic swine model of out-of-hospital cardiac arrest.

BACKGROUND: The 2005 Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care changed the previous ventilations-to-chest-compression algorithm for bystander cardiopulmonary resuscitation (CPR) from 2 ventilations before each 15 chest compressions (2:15 CPR) to 30 chest compressions before 2 ventilations (30:2 CPR). It was acknowledged in the guidelines that the change was based on a consensus rather than clear evidence. This study was designed to compare 24-hour neurologically normal survival between the initial applications of continuous chest compressions without assisted ventilations with 30:2 CPR in a swine model of witnessed out-of-hospital ventricular fibrillation cardiac arrest. METHODS AND RESULTS: Sixty-four animals underwent 12 minutes of ventricular fibrillation before defibrillation attempts. They were divided into 4 groups, each with increasing durations (3, 4, 5, and 6 minutes, respectively) of untreated ventricular fibrillation before the initiation of bystander resuscitation consisting of either continuous chest compression or 30:2 CPR. After the various untreated ventricular durations plus bystander resuscitation durations, all animals were given the first defibrillation attempt 12 minutes after the induction of ventricular fibrillation, followed by the 2005 guideline-recommended advanced cardiac life support. Neurologically normal survival at 24 hours after resuscitation was observed in 23 of 33 (70%) of the animals in the continuous chest compression groups but in only 13 of 31 (42%) of the 30:2 CPR groups (P=0.025). CONCLUSIONS: In a realistic model of out-of-hospital ventricular fibrillation cardiac arrest, initial bystander administration of continuous chest compressions without assisted ventilations resulted in significantly better 24-hour postresuscitation neurologically normal survival than did the initial bystander administration of 2005 guideline-recommended 30:2 CPR.

The impact of prehospital transport interval on survival in out-of-hospital cardiac arrest: implications for regionalization of post-resuscitation care.

OBJECTIVE: There is growing evidence that therapeutic hypothermia and other post-resuscitation care improves outcomes in out-of-hospital cardiac arrest (OHCA). Thus, transporting patients with return of spontaneous circulation (ROSC) to specialized facilities may increase survival rates. However, it is unknown whether prolonging transport to reach a designated facility would be detrimental. METHODS: Data from OHCA patients treated in EMS systems that cover approximately 70% of Arizona's population were evaluated (October 2004-December 2006). We analyzed the association between transport interval (depart scene to ED arrival) and survival to hospital discharge in adult, non-traumatic OHCA patients and in the subgroup who achieved ROSC and remained comatose. RESULTS: 1846 OHCA occurred prior to EMS arrival. Complete transport interval data were available for 1177 (63.8%) patients (study group). 253 patients (21.5%) achieved ROSC and remained comatose making them theoretically eligible for transport to specialized care. Overall, 70 patients (5.9%) survived and 43 (17.0%) comatose ROSC patients survived. Mean transport interval for the study group was 6.9 min (95% CI: 6.7, 7.1). Logistic regression revealed factors that were independently associated with survival: witnessed arrest, bystander CPR, method of CPR, initial rhythm of ventricular fibrillation, and shorter EMS response time interval. There was no significant association between transport interval and outcome in either the overall study group (OR=1.2; 0.77, 1.8) or in the comatose, ROSC subgroup (OR 0.94; 0.51, 1.8). CONCLUSION: Survival was not significantly impacted by transport interval. This suggests that a modest increase in transport interval from bypassing the closest hospital en route to specialized care is safe and warrants further investigation.

Minimally interrupted cardiac resuscitation by emergency medical services for out-of-hospital cardiac arrest.

CONTEXT: Out-of-hospital cardiac arrest is a major public health problem. OBJECTIVE: To investigate whether the survival of patients with out-of-hospital cardiac arrest would improve with minimally interrupted cardiac resuscitation (MICR), an alternate emergency medical services (EMS) protocol. DESIGN, SETTING, AND PATIENTS: A prospective study of survival-to-hospital discharge between January 1, 2005, and November 22, 2007. Patients with out-of-hospital cardiac arrests in 2 metropolitan cities in Arizona before and after MICR training of fire department emergency medical personnel were assessed. In a second analysis of protocol compliance, patients from the 2 metropolitan cities and 60 additional fire departments in Arizona who actually received MICR were compared with patients who did not receive MICR but received standard advanced life support. INTERVENTION: Instruction for EMS personnel in MICR, an approach that includes an initial series of 200 uninterrupted chest compressions, rhythm analysis with a single shock, 200 immediate postshock chest compressions before pulse check or rhythm reanalysis, early administration of epinephrine, and delayed endotracheal intubation. MAIN OUTCOME MEASURE: Survival-to-hospital discharge. RESULTS: Among the 886 patients in the 2 metropolitan cities, survival-to-hospital discharge increased from 1.8% (4/218) before MICR training to 5.4% (36/668) after MICR training (odds ratio [OR], 3.0; 95% confidence interval [CI], 1.1-8.9). In the subgroup of 174 patients with witnessed cardiac arrest and ventricular fibrillation, survival increased from 4.7% (2/43) before MICR training to 17.6% (23/131) after MICR training (OR, 8.6; 95% CI, 1.8-42.0). In the analysis of MICR protocol compliance involving 2460 patients with cardiac arrest, survival was significantly better among patients who received MICR than those who did not (9.1% [60/661] vs 3.8% [69/1799]; OR, 2.7; 95% CI, 1.9-4.1), as well as patients with witnessed ventricular fibrillation (28.4% [40/141] vs 11.9% [46/387]; OR, 3.4; 95% CI, 2.0-5.8). CONCLUSIONS: Survival-to-hospital discharge of patients with out-of-hospital cardiac arrest increased after implementation of MICR as an alternate EMS protocol. These results need to be confirmed in a randomized trial.

Point-of-care Head and Neck Sonography for Clinical Problem-solving: Impact of One-day Training Sessions on Medical Student Education.

Introduction The curriculum for medical student education is continuously evolving to emphasize knowledge acquisition with critical problem-solving skills. Medical schools have started to implement curricula to teach point-of-care ultrasound skills. To our knowledge, the expansion into head and neck sonography for medical student education is novel and has never been studied. Our objective was to determine the feasibility of implementing point-of-care head and neck sonography and critical problem-solving instruction for medical student education. Methods This was a cross-sectional study enrolling third-year medical students with minimal prior ultrasound experience. A one-day educational curriculum focusing on the use of head and neck ultrasound for clinical problem-solving was integrated into one of the week-long intersessions. The components of point-of-care ultrasound workshop included asynchronous learning, one-hour didactic lecture, followed by a pre-test assessment, then a one-day hands-on workshop, and finally a post-test assessment administered at the end of the training session. Results A total of 123 subjects participated in this study. Ninety-one percent completed the questionnaire prior to the workshop and 83% completed the post-test questionnaire. The level of comfort with using an ultrasound system significantly increased from 31% to 92%. Additionally, the comfort level in interpreting ultrasound images also significantly increased from 21% to 84%. Eighty-nine percent (95% CI, 86%-97%) had an interest in learning ultrasound and would enroll in an optional ultrasound curriculum if given the opportunity. Knowledge of specific ultrasound applications also increased from 60% (after asynchronous learning and lectures) to 95% (after additional hands-on sonographic training). Conclusion At our institution, we successfully integrated point-of-care head and neck sonography and critical problem-solving instruction for medical student education.