Prone Dispatch-Directed CPR in Out-of-Hospital Cardiac Arrest: Two Successful Cases.

Historically, dispatch-directed cardiopulmonary resuscitation (CPR) protocols only allow chest compression instructions to be delivered for patients able to be placed in the traditional supine position. For patients who are unable to be positioned supine, the telecommunicator and caller have no option except to continue attempts to position supine, which may result in delayed or no chest compressions being delivered prior to emergency medical services arrival. Any delay or lack of bystander chest compressions may result in worsening clinical outcomes of out-of-hospital cardiac arrest (OHCA) victims. We present the first two cases, to the best of our knowledge, of successfully delivered, bystander-administered, prone CPR instructions by a trained telecommunicator for two OHCA victims unable to be positioned supine.

Ability of Layperson Callers to Apply a Tourniquet Following Protocol-Based Instructions From an Emergency Medical Dispatcher.

Introduction: One of the greatest casualty-care improvements resulting from US military operations in Iraq and Afghanistan has been the reduction of preventable death from massive extremity hemorrhage - largely due to the widespread use of limb tourniquets. More recently, tourniquet use in civilian, prehospital settings has shown promise in reducing deaths in cases of catastrophic arterial limb hemorrhage. Telephone instructions by trained emergency medical dispatchers (EMDs) on applying an available tourniquet may help achieve such a benefit.Objectives: The objective of the study was to determine whether layperson callers can effectively stop simulated bleeding using an improvised or a commercial tourniquet, when provided with scripted instructions via phone from a trained protocol-aided EMD.Methods: This was a prospective, randomized trial involving layperson volunteers, done at four locations in Salt Lake City, Utah, USA. Volunteers were assigned randomly to three groups: one for each of two commonly available commercial tourniquets and one for an improvised tourniquet.Results: A total of 246 subjects participated in the study at the four locations between February 11, 2019 and June 22, 2019. The overall median time for all trials (i.e., elapsed time from the start to the end of the simulation) was 3 minutes and 19 seconds. Median time to stop the bleeding (i.e., elapsed time from the start of the simulation to the time the participant was able to successfully stop the bleeding) was 2 minutes and 57 seconds. Median tourniquet pressure was 256 mmHg and median-end blood loss was 1,365 mL. A total of 198 participants (80.49%) were able to completely stop the bleeding while 16 participants (6.5%) had the tourniquet applied with some bleeding still occurring, and 32 participants (13.01%) exceeded the threshold of 2,500 mL of blood loss, resulting in the "patient" not surviving.Conclusions: The study findings demonstrated that untrained bystanders provided with instructions via phone from a trained Emergency Medical Dispatcher applied a tourniquet and successfully stopped the bleeding completely in most cases.

Availability and Use of an Automated External Defibrillator at Emergency Medical Dispatch.

Objective: The aim of this study was to determine the frequency of automatic external defibrillator (AED) retrieval and placement by bystander callers when prompted by an Emergency Medical Dispatcher (EMD). Methods: This retrospective descriptive study utilized a convenience sample of emergency dispatch data collected from 23 Emergency Communication Centers (ECCs) spanning 14 states across the United States (U.S.) from July 11, 2014 to August 13, 2018, including all cases in which the EMD recorded any response to the AED availability prompt. Data were collected using ProQA, the software version of the Medical Priority Dispatch System. Primary outcome measures were (a) distribution of responses to the AED prompt; (b) percentage of cases in which an AED was retrieved; and (c) percentage of cases in which AED pads were placed by the bystander-caller. Results: A total of 2,200,285 cases were collected during the study period, in 18,904 (0.86%) of which the AED prompt was displayed (indicating suspected out of hospital cardiac arrest, or OHCA). Overall, an AED was reported as available 5.8% (n = 1,091) of the time the EMD recorded an answer to the AED prompt. In multiple-rescuer situations, a rescuer was sent to get the AED 2.8% (n = 523) of the time, as opposed to only 0.30% (n = 56) for single-rescuer calls. The AED was reported to be already on scene, by the patient, in 2.7% (n = 512) of the cases. A majority (72.0%; n = 417) of the time, rescuers who were sent to get an AED were unable to retrieve it, with single rescuers being successful more often (57.1% unable to retrieve, vs 73.6% for multiple rescuers). Conclusions: AEDs are reported as available by only a small percentage of callers to 911, and in the majority of cases in which a bystander rescuer is sent to retrieve an AED, one is never located or used. Sending someone to retrieve the AED may be more appropriate in multiple-rescuer situations than when a single bystander rescuer is alone on scene.

9-1-1 Triage of Non-Traumatic Chest Pain: Association with Hospital Diagnosis.

OBJECTIVE: Chest pain is one of the most common reasons people seek emergency care-and one of the most critical. In the United States, chest pain is the second most common reason for emergency department (ED) visits. A patient's primary complaint of "chest pain" may reflect a broad range of underlying causes; therefore, it is important that emergency medical service (EMS) agencies gain a thorough understanding of these cases, beginning with the initial management of chest pain in the 9-1-1 center. The primary objective of this study was to compare hospital-confirmed patient discharge diagnoses to all calls handled by emergency medical dispatchers (EMDs) using the Chest Pain/Chest Discomfort (Non-Traumatic) Chief Complaint Protocol. METHODS: The retrospective descriptive study utilized emergency medical dispatch, EMS, and hospital datasets, collected at two emergency communication centers in North America, from January 1, 2013 to December 31, 2014. Patients who were dispatched using the Chest Pain/Chest Discomfort Chief Complaint Protocol and matched to hospital datasets were included. The primary outcome was the number and percentage of cases classified as ischemic heart disease (IHD), other cardiac-related conditions, or non-cardiac-related conditions associated with chest pain. We also evaluated the distribution of causes of chest pain across demographic indicators and dispatch determinants. RESULTS: 3,007 cases were identified as "chest pain" at dispatch for which corresponding hospital records were identified. Cases in the study were obtained by linking EMS/Hospital and Emergency Medical Dispatch datasets. Of these cases, 47.1% (n = 1,417) were due to cardiac-related causes of chest pain, 61.5% of which were Ischemic Heart Disease (IHD), while the rest had other cardiac-related causes. Of the IHDs, 32.1% were Acute Myocardial Infarction (AMI). CONCLUSIONS: Underlying causes of non-traumatic chest pain reported to 9-1-1 demonstrate a wide range of etiologies, with a mix similar to that of chest pain patients in several other healthcare settings, including hospital emergency departments. Most IHD events are triaged by EMDs to the (highest) DELTA priority level, while the CHARLIE level captures nearly all of the remaining IHD cases.

Predictive Ability of an Emergency Medical Dispatch Stroke Diagnostic Tool in Identifying Hospital-Confirmed Strokes.

BACKGROUND: Early hospital notification of a possible stroke arriving via emergency medical services (EMS) can prepare stroke center personnel for timely treatment, especially timely administration of tissue plasminogen activator. Stroke center notification from the emergency dispatch center-before responders reach the scene-may promote even earlier and faster system activation, meaning that stroke center teams may be ready to receive patients as soon as the ambulance arrives. This study evaluates the use of a Medical Priority Dispatch System (MPDS; Priority Dispatch Corp., Salt Lake City, UT) Stroke Diagnostic Tool (SDxT) to identify possible strokes early by comparing the tools' results to on-scene and hospital findings. METHODS: The retrospective descriptive study utilized stroke data from 3 sources: emergency medical dispatch, EMS, and emergency department/hospital. RESULTS: A total of 830 cases were collected between June 2012 and December 2013, of which 603 (72.7%) had matching dispatch records. Of the 603 cases, 304 (50.4%) were handled using MPDS Stroke Protocol 28. The SDxT had an 86.4% ability (OR [95% CI]: 2.3 [1.5, 3.5]) to effectively identify strokes among all the hospital-confirmed stroke cases (sensitivity), and a 26.6% ability to effectively identify nonstrokes among all the hospital-confirmed nonstroke cases (specificity). CONCLUSIONS: The SDxT demonstrated a very high sensitivity, compared to similar tools used in the field and at dispatch. The specificity was somewhat low, but this was expected-and is intended in the creation of protocols to be used over the phone in emergency situations. The tool is a valuable method for identifying strokes early and may allow early hospital notification.

Outcome accuracy of the Emergency Medical Dispatcher's initial selection of a diabetic problems protocol.

INTRODUCTION: Diabetes mellitus, although a chronic disease, also can cause acute, sudden symptoms requiring emergency intervention. In these cases, Emergency Medical Dispatchers (EMDs) must identify true diabetic complaints in order to determine the correct care. In 911 systems utilizing the Medical Priority Dispatch System (MPDS), International Academies of Emergency Dispatch-certified EMDs determine a patient's chief complaint by matching the caller's response to an initial pre-scripted question to one of 37 possible chief complaints protocols. The ability of EMDs to identify true diabetic-triggered events reported through 911 has not been studied. OBJECTIVE: The primary objective of this study was to determine the percentage of EMD-recorded patient cases (using the Diabetic Problems protocol in the MPDS) that were confirmed by either attending paramedics or the hospital as experiencing a diabetic-triggered event. METHODS: This was a retrospective study involving six hospitals, one fire department, and one ambulance service in Salt Lake City, Utah USA. Dispatch data for one year recorded under the Diabetic Problems protocol, along with the associated paramedic and hospital outcome data, were reviewed/analyzed. The outcome measures were: the percentage of cases that had diabetic history, percentage of EMD-identified diabetic problems cases that were confirmed by Emergency Medical Services (EMS) and/or hospital records as true diabetic-triggered events, and percentage of EMD-identified diabetic patients who also had other medical conditions. A diabetic-triggered event was defined as one in which the patient's emergency was directly caused by diabetes or its medical management. Descriptive statistics were used for categorical measures and parametric statistical methods assessed the differences between study groups, for continuous measures. RESULTS: Three-hundred ninety-three patient cases were assigned to the Diabetic Problems Chief Complaint protocol. Of the 367 (93.4%) patients who had a documented history of diabetes, 279 (76%) were determined to have had a diabetic-triggered event. However, only 12 (3.6%) initially assigned to this protocol did not have a confirmed history of diabetes. CONCLUSIONS: Using the MPDS to select the Diabetic Problems Chief Complaint protocol, the EMDs correctly identified a true diabetic-triggered event the majority of the time. However, many patients had other medical conditions, which complicated the initial classification of true diabetic-triggered events. Future studies should examine the associations between the five specific Diabetic Problems Chief Complaint protocol determinant codes (triage priority levels) and severity measures, eg, blood sugar level and Glasgow Coma Score.

Aspirin administration by emergency medical dispatchers using a protocol-driven aspirin diagnostic and instruction tool.

BACKGROUND: The American College of Cardiology and the American Heart Association recommend early aspirin administration to patients with symptoms of acute coronary syndrome (ACS)/acute myocardial infarction (AMI). The primary objective of this study was to determine if Emergency Medical Dispatchers (EMD) can provide chest pain/heart attack patients with standardised instructions effectively, using an aspirin diagnostic and instruction tool (ADxT) within the Medical Priority Dispatch System (MPDS) before arrival of an emergency response crew. METHODS: This retrospective study involved three dispatch centres in the UK and USA. We analysed 6 months of data involving chest pain/heart attack symptoms taken using the MPDS chest pain and heart problems/automated internal cardiac defibrillator protocols. RESULTS: The EMDs successfully completed the ADxT on 69.8% of the 44141 cases analysed. The patient's mean age was higher when the ADxT was completed, than when it was not (mean ± SD: 53.9 ± 19.9 and 49.9 ± 20.2; p<0.001, respectively). The ADxT completion rate was higher for second-party than first-party calls (70.3% and 69.0%; p=0.024, respectively). A higher percentage of male than female patients took aspirin (91.3% and 88.9%; p=0.001, respectively). Patients who took aspirin were significantly younger than those who did not (mean ± SD: 61.8 ± 17.5 and 64.7 ± 17.9, respectively). Unavailability of aspirin was the major reason (44.4%) why eligible patients did not take aspirin when advised. CONCLUSIONS: EMDs, using a standardised protocol, can enable early aspirin therapy to treat potential ACS/AMI prior to responders' arrival. Further research is required to assess reasons for not using the protocol, and the significance of the various associations discovered.

The accuracy of emergency medical dispatcher-assisted layperson-caller pulse check using the medical priority dispatch system protocol.

INTRODUCTION: Knowing the pulse rate of a patient in a medical emergency can help to determine patient acuity and the level of medical care required. Little evidence exists regarding the ability of a 911 layperson-caller to accurately determine a conscious patient's pulse rate. Hypothesis The hypothesis of this study was that, when instructed by a trained emergency medical dispatcher (EMD) using the scripted Medical Priority Dispatch System (MPDS) protocol Pulse Check Diagnostic Tool (PCDxT), a layperson-caller can detect a carotid pulse and accurately determine the pulse rate in a conscious person. METHODS: This non-randomized and non-controlled prospective study was conducted at three different public locations in the state of Utah (USA). A healthy, mock patient's pulse rate was obtained using an electrocardiogram (ECG) monitor. Layperson-callers, in turn, initiated a simulated 911 phone call to an EMD call-taker who provided instructions for determining the pulse rate of the patient. Layperson accuracy was assessed using correlations between the layperson-caller's finding and the ECG reading. RESULTS: Two hundred sixty-eight layperson-callers participated; 248 (92.5%) found the pulse of the mock patient. There was a high correlation between pulse rates obtained using the ECG monitor and those found by the layperson-callers, overall (94.6%, P < .001), and by site, gender, and age. CONCLUSIONS: Layperson-callers, when provided with expert, scripted instructions by a trained 911 dispatcher over the phone, can accurately determine the pulse rate of a conscious and healthy person. Improvements to the 911 instructions may further increase layperson accuracy.

Medical Priority Dispatch System breathing problems protocol key question combinations are associated with patient acuity.

INTRODUCTION: The Breathing Problems Chief Complaint (CC) protocol in the Medical Priority Dispatch System (MPDS) was the system's most frequently used protocol. While "severe breathing problems" is a significant predictor of cardiac arrest (CA), previous data have demonstrated that the DELTA-level determinant codes in this CC contain patients across a wide spectrum of acuity. HYPOTHESIS: The hypothesis in this study was that certain combinations of caller answers to the breathing problems protocol key questions (KQs) are correlated with different but specific patient acuities. METHODS: This was a retrospective study conducted at one International Academies of Emergency Dispatch (IAED) Accredited Center of Excellence. Key Question combinations were generated and analyzed from 11 months of dispatch data, and extracted from MPDS software and the computer assisted dispatch system. Descriptive statistics were used to evaluate measures between study groups. RESULTS: Forty-two thousand cases were recorded; 52% of patients were female and the median age was 61 years. Overall, based on the original MPDS Protocol (before generating KQ combinations), patients with abnormal breathing and clammy conditions were the youngest. The MPDS DELTA-level constituted the highest percentage of cases (74.0%) and the difficulty speaking between breaths (DSBB) condition was the most prevalent (50.3%). Ineffective breathing and not alert conditions had the highest cardiac arrest quotient (CAQ). Based on the KQ combinations, the CA patients who also had the not alert condition were significantly older than other patients. The percentage of CA outcomes in asthmatic patients was significantly higher in DSBB plus not alert; DSBB plus not alert plus changing color; and DSBB plus not alert plus clammy conditions cases, compared to asthmatic abnormal breathing cases. CONCLUSIONS: The study findings demonstrated that MPDS KQ answer combinations relate to patient acuity. Cardiac arrest patients are significantly less likely to be asthmatic than those without CA, and vice versa. Using a prioritization scheme that accounts for the presence of either single or multiple signs and/or symptom combinations for the Breathing Problems CC protocol would be a more accurate method of assigning DELTA-level cases in the MPDS.

9-1-1 Caller-Described Heart Attack Symptoms.

INTRODUCTION: Heart attacks (HAs) present clinically with varying symptoms, which are not always described by patients as chest pain (CP) or chest discomfort (CD). Emergency Medical Dispatchers (EMDs) select the CP/CD dispatch protocol for non-chest pain HA symptoms or classic HA complaint of CP/CD. Nevertheless, it is still unknown how often callers report HA symptoms other than CP/CD. OBJECTIVES: The objective of this study was to characterize the caller's descriptions of the primary HA symptoms, descriptions of the other HA symptoms, and the use of a case entry (CE) question clarifier. METHODS: A retrospective descriptive study analyzed randomly selected EMD audios (where CD/CD protocol was used) from five accredited emergency communication centers in the United States. Several Quality Performance Review (QPR) experts reviewed the audios and recorded callers' initial problem descriptions, the use of and responses to the CE question clarifier, including the EMD-assigned final determinant code. RESULTS: A total of 1,261 audios were reviewed. The clarifier was used only 8.5% of the time. The CP/CD symptoms were mentioned alone or with other problems 87.0% of the time. Overall, CP symptom was mentioned alone 70.8%, HA alone 4.0%, and CD symptom alone 1.4% of the time. CONCLUSION: 9-1-1 callers report potential HA cases using a variety of terms and descriptions-most commonly CP. Other less-common symptoms associated with a HA may be mentioned. Therefore, EMDs must be well-trained to be prepared to probe the caller with a clarifying query to elicit more specific information when "having a heart attack" is the only complaint initially mentioned.

Pentoxifylline as an adjunct therapy in children with cerebral malaria.

BACKGROUND: Pentoxifylline (PTX) affects many processes that may contribute to the pathogenesis of severe malaria and it has been shown to reduce the duration of coma in children with cerebral malaria. This pilot study was performed to assess pharmacokinetics, safety and efficacy of PTX in African children with cerebral malaria. METHODS: Ten children admitted to the high dependency unit of the Kilifi District Hospital in Kenya with cerebral malaria (Blantyre coma score of 2 or less) received quinine plus a continuous infusion of 10 mg/kg/24 hours PTX for 72 hours. Five children were recruited as controls and received normal saline instead of PTX. Plasma samples were taken for PTX and tumour necrosis factor (TNF) levels. Blantyre Coma Score, parasitemia, hematology and vital signs were assessed 4 hourly. RESULTS: One child (20%) in the control group died, compared to four children (40%) in the PTX group. This difference was not significant (p = 0.60). Laboratory parameters and clinical data were comparable between groups. TNF levels were lower in children receiving PTX. CONCLUSIONS: The small sample size does not permit definitive conclusions, but the mortality rate was unexpectedly high in the PTX group.

Association between patient unconscious or not alert conditions and cardiac arrest or high-acuity outcomes within the Medical Priority Dispatch System "Falls" protocol.

INTRODUCTION: Falls are one of the most common types of complaints received by 9-1-1 emergency medical dispatch centers. They can be accidental or may be caused by underlying medical problems. Though "not alert" falls patients with severe outcomes mostly are "hot" transported to the hospital, some of these cases may be due to other acute medical events (cardiac, respiratory, circulatory, or neurological), which may not always be apparent to the emergency medical dispatcher (EMD) during call processing. OBJECTIVES: The objective of this study was to characterize the risk of cardiac arrest and "hot-transport" outcomes in patients with "not alert" condition, within the Medical Priority Dispatch System (MPDS®) Falls protocol descriptors. METHODS: This retrospective study used 129 months of de-identified, aggregate, dispatch datasets from three US emergency communication centers. The communication centers used the Medical Priority Dispatch System version 11.3-OMEGA type (released in 2006) to interrogate Emergency Medical System callers, select dispatch codes assigned to various response configurations, and provide pre-arrival instructions. The distribution of cases and percentages of cardiac arrest and hot-transport outcomes, categorized by MPDS® code, was profiled. Assessment of the association between MPDS® Delta-level 3 (D-3) "not alert" condition and cardiac arrest and hot-transport outcomes then followed. RESULTS: Overall, patients within the D-3 and D-2 "long fall" conditions had the highest proportions (compared to the other determinants in the "falls" protocol) of cardiac arrest and hot-transport outcomes, respectively. "Not alert" condition was associated significantly with cardiac arrest and hot-transport outcomes (p<0.001). CONCLUSIONS: The "not alert" determinant within the MPDS® "fall" protocol was associated significantly with severe outcomes for short falls (<6 feet; 2 meters) and ground-level falls. As reported to 9-1-1, the complaint of a "fall" may include the presence of underlying conditions that go beyond the obvious traumatic injuries caused by the fall itself.

The effect of blood transfusion on outcomes among African children admitted to hospital with Plasmodium falciparum malaria: a prospective, multicentre observational study.

BACKGROUND: Infection with Plasmodium falciparum leads to severe malaria and death in approximately 400 000 children each year in sub-Saharan Africa. Blood transfusion might benefit some patients with malaria but could potentially harm others. The aim of this study was to estimate the association between transfusion and death among children admitted to hospital with P falciparum malaria. METHODS: In this prospective, multicentre observational study, we analysed admissions to six tertiary care hospitals in The Gambia, Malawi, Gabon, Kenya, and Ghana that participated in the Severe Malaria in African Children network. Patients were enrolled if they were younger than 180 months and had a Giemsa-stained thick blood smear that was positive for P falciparum. Blood transfusion (whole blood at a target volume of 20 mL per kg) was administered at the discretion of the responsible physicians who were aware of local and international transfusion guidelines. The primary endpoint was death associated with transfusion, which was estimated using models adjusted for site and disease severity. We also aimed to identify factors associated with the decision to transfuse. The exploratory objective was to estimate optimal haemoglobin transfusion thresholds using generalised additive models. FINDINGS: Between Dec 19, 2000, and March 8, 2005, 26 106 patients were enrolled in the study, 25 893 of whom had their transfusion status recorded and were included in the primary analysis. 8513 (32·8%) patients received a blood transfusion. Patients were followed-up until discharge from hospital for a median of 2 days (IQR 1-4). 405 (4·8%) of 8513 patients who received a transfusion died compared with 689 (4·0%) of 17 380 patients who did not receive a transfusion. Transfusion was associated with decreased odds of death in site-adjusted analysis (odds ratio [OR] 0·82 [95% CI 0·71-0·94]) and after adjusting for the increased disease severity of patients who received a transfusion (0·50 [0·42-0·60]). Severe anaemia, elevated lactate concentration, respiratory distress, and parasite density were associated with greater odds of receiving a transfusion. Among all study participants, transfusion was associated with improved survival when the admission haemoglobin concentration was up to 77 g/L (95% CI 65-110). Among those with impaired consciousness (Blantyre Coma Score ≤4), transfusion was associated with improved survival at haemoglobin concentrations up to 105 g/L (95% CI 71-115). Among those with hyperlactataemia (blood lactate ≥5·0 mmol/L), transfusion was not significantly associated with harm at any haemoglobin concentration-ie, the OR of death comparing transfused versus not transfused was less than 1 at all haemoglobin concentrations (lower bound of the 95% CI for the haemoglobin concentration at which the OR of death equals 1: 90 g/L; no upper bound). INTERPRETATION: Our findings suggest that whole blood transfusion was associated with improved survival among children hospitalised with P falciparum malaria. Among those with impaired consciousness or hyperlactataemia, transfusion was associated with improved survival at haemoglobin concentrations above the currently recommended transfusion threshold. These findings highlight the need to do randomised controlled trials to test higher transfusion thresholds among African children with severe malaria complicated by these factors. FUNDING: US National Institute of Allergy and Infectious Diseases.

Effect of a Medical Priority Dispatch System key question addition in the seizure/convulsion/fitting protocol to improve recognition of ineffective (agonal) breathing.

OBJECTIVE: To investigate the impact of a new assessment question in the Medical Priority Dispatch System (MPDS) seizure protocol on the ability of the Emergency Medical Dispatchers (EMDs) to identify the presence of agonal or ineffective breathing. METHODS: A retrospective comparative study was conducted using two datasets-each representing two versions of the MPDS protocols (version 10.4 and version 11.2) at the London Ambulance Service (LAS). The "before" dataset (April 2004 to March 2005, version 10.4) did not have a specific assessment Key Question to identify the presence of irregular/agonal breathing. The question was added in the "after" dataset (April 2005 to March 2006, version 11.2). The datasets comprised the number of patients, calls, responses, incidents, and outcome (i.e., cardiac arrest [CA] and blue-in [BI]) parameters categorized using MPDS determinant codes. A distribution of these parameters was stratified by protocol version. Two-by-two contingency tables to determine association between ("before" and "after") protocols and CA outcome were generated. The likelihood of classifying CA outcome under the "Not fitting now and breathing regularly (verified)"-protocol 12 ALPHA-level 1 (12-A-1) and combined DELTA descriptor codes, was established. Odds ratios (OR) and p-values at significance level of 0.05 cut-off were used to determine any significant associations. RESULTS: For both datasets, the percentage of the emergency parameters increased with increasing determinant level from ALPHA to DELTA. The percentage of CA outcome in the 12-A-1 descriptor code in protocol version 11.2 was lower than that in version 10.4 (0.18% vs. 0.24%). Within protocol version 11.2, CA outcome was twice more likely in the combined DELTA descriptor codes when compared to other protocol 12 descriptor codes (OR(95%CI): 2.10(1.30, 1.40), p=0.002). CONCLUSIONS: The addition of the new assessment question for "breathing regularly" to the dispatch question sequence in the MPDS seizure protocol provides a valuable tool for identifying true cardiac arrest patients. Most of these cases appeared to be specifically captured by the new code 12 DELTA-level 3 (12-D-3): "Irregular Breathing".

The Medical Priority Dispatch System's ability to predict cardiac arrest outcomes and high acuity pre-hospital alerts in chest pain patients presenting to 9-9-9.

OBJECTIVE: To establish emergency medical dispatcher (EMD) predictability of cardiac arrest (CA) and high acuity (blue in - BI) outcomes in chest pain patients by using the Medical Priority Dispatch System's (MPDS) priority levels, and its more specific clinical determinant codes. METHODS: A retrospective descriptive study was done on a one year's worth of aggregate 999 call data comprising number of patients, calls, incidences, and outcomes (as determined by paramedics) obtained from the London Ambulance Service (LAS). We used Fisher's exact test to establish and quantify associations (through odds ratios, 95% CI and p-values) between MPDS priority levels and patient outcomes, stratifying by various pairing of MPDS priority level determinant codes. RESULTS: 11.4% of the total calls were classified under the chest pain protocol (MPDS protocol 10). Of all the CA cases (n=3377), 3.1% (n=106) were classified under the chest pain protocol. MPDS priority levels were significantly associated with CA patient outcome (p=0.030) and BI patient outcome (p<0.001). Only the advanced life support response-levels CHARLIE/DELTA pairing was significantly associated with CA outcome (p=0.010) with CA outcome nearly twice more likely in the combined DELTA-priority level codes. ALPHA/CHARLIE and ALPHA/DELTA-level pairings were significantly associated with BI outcome (p<0.001 each), with increased odds of BI outcome in the CHARLIE and DELTA-priority levels. Clinically, the DELTA-level 4 code demonstrated reduced odds of CA and BI outcome when paired with CHARLIE-level patients, than the other DELTA-level patients. CONCLUSIONS: Significant associations existed between patient outcomes, as measured in this study, and the MPDS (UKE version) Protocol 10 (Chest Pain) priority levels and specific determinant codes. The (UKE version) DELTA-level 4 determinant code does not belong in the DELTA-priority level, and should be moved to the CHARLE-level, or eliminated altogether--to bring this protocol version in line with other international versions of the MPDS.

Profile of emergency medical dispatch calls for breathing problems within the medical priority dispatch system protocol.

INTRODUCTION: A common chief complaint to emergency dispatch communication centers worldwide is "breathing problems". The chief complaint of breathing problems represents a wide spectrum of underlying diseases, patient conditions, and onset types. The current debate is on the potential ability of a dispatch protocol to safely and with high specificity, differentiate patients with minor or non-critical conditions from those conditions that pose risk to the patient and require advanced life support evaluation and care. This issue also has extended into the paramedic prehospital evaluation realm. OBJECTIVE: The objective of this study was to describe the distribution of Medical Priority Dispatch System (MPDS) codes representing the spectrum of clinical descriptions within the breathing problems chief complaint and their associated outcomes, at the scene and during transport, as determined by [UK] paramedics. METHODS: A retrospective, one-year study (September 2005 to August 2006) of a de-identified aggregate dataset from the London Ambulance Service (LAS) Trust was evaluated. A profile of the distribution of calls, incidents, patients, and outcomes (cardiac arrest [CA] and blue-in [BI] high acuity i.e., patients transported with lights and siren based on paramedic protocol) for the breathing problems chief complaint was evaluated. Odds ratios and 95% confidence intervals (CI) were used to quantify associations between the MPDS priority level's concurrent asthmatic conditions and outcomes. Two-sided Fisher's exact p-values were obtained to determine statistically significant associations, at a level of0.05. RESULTS: Sixteen percent (95,848/599,093) of all the patients were classified under the breathing problems chief complaint. Of these 95,848 patients, 367 (0.38%) were CA outcomes, and 7.82% (n = 7,493) were BI outcomes.The Cardiac Arrest Quotient (i.e., the number of CA cases as a percentage of the number of patients) for the ECHO priority level was 46 times higher than was that of non-ECHO priority levels: DELTA and CHARLIE (17.05% vs. 0.37%). Asthmatics were associated with CA outcome (OR(95%CI): 0.60(0.47,0.77), p <0.001), but not with BI outcome. CONCLUSIONS: The MPDS coding yielded a richer mix of severe outcomes in the higher priority levels.The Severe Respiratory Distress coding had the greatest number of patients and severe outcomes. Future studies that help refine the Severe Respiratory Distress code in the MPDS by more specific subgroups of patients would be beneficial.

Hospital-Confirmed Acute Myocardial Infarction: Prehospital Identification Using the Medical Priority Dispatch System.

Introduction Early recognition of an acute myocardial infarction (AMI) can increase the patient's likelihood of survival. As the first point of contact for patients accessing medical care through emergency services, emergency medical dispatchers (EMDs) represent the earliest potential identification point for AMIs. The objective of the study was to determine how AMI cases were coded and prioritized at the dispatch point, and also to describe the distribution of these cases by patient age and gender. Hypothesis/Problem No studies currently exist that describe the EMD's ability to correctly triage AMIs into Advanced Life Support (ALS) response tiers. METHODS: The retrospective descriptive study utilized data from three sources: emergency medical dispatch, Emergency Medical Services (EMS), and emergency departments (EDs)/hospitals. The primary outcome measure was the distributions of AMI cases, as categorized by Chief Complaint Protocol, dispatch priority code and level, and patient age and gender. The EMS and ED/hospital data came from the Utah Department of Health (UDoH), Salt Lake City, Utah. Dispatch data came from two emergency communication centers covering the entirety of Salt Lake City and Salt Lake County, Utah. RESULTS: Overall, 89.9% of all the AMIs (n=606) were coded in one of the three highest dispatch priority levels, all of which call for ALS response (called CHARLIE, DELTA, and ECHO in the studied system). The percentage of AMIs significantly increased for patients aged 35 years and older, and varied significantly by gender, dispatch level, and chief complaint. A total of 85.7% of all deaths occurred among patients aged 55 years and older, and 88.9% of the deaths were handled in the ALS-recommended priority levels. CONCLUSION: Acute myocardial infarctions may present as a variety of clinical symptoms, and the study findings demonstrated that more than one-half were identified as having chief complaints of Chest Pain or Breathing Problems at the dispatch point, followed by Sick Person and Unconscious/Fainting. The 35-year age cutoff for assignment to higher priority levels is strongly supported. The Falls and Sick Person Protocols offer opportunities to capture atypical AMI presentations. Clawson JJ , Gardett I , Scott G , Fivaz C , Barron T , Broadbent M , Olola C . Hospital-confirmed acute myocardial infarction: prehospital identification using the Medical Priority Dispatch System. Prehosp Disaster Med. 2018;33(1):29-35.

Can a Software-Based Metronome Tool Enhance Compression Rate in a Realistic 911 Call Scenario Without Adversely Impacting Compression Depth for Dispatcher-Assisted CPR?

IntroductionImplementation of high-quality, dispatcher-assisted cardiopulmonary resuscitation (DA-CPR) is critical to improving survival from out-of-hospital cardiac arrest (OHCA). However, despite some studies demonstrating the use of a metronome in a stand-alone setting, no research has yet demonstrated the effectiveness of a metronome tool in improving DA-CPR in the context of a realistic 911 call or using instructions that have been tested in real-world emergency calls.HypothesisUse of the metronome tool will increase the proportion of callers able to perform CPR within the target rate without affecting depth. METHODS: The prospective, randomized, controlled study involved simulated 911 cardiac arrest calls made by layperson-callers and handled by certified emergency medical dispatchers (EMDs) at four locations in Salt Lake City, Utah USA. Participants were randomized into two groups. In the experimental group, layperson-callers received CPR pre-arrival instructions with metronome assistance. In the control group, layperson-callers received only pre-arrival instructions. The primary outcome measures were correct compression rate (counts per minute [cpm]) and depth (mm). RESULTS: A total of 148 layperson-callers (57.4% assigned to experimental group) participated in the study. There was a statistically significant association between the number of participants who achieved the target compression rate and experimental study group (P=.003), and the experimental group had a significantly higher median compression rate than the control group (100 cpm and 89 cpm, respectively; P=.013). Overall, there was no significant correlation between compression rate and depth. CONCLUSION: An automated software metronome tool is effective in getting layperson-callers to achieve the target compression rate and compression depth in a realistic DA-CPR scenario.Scott G, Barron T, Gardett I, Broadbent M, Downs H, Devey L, Hinterman EJ, Clawson J, Olola C. Can a software-based metronome tool enhance compression rate in a realistic 911 call scenario without adversely impacting compression depth for dispatcher-assisted CPR? Prehosp Disaster Med. 2018;33(4):399-405.

Cardiac arrest predictability in seizure patients based on emergency medical dispatcher identification of previous seizure or epilepsy history.

OBJECTIVE: To determine predictability of at-scene cardiac arrest from a dispatch determined patient history of seizure or epilepsy ("E" history). DESIGN AND METHODS: A retrospective study of a 1 year dataset from the London Ambulance Service (LAS) National Health Service (NHS) Trust was undertaken. Each of the nine determinant codes on the Medical Priority Dispatch System (MPDS) seizure protocol [Heward A, Damiani M, Hartley-Sharpe C. Does the use of the Advanced Medical Priority Dispatch System affect cardiac arrest detection? Emerg Med J 2004;21:115-8.] was examined for the addition of the "E" suffix finding. The cardiac arrest predictability of cases with reported "E" history was compared to those without using a protocol process to detect the infrequent but predictable presence of seizures caused by anoxic cardiac arrest. RESULTS: Only protocol codes 12-A-1, 12-D-2, 12-D-3, and 12-D-4 demonstrated significant associations between outcomes and determinant codes (p=0.016, 0.007, <0.001, and 0.048, respectively). These codes showed reduced risk of predicting CA with the "E" suffix protocol determinant codes (RD (95% CI): -0.0025 (-0.0044, -0.0005), chi-square p=0.009; RD (95% CI): -0.0024 (-0.0042, -0.0005), p=0.005; RD (95% CI): -0.020 (-0.029, -0.011), p<0.001; RD (95% CI): -0.01 (-0.017, -0.005), and p=0.034, respectively). CONCLUSIONS: Knowing whether a seizure patient is an epileptic or has had previous seizures is of clinical value and relevant to dispatch. By improving the discernment of the seizure protocol regarding seizure associated with anoxic cardiac arrest predictability, this information may now be applied at the response level as well as to emergency medical dispatcher's (EMD) decisions to stay on the telephone to enhance the monitoring of these patients.

Accuracy of emergency medical dispatchers' subjective ability to identify when higher dispatch levels are warranted over a Medical Priority Dispatch System automated protocol's recommended coding based on paramedic outcome data.

OBJECTIVES: To establish the accuracy of the emergency medical dispatcher's (EMD's) decisions to override the automated Medical Priority Dispatch System (MPDS) logic-based response code recommendations based on at-scene paramedic-applied transport acuity determinations (blue-in) and cardiac arrest (CA) findings. METHODS: A retrospective study of a 1 year dataset from the London Ambulance Service (LAS) National Health Service (NHS) Trust was undertaken. We compared all LAS "bluing in" frequency (BIQ) and cardiac arrest quotient (CAQ) outcomes of the incidents automatically recommended and accepted as CHARLIE-level codes, to those receiving EMD DELTA-overrides from the auto-recommended CHARLIE-level. We also compared the recommended DELTA-level outcomes to those in the higher ECHO-override cases. RESULTS: There was no significant association between outcome (CA/Blue-in) and the determinant codes (DELTA-override and CHARLIE-level) for both CA (odds ratio (OR) 0, 95% confidence interval (CI) 0 to 41.14; p = 1.000) and Blue-in categories (OR 0.89, 95% CI 0.34 to 2.33; p = 1.000). Similar patterns were observed between outcome and all DELTA-level and ECHO-override codes for both CA (OR 0, 95% CI 0 to 70.05; p = 1.000) and Blue-in categories (OR 1.17, 95% CI 0 to 7.12; p = 0.597). CONCLUSION: This study contradicts the belief that EMDs can accurately perceive when a patient or situation requires more resources than the MPDS's structured interrogation process logically indicates. This further strengthens the concept that automated, protocol-based call taking is more accurate and consistent than the subjective, anecdotal or experience-based determinations made by individual EMDs.